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CASE REPORT

Tuberculous Sacroiliitis With Constitutional Symptom: A Case Report

Yu-Jen Chen *, Ming-Tsung Chuang*, Gin-Chung Liu*, Tsyh-Jyi Hsieh*#

* Department of Medical Imaging, Kaohsiung Medical University Hospital
#Department of Medical Imaging, Kaohsiung Municipal Hsiao-Kang Hospital

Address for Correspondence:
Tsyh-Jyi Hsieh, MD
Department of Medical Imaging, Kaohsiung Medical University Hospital
No. 100 Tz-You 1st road, Kaohsiung, 807 Taiwan
Phone: 886-7-3208235
Fax number: 886-7-3154208
E-mail address: gemuse66@gmail.com

Abstract:

We report a case of a 59 year-old female patient, who has a history of restrictive pericarditis, presented as cough, high fever and dyspnea at admission. Eight days after admission, she complained of right buttock pain. Diagnosis of tuberculous sacroiliitis was made by CT-guide aspiration for histology and culture. After administration of antitubercular agents, symptoms improved dramatically and the patient discharged. In this case, CT-guide aspiration plays an important role in patients with atypical presenting symptoms with minimal intervention. Active tuberculosis was also proved three month later by acid-fast stain of sputum.
Keywords: Tuberculosis, sacroiliitis

J.Orthopaedics 2007;4(2)e29

 

Case report:

A 59 year-old female had medical history of pericardial tumor post operation, constrictive pericarditis, atrial fibrillation and congestive liver cirrhosis. Anti-tuberculosis drugs history was also related. She had been experiencing coughing with yellowish sputum for 3 weeks. Fever (38.8oC), chills, dyspnea and chest tightness were also present for several days. Laboratory data showed progressive inflammation (C-reactive protein 25.64à53.73μg/ml). Chest X-ray showed consolidation of the left lung. Chest CT showed constrictive heart failure and pericardial effusion with calcifications (Fig 1). She was treated under the impression of pneumonia. However, fever didn’t subside.

Right buttock pain was complained at the 8th day after admission. The plain film revealed widening of right sacroiliac (S-I) joint and haziness of the subchondral bone (Fig 2). MRI was arranged and showed edematous change of right iliac bone adjacent to the right S-I joint (Fig 3).

Fig 1.Reformatted coronal image of chest CT revealed constrictive pericarditis with pericardial effusion and calcifications Fig 2.Radiograph of right hip joint showing mild widening and haziness (arrow) at lower portion of right sacroiliac joint

Fig 3a.Coronal T2-seighted images of pelvis showing hyperintensities, representing bone marrow edema. 
Post enhanced T1-weighted coronal

Fig 3b.showing heterogeneous enhancement (arrow)

Due to no significant abscess formation being identified in the MRI study, Ga-67 whole body scan was performed for infectious source detection and revealed mild active gallium-avid lesions in the right S-I joint.

With clinical correlation, CT-guided aspiration was performed for right S-I joint and a small amount of turbid fluid was aspirated. Histology showed PMN, lymphocytes and histiocytes. Smear of the fluid showed no acid-fast bacilli. However, growth of bacilli in Lowenstein-Jensen established the diagnosis of tuberculosis sacroiliitis.

Fever, chills, cough, dyspnea and chest tightness were relieved after administration of anti-tuberculosis agents. Follow-up CRP was also decreased in level (53.73à14.65μg/ml). The patient was discharged with some complications caused by anti-tuberculosis agents (dizziness, anorexia, GI upset, elevated GOT/GPT) and general condition was stable.

Discussion :

Tuberculosis is the most common infectious disease in the world, especially in South-East Asia [2]. According to World Health Organization (WHO), the prevalence of tuberculosis globally is about 0.23% [2].

Extra-pulmonary tuberculosis accounts for 15–30% of cases [4-5]. In all tuberculosis cases, bone and joint involvement account for about 1~5% [1]. In bone invasion, about half involve the spine, mainly the thoracolumbar junction. The S-I joint is rarely involved, in only 3~9.7% of these cases. Tuberculous in S-I joint is frequently missed because of the vague symptoms and poor localizing signs [3]. Therefore, increased vigilance is required for diagnosis.

Difficult walking, buttock pain, nerve root pain in the lower limbs [7], and low back pain may occur as onset symptoms in sacroiliac tuberculosis. It is difficult to diagnose due to the vague and non-specific presentations. Thus, the mean time from symptom onset to diagnosis is 5.5 months in the literature [8]. In our case, fever, cough and dyspnea without buttock pain were present at first. Misdiagnosis of pneumonia was made according to symptoms, laboratory data and chest X-ray. Finally, buttock pain was complained about after eight days and X-ray for right hip was performed.

In the earliest stage of sacroiliac tuberculosis, X-ray may not show any abnormalities. Mild haziness and widening of the S-I joint, especially in the lower part, can be the earliest changes followed by bone erosion. In a subacute or indolent case, sclerotic change of subchondral bone is common in later stages [9]. Bone scan is helpful for early detection of the lesion with increase uptake [10]. CT shows more delicate anatomy than X-ray, and MRI provides differential diagnosis between soft tissue tumor and pyogenic arthritis [11].

In our case, subtle changes such as haziness at lower portion of right S-I joint were noted. Non-specific edema with minimal fluid accumulation adjacent to right S-I joint also made diagnosis difficult. Nevertheless, buttock pain and history anti-tuberculosis agents were the key points to aim our direction of diagnosis to tuberculosis sacroiliitis. CT-guide aspiration provides a method with minimal invasive for diagnosis.

Tuberculosis in S-I joint is often associated with tuberculous lesions elsewhere, and it commonly originates from a tuberculous psoas muscle abscess or tuberculous spondylitis [6], which was not shown in our case. However, tuberculous pericarditis, though not proved, was suspected as the site of primary origin.

The CA125 level of our patient has been persistently high (>500 U/ml, normal range<35U/ml) for several years. However, there was no evidence of gynecologic malignancy after general survey by pelvic CT. Yilmaz reported that CA 125 is beneficial in the determination of tuberculosis activity and in differentiation between active and inactive pulmonary tuberculosis [12]. In our case, active tuberculosis was proved three months later by acid-fast stain of sputum, though it was negative at admission.

Except for the high CA125 level, history of constrictive pericarditis was also present in our patient. No direct evidence of tuberculous pericarditis was present after biopsy. However, inspissated fragments, debris and blood clots, indicating a chronic inflammatory process of the pericardium. Furthermore, in the report of Nakanishi Y, significant elevation of serum CA125 was noted in patients with tuberculous pleurisy [13]. It also offered an indirect evidence of tuberculous pericarditis in our case.

Conclusion:

Though tuberculous sacroiliitis is hard to diagnose due to vague symptoms and poor localizing signs. In patients that with atypical presenting symptoms, images, such as MRI, and CT-guide aspiration biopsy are good diagnostic method with minimal intervention. It is also important to survey the tuberculous lesions elsewhere.

Reference :

  1. Davies PD, Humphries MJ, Byfield SP, Nunn AJ, Darbyshire JH, Citron KM, Fox W: Bone and joint tuberculosis. A survey of notifications in England and Wales. J Bone Joint Surg Br 1984;66(3):326–330

  2. Http://www.who.int/mediacentre/factsheets/fs104/en/#global

  3. Gordan G, Kabins SA: Pyogenic sacroiliitis. Am J Med 1980; 69:50–56

  4. Hopewell PC: A clinical view of tuberculosis. Imaging of tuberculosis and craniospinal tuberculosis. Radiol Clin North Am 1995;33:641–53.

  5. Sharif HS, Morgan JL,AI Shahed MS,AI ThagafiMY: Role of CT and MR imaging in the     management of tuberculous spondylitis. Radiol Clin North Am 1995;33:787–804.

  6. Kim NH, Lee HM, Yoo JD, Suh JS: Sacroiliac joint tuberculosis. Classification and treatment.Clin Orthop 1999;358:215–222

  7. Chen WS: Chronic sciatica caused by tuberculous sacroiliitis. A case report. Spine 1995;20:1194–6.

  8. Gonzalez-Gay MA, Garcia-Porrua C, Cereijo MJ, Rivas MJ, Ibanez D, Mayo J: The clinical spectrum of osteoarticular tuberculosis in non-human immunodeficiency virus patients in a defined area of northwestern Spain. Clin Exp Rheumatol 1999;17:663–669.

  9.  Delbarre F, Rondier J, Delrieu F, Evrard J, Coyla J, Menkes J, et al: Pyogenic infection of the     sacroiliac joint. J Bone Joint Surg 1975;57:819.

  10. Salomon CG, Ali A, Fordham EW: Bone scintigraphy in tuberculous sacroiliitis Clin Nucl Med 1986; 11(6):407–408

  11.  Hong SH, Kim SM, Ahn JM, Chung HW, Shin MJ, Kang HS: Tuberculous versus pyogenic arthritis: MR imaging evaluation. Radiology 2001; 218(3):848–853

  12. Yilmaz A, Ece F, Bayramgurler B, Akkaya E, Baran R., Int J Tuberc Lung Dis. 2002

  13. 13. Nakanishi Y, Hiura K, Katoh O, Yamaguchi T, Kuroki S, Aoki Y, Yamada H: Clinical significance of serum CA125 in patients with tuberculous pleurisy. Kekkaku. 1991 Aug;66(8):525-30.

 

This is a peer reviewed paper 

Please cite as :Yu-Jen Chen : Tuberculous Sacroiliitis With Constitutional Symptom - A Case Report

J.Orthopaedics 2007;4(2)e29

URL: http://www.jortho.org/2007/4/2/e29

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