Group Title: Cases Journal 2010, 3:67
Title: Mycobacterium tuberculosis osteomyelitis in a patient with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) : a case report
CITATION PDF VIEWER THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00100245/00001
 Material Information
Title: Mycobacterium tuberculosis osteomyelitis in a patient with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) : a case report
Series Title: Cases Journal 2010, 3:67
Physical Description: Archival
Creator: Mannepalli S
Mitchell-Samon L
Guzman N
Relan M
McCarter YS
Publication Date: 40232
 Record Information
Bibliographic ID: UF00100245
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: Open Access: http://www.biomedcentral.com/info/about/openaccess/

Downloads

This item has the following downloads:

mycobacterium ( PDF )


Full Text


Mannepalli et al. Cases Journal 2010, 3:67
http://www.casesjournal.com/content/3/1/67


CASES
JOURNAL


Mycobacterium tuberculosis osteomyelitis in a

patient with human immunodeficiency virus/

acquired immunodeficiency syndrome (HIV/AIDS):

a case report

Supriya Mannepallil*, Levonne Mitchell-Samon2, Nilmarie Guzman', Manish Relani, Yvette S McCarter3


Abstract
The incidence of tuberculosis is increasing in the United States. Extra-pulmonary involvement is more common in
patients with HIV/AIDS. The diagnosis of Tuberculosis osteomyelitis requires a high degree of suspicion for accurate
and timely diagnosis.
We present a case of a 49 year old Caucasian male with HIV/AIDS who presented with a four-month history of soft
tissue swelling in the left proximal thigh unresponsive to various broad spectrum antibiotics who was eventually
diagnosed with Mycobacterium tuberculosis osteomyelitis of the left proximal femur.


Case report
A 49 year old Caucasian male with HIV/AIDS was
admitted with a four-month history of soft tissue swel-
ling in the left proximal thigh. He initially noticed a
small red nodule on the skin over the left thigh which
eventually increased in size and ruptured with yellow-
ish-green drainage. He reported that he had visited the
emergency room at that time and was diagnosed as hav-
ing a left thigh abscess which was incised and drained.
No cultures were obtained during that visit. He was
seen in follow-up at the HIV clinic where cultures of
the drainage were obtained and he was given a prescrip-
tion for minocycline. He had resolution of the drainage
but relapsed 1 month later with pain and drainage from
the left hip while still taking minocycline. He presented
to the hospital in a "desperate attempt to seek medical
attention" secondary to the persistent pain, swelling, yel-
lowish drainage and difficulty with ambulation requiring
the use of crutches.
On review of symptoms, the patient reported severe
pain of the left lower extremity and hip which had gra-
dually worsened to a severity scale of 10 out of 10. He
denied any trauma to the site, associated fevers, or

* Correspondence' msupriyagmail com
infectious Diseases Division, University of Florida College of Medicine
Jacksonville, Florida, USA


chills. No other acute symptoms were reported by the
patient.
Patient denied any significant past medical history
except HIV which was initially diagnosed in 2000. His
nadir CD4 was 247 cells/mm3 and he was started on anti-
retroviral therapy in 2001. At his last clinic visit less than 3
months prior, he had an absolute CD4 count of 540 cells/
uL and a HIV RNA viral load of < 50 copies on his current
regimen of zidovudine/lamivudine and lopinavir/ritonavir
He reported no known drug allergies. In reviewing the
out-patient records, patient also had a history of a positive
tuberculin skin test in 2002 for which he reportedly took 6
months of isoniazid and vitamin B6. The outpatient
records also indicated that he had complaints of swelling
and drainage from the left hip as far back as 2002. He had
one bacterial culture growing Stenotrophomonas spp. for
which he was treated with trimethoprim-sulfamethoxizole
and ciprofloxacin with partial resolution of drainage. Sub-
sequently he had multiple negative bacterial cultures from
this drainage, and multiple courses of antibiotics between
2002 and 2003. Specimens for acid-fast bacilli were sent in
2002 for which the smears were negative but the sample
was insufficient for AFB culture. Since 2003 and the time
of this presentation he has had episodes of exacerbations
and remissions of the current problem but lacked funding
for further diagnostic work-up. He smoked one pack of


2010 Mannepalli et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Bi Vlled Central Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.







Mannepalli et al. Cases Journal 2010, 3:67
http://www.casesjournal.com/content/3/1/67


cigarettes per day but denied any alcohol or recreational
drug use. He denied any recent travel or exposure to any
animals. The patient had been homeless for several years,
but denied history of incarceration.
On evaluation the patient was thin and poorly nour-
ished, but in no acute distress. The blood pressure was
110/50 mm Hg, pulse 74 beats per minute, temperature
97.9F, and respirations 18 breaths per minute. In gen-
eral, he appeared to be cachectic. His cardiovascular,
gastrointestinal and respiratory system examination was
normal. A 7 cm x 4 cm fluctuant, tender soft tissue
swelling was present on the lateral aspect of the left
proximal thigh. A sinus tract was present distal to the
left greater trochanter with yellowish green drainage
oozing from the sinus and it could be probed with a
swab to a depth of approximately 5 cm. There was no
erythema of the surrounding skin. Motor and sensory
examinations were normal and there was no lymphade-
nopathy noted in the inguinal areas.
Routine laboratory data were normal, including com-
plete blood count, renal and liver function tests. Ery-
throcyte sedimentation rate (ESR) was 255. Plain x-ray
images of the left hip and femur were negative for any
bone abnormality. Blood cultures were negative.
CT scan of the left lower extremity showed a 25 mm
x 40 mm x 140 mm fluid collection with peripheral
enhancement involving the gluteus medius and vastus
lateralis muscles (Figure 1).
The patient was admitted with a diagnosis of left thigh
soft tissue abscess with sinus tract. A bedside incision
and drainage procedure was performed by General


surgery. Cultures from the incision and drainage initially
grew Streptococcus agalactiae and treatment was started
with clindamycin IV by the primary team. Due to the
chronicity of the wound, further evaluation with a MRI
was pursued specifically to rule out underlying tumor or
osteomyelitis.
MRI of the left thigh showed a sinus tract within the
proximal left thigh communicating with a loculated
fluid collection contiguous with the gluteus medius and
pyriformis muscles. It also revealed increased bone mar-
row signal intensity consistent with osteomyelitis of the
proximal femur. (Figure 2 and 3)
The differential diagnosis considerations included
chronic pyogenic osteomyelitis, primary bone tumor,
secondary metastasis, inflammatory arthritis, sarcoma,
or tuberculous osteomyelitis.
The antibiotics were changed at this time to merope-
nem, vancomycin and levofloxacin to empirically treat


Figure 1 CT scan of left lower extremity showing a 25 mm x
40 mm x 140 mm fluid collection (-) and peripheral
enhancement of the gluteus medius and vastus lateralis
muscles.


Figure 3 MRI of the left thigh showing a sinus tract (-) from
the proximal femur.


Page 2 of 4






Mannepalli et al. Cases Journal 2010, 3:67
http://www.casesjournal.com/content/3/1/67


the most common etiologic agents of osteomyelitis while
awaiting a more definitive diagnosis. Although tubercu-
lous osteomyelitis was considered, it was lower on the
differential and levofloxacin was added to give adequate
therapy for pseudomonas as a potential pathogen. The
patient then underwent a CT-guided percutaneous
biopsy of the left greater trochanter to confirm the diag-
nosis. Cultures of the bone biopsy were negative for
aerobic and anaerobic organisms as well as fungi. Acid
fast bacilli smears were also negative. The histopathol-
ogy on the CT-guided bone biopsy did not reveal any
active osteomyelitis. The patient was transferred to our
long-term care unit with the plan to complete a 6-week
course of empiric treatment for osteomyelitis with
piperacillin/tazobactam, vancomycin and levofloxacin.
The cultures eventually grew Mycobacterium tuberculo-
sis at 5 weeks.
The patient was then started on a 4-drug anti-tuber-
cular therapy with isoniazid, rifampin, ethambutol, pyra-
zinamide and vitamin B6, based on the susceptibility
pattern of the Mycobacterium tuberculosis isolated. A
work-up to evaluate for pulmonary tuberculosis was
negative. The patient was discharged with follow-up by
a home wound care team, as well as, outpatient directly-
observed therapy for tuberculous osteomyelitis for a
total duration of nine months.
At his out-patient follow-up visit at our clinic he has
shown good clinical improvement with complete closure
of the sinus tract. He does, however, continue to com-
plain of left hip pain but is able to ambulate without
any assistive device. The Orthopedic service did not
recommend any immediate surgical intervention and he
will be followed up by orthopedics also as outpatient.

Discussion
The incidence of tuberculosis is increasing in the United
States [1]. Some of the factors attributing to this rise
include the increasing number of people with HIV,
increased international travel and the increase in the
aging population (1). One fifth of the cases of tuberculo-
sis have extra pulmonary involvement and this is more
common in patients with HIV/AIDS. HIV/AIDS is an
important risk factor for reactivation of the latent tuber-
culous infection [2]. Due to the higher incidence of
extra pulmonary tuberculosis in HIV-infected patients,
clinicians should always consider it in the differential
diagnosis of osteomyelitis. An important opportunity for
diagnosis was missed in this case at his emergency room
visit when no cultures were sent from the incision and
drainage procedure.
The diagnosis of tuberculous osteomyelitis requires a
high degree of suspicion for accurate and timely diagno-
sis. Challenges in the diagnostic work up include lack of
familiarity with the spectrum of tuberculous


osteomyelitis bone lesions and not considering it in the
differential early on [3]. The incidence of skeletal mani-
festations in tuberculosis is very low, (only 1-3%) and
the spine is most commonly involved, followed by
femur, tibia and fibula [4]. Tuberculous osteomyelitis
occurs secondary to lymphohematogenous spread of
Mycobacterium tuberculosis from a pulmonary focus [5].
Clinical symptoms are very nonspecific and can
include insidious onset of pain, swelling, decreased
range of motion and difficulty ambulating. Patients may
also have weight loss, night sweats, generalized malaise
and decreased appetite. Tuberculosis of the bone can go
unnoticed for a long time until there is extension of the
disease to skin and adjacent structures including the
joints [[1,3], and [4]].
A significant challenge in the diagnosis of tuberculous
osteomyelitis is that the smears for acid-fast bacilli are
often negative, leading to a delay in diagnosis while
waiting for the organisms to grow in culture media
[6,7]. Polymerase chain reaction or nucleic amplification
assays may be helpful in obtaining an earlier diagnosis;
however, a negative result does not rule out
tuberculosis.
Radiological findings include metaphyseal or epiphy-
seal destruction without sclerosis, sequestration, perios-
teal reaction and joint involvement. Unlike pyogenic
osteomyelitis, there is sparing of the articular margins
and cartilage space. Sometimes a solitary lytic lesion
may be seen which can mimic neoplasia [[1,4], and [8]].
A positive tuberculin skin test is an important clue in
patients with tuberculosis, but it can be negative in 10%
of the patients. Although in some patients the ESR can
be elevated, it is often normal [9,10]. The gold standard
for diagnosis is the isolation of Mycobacterium tubercu-
losis from cultures of bone biopsy material. Histopathol-
ogy of the bone lesions also is very helpful in
confirming the diagnosis [[1,4], and [11]].

Differential diagnosis
Differential diagnosis often includes chronic pyogenic
osteomyelitis, primary bone tumor, secondary metasta-
sis, granulomatous diseases, inflammatory arthritis and
sarcoma [[4,6] and [12]].

Treatment
Patients with a diagnosis of tuberculous osteomyelitis
should be evaluated for pulmonary tuberculosis and in
the hospital setting placing the patient in respiratory iso-
lation would not be unreasonable, until this is ruled out.
The Centers for Disease Control (CDC) published
Guidelines for the Treatment of Opportunistic Infec-
tions recommends including a chest radiograph in the
evaluation of suspected HIV-related TB regardless of
the possible anatomic site of disease. "Sputum samples


Page 3 of 4







Mannepalli et al. Cases Journal 2010, 3:67
http://www.casesjournal.com/content/3/1/67


for AFB smear and culture should be obtained from
patients with pulmonary symptoms and chest radio-
graphic abnormalities. .....A positive AFB smear result in
any specimen (sputum, needle aspirate, tissue biopsy)
represents some form of mycobacterial disease but does
not always represent TB. Because TB is the most viru-
lent mycobacterial pathogen and can be spread from
person to person, patients with smear-positive results
should be considered to have TB disease until definitive
mycobacterial species identification is made." [13]
Patients with the diagnosis of tuberculous osteomyeli-
tis should be treated with anti-tubercular multi-drug
therapy. First line treatment commonly includes isonia-
zid, vitamin B6, rifampin, ethambutol and pyrazinamide.
Final therapy should always be based on the susceptibil-
ities of the Mycobacterium tuberculosis isolated. Other
second line agents include aminoglycosides, and quino-
lones [[1,6,11] and [14]].
The duration of treatment may vary from 6 months to
12 months. Patients may need up to 12 months or an
even longer course of therapy based on the clinical
response. The CDC recommends a 6- to 9-month regi-
men (2 months of INH, RIF, PZA, and EMB followed
by 4-7 months of INH and RIF) for patients with extra-
pulmonary TB and states that 'for CNS disease and
bone and joint TB, many experts recommend 9-12
months' [13] The World Health Organization (WHO)
guidelines also endorse a 6-9 month regimen of anti-
tuberculous therapy [14]. Surgery is rarely indicated in
early cases. Radical debridement is only indicated in
advanced disease, or if there is no improvement on
medical therapy. Patients that develop significant joint
involvement may need arthrodesis or total joint arthro-
plasty [[1,6,11], and [13]].

Conclusion
Diagnosis of Mycobacterium tuberculosis osteomyelitis
requires high degree of clinical suspicion for accurate
and timely diagnosis. Tuberculous osteomyelitis should
be considered in the differential in patients with persis-
tent or recurrent skin and soft tissue infections, espe-
cially in patients with risk factors of immunosuppression
or a positive tuberculin skin test.

Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.


Author details
infectious Diseases Division, University of Florida College of Medicine-
Jacksonville, Florida, USA 2Disease Control Division, Duval County Health


Department, Jacksonville, Florida, USA Department of Pathology, University
of Florida College of Medicine, Jacksonville, Florida, USA

Authors' contributions
SM drafted the manuscript and participated in the management of this case
LM participated in the management of this case in the inpatient and
outpatient setting and edited and revised the manuscript NG participated in
editing the manuscript MR participated in the management of this case YM
participated in performing the laboratory diagnostic assays All authors read
and approved the final manuscript

Competing interests
The authors declare that they have no competing interests

Received: 14 October 2009 Accepted: 23 February 2010
Published: 23 February 2010

References
SWatts HG, Lifeso RM' Current Concepts Review Tuberculosis of Bones
and Joints. Journal of Bone and Joint Surgery 1996, 78-A(2)'288
2 Goodman PC Tuberculosis and AIDS. Radio Clin North Am 1995,
33707-17
3 Walker GF' Failure of early recognition of skeletal tuberculosis. Bnt Med J
1968, 1 682-3
4 Vohra R, Kang HS, Dogra S, Saggar RR, Sharma R Tuberculous
osteomyelitis. J Bone Joint Surg Br 1997, 79562-6
5 Vallejo JG, Ong LT, Starke JR Tuberculous osteomyelitis of the long bones
in children. Pediatr infect Dis J 1995, 14524-6
6 Agarwal S, Caplivski D, Bottone EJ Disseminated tuberculosis presenting
with finger swelling in a Patient with tuberculous osteomyelitis: a case
report. Ann Cln Microbiol Antimicrob 2005, 4'18
7 Glassroth J Diagnosis of tuberculosis. Tuberculosis A Comprehensive
International Approach New York, Marcel DekkerReichman LB, Hershfield ES
1993, 149-165
8 Abdeleahad IF, Bianchi S, Martinoli C, Klein M, Hermann G Atypical extra
spinal musculoskeletal tuberculosis in immunocompetent patients, a
review. Part 1: Atypical osteoarticualr tuberculosis and tuberculous
osteomyelitis. Can Assoc Radiol J 2006, 57(2)'86-94
9 Tripathi AK Gupta N, Khanna M, Ahmad R, Tripathi P Tuberculosis
presenting as osteolytic soft tissue swellings of skull in HIV positive
patient: a case report. Indian J Tuberc 2007, 54193-195
10 Fisk TL, Hon HM, Lennox IL, et a/ Detection of latent tuberculosis among
HIV infected patients after initiation of highly active anti-retroviral
therapy. AIDS 2003, 121102-1004
11 Vaughan KD Extra spinal osteoarticular osteomyelitis A forgotten entity?
West Indian Med J 2005, 54(3) 202
12 Yuen MC, Tung WK An uncommon cause of foot ulcer: tuberculous
osteomyelitis. Emerg Med J 2001, 18140-141
13 CDC Guidelines for Prevention and Treatment of Opportunistic
Infections In HIV- Infected Adults and Adolescents. MMWR 2009, 58'1-198
14 WHO/CDS/TB/2003.313 Treatment of tuberculosis: guidelines for
national programmes, third edition. Revision approved by STAG. 2004

doi:1 0.1186/1757-1626-3-67
Cite this article as: Mannepalli et al Mycobacterium tuberculosis
osteomyelitis in a patient with human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS): a case report. Cases Journal
2010 3'67


Page 4 of 4




University of Florida Home Page
© 2004 - 2010 University of Florida George A. Smathers Libraries.
All rights reserved.

Acceptable Use, Copyright, and Disclaimer Statement
Last updated October 10, 2010 - - mvs