Tuberculosis infection of the ischium in a patient with poorly controlled diabetes mellitus: A case report

doi:10.21203/rs.3.rs-3881519/v1

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Case Report

Tuberculosis infection of the ischium in a patient with poorly controlled diabetes mellitus: A case report

https://doi.org/10.21203/rs.3.rs-3881519/v1

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Primary tuberculosis infection of the ischium is rare and challenging, particularly in immunocompromised patients. We present the case of a 74-year-old man with poorly controlled diabetes mellitus who developed persistent pain and swelling, even the sinus discharged from the left gluteal fold region. Imaging studies revealed lytic lesions in the ischium, cortical destruction, and soft tissue involvement. Histopathological examination confirmed that caseous necrosis occurred. The patient was initiated appropriate treatment for tuberculosis infection, and his symptoms improved without disease progression. Primary tuberculosis infection poses significant diagnostic challenges due to overlapping clinical and radiological features. Early recognition and a multidisciplinary approach involving infectious disease specialists, pulmonologists, radiologists, and surgeons are crucial for optimal management. The prognosis of this infection is poor, emphasizing the importance of timely diagnosis and treatment. To improve outcomes, comprehensive screening and early detection of infections in high-risk patients, such as those with uncontrolled diabetes, are essential. Future advancements in diagnostic tools may facilitate prompt and accurate diagnosis. Clinicians should maintain a high index of suspicion and employ appropriate diagnostic techniques to ensure early identification and effective management of these complex infections.

Ischium

Tuberculosis

Infection

Diabetes mellitus

Although tuberculosis (TB) can be treated, it is still an important health problem in developing countries, including China. In recent years, it has been proven to be a common opportunistic infection in individuals with diabetes[1, 2]. Tuberculosis usually affects the lungs, although extrapulmonary sites can also be involved[3]. Osteoarticular tuberculosis (OATB), also known as bone and joint TB or musculoskeletal TB, was even identified in the spine of Egyptian mummies approximately 9000 years ago and is considered a rare form of TB. In China, OATB accounts for 5–10% of all TB cases [4–6]. Tuberculosis of the ischium is uncommon, especially in the absence of pulmonary disease, with primary tuberculosis of the ischium being a diagnostic challenge for clinicians[7]. Here, we report a case in which an intramedullary cervical tuberculoma was successfully treated via a combination of surgery and antitubercular chemotherapy.

A 74-year-old male patient reported to the Hospital Outpatient Department, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, Nanning, with pain, swelling and sinus discharge through the left gluteal fold region for the past week. The patient had no history of cough, low-grade fever, night sweats, or other symptoms. The patient had a long history of type II diabetes with fluctuating glycemic control despite medication. A history of trauma, smoking, alcohol intake, previous lung TB and TB contact was negative. The patient had no history of AIDS. One month prior, a lesion appeared on the patient's left gluteal fold region. The mass started as a pimple, progressing to tender swelling with mild pain. After three weeks, swelling bursts and yellow pus discharge were noted. A physical examination revealed that the left hip region was swollen, ranging in diameter by 7 cm. The abscess progresses toward the surface of the skin, and fluctuations can be felt. The patient felt pain, no redness, and no heat. There was sinus formation in the left gluteal fold region, which could spontaneously rupture and drain pale yellow pus(Fig. 1).

The erythrocyte sedimentation rate (ESR) was elevated to 41 mm/hour, the glycosylated hemoglobin (HbA1c) level was 6.8%, and the other laboratory parameters were normal. Hypoechoic areas on local ultrasound. Computed tomography(CT) revealed that the ischium was destroyed, a peripheral soft tissue abscess was observed, and dead bone was observed around the sinus(Fig. 2). Magnetic resonance imaging revealed an abnormal signal shadow in the subcutaneous soft tissue of the left hip and bone resorption in the left sciatic bone, indicating the presence of infectious or tuberculous lesions. Moreover, a chest radiograph did not reveal any abnormalities. The subsequent sputum smear and culture results were negative. Surgery was scheduled, and debridement and vacuum sealing drainage (VSD) were applied to the gluteal fold. A significant quantity of yellowish pus was discovered in the sinus, along with caseous necrotic substances. The samples were subjected to histopathology, which revealed epithelioid cell granulomas, Langhans giant cells and scant necrosis (Fig. 3). Following the operation, multidrug anti-tuberculosis therapy, which included rifampicin (RIF), isoniazid (INH), pyrazinamide (PZA), and ethambutol (EMB), was administered. In addition, the hypoglycemic regimen consisted of empagliflozin, acarbose before each meal, and degludec insulin at bedtime.

Tuberculosis is an infectious bacterial infection that primarily affects the lungs but can also spread to other organs[8]. Patients may develop the disease without realizing it, with symptoms progressing slowly. His fever, night sweats, loss of appetite, weight loss, fatigue, and other systemic symptoms were low. As the disease progresses, compressive fractures and paravertebral abscesses may occur, leading to deformities of the spine protruding backward and corresponding neurological symptoms due to spinal cord compression[9, 10].

A diagnosis of tuberculosis could not be ruled out, even though no tuberculosis lesions were observed on chest CT or no TB bacilli[11]. Notably, even in the absence of tuberculosis lesions on pulmonary CT, the possibility of having tuberculosis cannot be definitively excluded. Occasionally, tuberculosis lesions may be subtle or inconspicuous on CT images[12]. A negative culture for Mycobacterium tuberculosis does not completely rule out the possibility of tuberculosis[13]. Although sputum smear and culture are common methods for diagnosing pulmonary tuberculosis, they are not the only diagnostic tools available. Sometimes, even if the sputum smear and culture results are negative, the patient may still have tuberculosis.

To reduce the incidence of bone diseases that occur in older patients complicated by diabetes, it is essential to achieve and maintain good metabolic control. The relationship between diabetes and tuberculosis is a complex orthopedic issue[14, 15]. Diabetes mellitus can affect the immune system of patients, potentially increasing susceptibility to tuberculosis, including osteoarticular tuberculosis. Poor blood sugar control in diabetic patients may further weaken their immune function, increasing the risk of contracting tuberculosis[16]. Additionally, diabetes mellitus itself can also impact bone health. Diabetic patients may experience issues with decreased bone density and an increased risk of fractures, which are related to changes in bone mineral density (BMD) and the amplification of vascular complications[17]. Overall, diabetic patients may be more prone to contracting OAB due to a weakened immune system, and their bone health may also be affected by diabetes mellitus. Therefore, maintaining good blood sugar control and good bone health is very important for diabetic patients.

This case is interesting for several reasons. First, tuberculosis of the ischium bone is an infrequent entity that can mimic other bone diseases, such as cancer, osteomyelitis, or arthritis. Second, tuberculosis of the ischium bone can occur without lung involvement, making diagnosis and treatment difficult. Third, TB of the ischium bone can affect people of any age and ethnicity, although it is more common in countries with a high TB incidence. Fourth, tuberculosis of the ischium bone requires long-term treatment with antituberculosis drugs to prevent complications and relapses.

Sciatic tuberculosis is a sporadic disease. This disease is insidiou and lacks the typical symptoms of tuberculosis. It may manifest as painless swelling in the buttock fold or drainage from the breast. The affected skin may become inflamed but typically without redness or fever, distinguishing it from bacterial infections. This constitutes a decisive characteristic of tuberculosis infection. Due to the contagious nature of tuberculosis and its impact on the body, timely diagnosis and treatment are crucial. In this context, our article provides valuable information about this uncommon form of extrapulmonary tuberculosis.

• -Ethics approval and consent to participate

Not applicable.

• -Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

• -Availability of data and materials

To protect the privacy and confidentiality of the patient, we did not share the raw data in any public repository. This is a case report of a single patient. We followed the hospital’s routine procedure and kept the original reports, laboratory tests, imaging studies and outpatient records in the medical records.

• -Competing interests

Not applicable.

• -Funding

Not applicable.

• -Authors' contributions

Conception and design: YH and HL. Provision of study material or patients: YH, ML, GW, SM and HL. Collection and assembly of data: YH, YZ and HL. Data analysis and interpretation: YH, HL, LH and XL. Manuscript writing: YH. Final approval of manuscript: All authors.

• -Availability of Data and Materials

All data generated or analysed during this study are included in this published article.

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No competing interests reported.

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Tuberculosis infection of the ischium in a patient with poorly controlled diabetes mellitus: A case report

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