You are on page 1of 4

Primary Tubercular Abscess of Thigh in an Immunocompetent Individual

Paras Kathuria*, Naresh Kumar*, Mukesh Kumar**, Gaurav S Pradhan***

Primary tuberculous muscular abscess is a rare manifestation of
musculoskeletal tuberculosis especially in an immunocompetent individual. It
can cause a diagnostic dilemma for a physician or surgeon because of its
presentation similar to pyogenic abscess, hematomas and soft tissue sarcomas.
We present a case of a 19 year old immunocompetent boy who presented with
short duration of fever and swelling in the left thigh. Investigations revealed
the cause of intramuscular abscess in vastus lateralis as tuberculosis. Patient
improved after antitubercular therapy.

Keywords: Tubercular abscess, Vastus lateralis, Immunocompetent,


Tuberculosis affects a significant percentage of the intra-muscular injection or trauma at the affected
world's population and musculoskeletal site. Patient did not give any history suggestive of
tuberculosis constitutes only 3% of all cases.1 diabetes, immunosuppression or any long term
Skeletal muscle tuberculosis is a rare entity in systemic illness in the past. He specifically denied
itself because muscle is an unfavorable site for any history of respiratory complaints and close
survival and multiplication of Mycobacterium contact with tuberculosis. On examination, he was
tuberculosis.2 It is usually misdiagnosed as febrile with respiratory rate of 16/min and heart
pyogenic abscess, tumor or hematoma because of rate of 110 beats/min. There was no pallor or
its nonspecific clinical features. Tuberculosis lymphadenopathy. Examination of local area
involves skeletal muscles by extension from bone, revealed a diffuse swelling over left thigh along
synovial lining of joints or tendon sheaths or by with redness and tenderness. Examination of hip
hematogenous dissemination and rarely by direct and knee was normal on both the sides. There was
inoculation.3 However, primary muscular no spinal tenderness, deformity or any para-spinal
involvement by tuberculosis without osseous swelling. Rest of the systemic examination was
involvement is rare. We present a case of primary within normal limits. Blood investigations
intramuscular tubercular abscess of the left thigh revealed neutrophilic leukocytosis with TLC of
with no underlying bony lesion. 24,000 and 92% polymorphs and ESR of
68mm/hour. Blood culture was sterile. Chest X-
Case Report ray and USG abdomen were normal. USG of left
thigh revealed a large heterogeneous collection
A 19 year old, well built boy, resident of Delhi, over left thigh mainly along the intramuscular
presented with complaints of high grade fever, planes with septations. X-rays of dorsolumbar
pain and gradually progressive swelling in left spines and bilateral hip joints were normal (fig. 1).
thigh since last 10 days. There was no history of

Department of Medicine, Maulana Azad Medical College & associated Lok Nayak Hospital, New Delhi.
Department of Microbiology, Sardar Patel Medical College, Bikaner, Rajasthan.
Department of Radiodiagnosis, Maulana Azad Medical College, & associated Lok Nayak Hospital, New Delhi.
Correspondence to: Dr. Naresh Kumar, Associate Professor of Medicine, 16/554, Joshi Road, Karol Bagh, New Delhi-
E-mail Id:

© ADR Journals 2015. All Rights Reserved.

11 Kathuria P et al.

Figure 1.X-ray left hip joint: Showing normal joint and the underlying bone

In view of short presentation with fever and walled collection predominantly within vastus
swelling of thigh, provisional diagnosis of lateralis which was hypointense on T1W image
pyogenic muscular abscess was made and patient and hyperintense on T2W images along with
was started on broad spectrum antibiotics. MRI surrounding muscles also showing edematous
revealed 18x7x3 cm large heterogeneous thick- changes (Figures 2&3).

Figure 2.A Coronal section of Lt. thigh on MRI: Collection noted in Lt. Vastus lateralis with thick
enhancing walls with presence of loculations on postgado images. Underlying marrow (femoral shaft) is
normal in signal intensity.

J. Adv. Res. Med. 2015; 2(2): 10-13. ISSN: 2349-7181

Kathuria P et al. 12

Figure 3.An Axial section of Lt. Thigh on MRI showing the collection in vastus lateralis with normal
underlying bone intensity

Right femur muscles and bilateral hip joints and but then it usually involves a single large muscle
spines showed normal morphology and signal with quadriceps femoris being the most common
pattern. Patient did not respond at all after three muscle.6
days of antibiotic therapy. Abscess was drained
and the cytological examination revealed mainly Pathogenesis of tubercular pyomyositis is still not
necrosis. Pus culture was sterile for pyogenic clear. Tubercular pyomyositis is usually caused by
organism and AFB stain was also negative. invasion from the adjacent structures e.g.,
Mantoux test was also negative. However, TB underlying bone, tendon sheaths of adjoining
PCR from the aspirated pus came out to be joints rather than as primary infection or by
positive and then patient was started on 4 drug hematogenous spread from a distant primary
Anti Tubercular therapy (ATT) (HRZE). Patient lesion.7 In a series, it was observed that tubercular
started improving after initiating ATT and after 2 myositis occurred due to contiguous spread in
months his swelling completely regressed. His more than 60% of patients, hematogenous spread
ATT was modified to 2 drug regimen and was in approximately 30% cases and 8% of cases were
given for a year in total. He did well with the anti- due to direct inoculation.1 We could not find any
tubercular therapy alone. adjoining or distant focus of tuberculosis in our
case. The underlying bony structure was normal in
Discussion our case as there was no marrow edema or
periosteal reaction on MRI and radiographs. The
Musculoskeletal tuberculosis occurs in 3% cases pyomyositis typically progresses in three stages.8
of all tuberculosis and presents mainly as arthritis, However, tubercular pyomyositis does not follow
osteomyelitis and spondylitis.1 Pyomyositis those classical three stages of pyogenic
usually describes bacterial infection of skeletal pyomyositis.7 Also, tubercular bacilli do not
muscles with formation of abscess within it.2 produce any proteolytic enzymes, so it is not a
Infection of muscle with tubercular bacilli is pyogenic infection.2
extremely rare with reported incidence of 0.15-2%
Pyomyositis typically presents with fever and pain
of extra- pulmonary tuberculosis.4 The possible
localized to a muscle group. Clinical features of
reasons for the resistance of skeletal muscles to
tubercular abscesses are generally nonspecific.
tubercular infections include poor oxygen content,
Typical constitutional symptoms like fever, weight
high lactic acid concentration and paucity of
loss, and loss of appetite may not be seen in many
reticuloendothelial cells in it.2 Tubercular myositis
cases and hence this can often be misdiagnosed as
is generally seen in immunocompromised
sarcoma, parasitic infection or hematoma with
individuals although few cases have been reported
secondary infection.7 Usually, the presentation of
in immunocompetent patients as well.5,6 Thigh
tubercular pyomyositis is subacute or chronic, but
muscles are rarely involved by tubercular bacilli
in our case, the presentation was more acute like

SSN: 2349-7181 J. Adv. Res. Med. 2015; 2(2): 10-13.

13 Kathuria P et al.

that of a pyogenic infection. So, high index of diagnosis and treatment with ATT may alleviate
clinical suspicion in an endemic country like India the need for surgical interventions and the
is the key to the early diagnosis. prognosis is good.

Work- up of the patients include blood parameters References

which may exclude other causes and the only
consistent finding in tuberculosis may be 1. Wang JY, Lee LN, Hsueh PR et al.
increased ESR. Other features may be anemia, Tuberculous myositis: a rare but existing
leukocytosis and increased creatine phosphokinase clinical entity. Rheumatology 2003; 42(7):
(CPK) levels. Tuberculin test may guide in 836-40.
making diagnosis but it is not always positive. 2. Sen RK, Tripathy SK, Dhatt S. Primary
Initial radiological work- up includes X-ray of tuberculous pyomyositis of forearm
local part, CT scan and MR imaging which can muscles. Indian Journal of Tuberculosis 2010;
detect the underlying bony pathology, if present. 57: 34-40.
MR imaging is more accurate in evaluation of 3. Abdelwahab IF, Bianchi S, Martinoli C et al.
loco- regional extension of pyomyositis.9 MRI, Atypical extraspinal musculoskeletal
especially with gadolinium enhancement, is very tuberculosis in immunocompetent patients,
helpful in diagnosis as it can differentiate between tuberculous myositis, tuberculous bursitis, and
tubercular and pyogenic abscess.10 Diagnosis is tuberculous tenosynovites. Canadian Assoc-
usually confirmed by tissue diagnosis. Needle iation of Radiologists Journal 2006; 57: 278-
aspiration from the lesion shows necrosis with or 86.
without granuloma. Yield of AFB is not so high in
4. Modi MA, Mate AD, Nasta AM. Primary
these cases. Incisional biopsy may be helpful if
Tuberculous Pyomyositis of Quadriceps
needle aspiration fails to establish the diagnosis.
Femoris in an Immunocompetent Individual.
Polymerase chain reaction (PCR), a very sensitive
Case Reports in Infectious Diseases
test, is a tool for rapid confirmation of diagnosis.
2013; 723879.
However, biopsy and culture may further confirm
the diagnosis.8 Once soft tissue tuberculosis is 5. Bhatty SM, Prakash JS, John B. Primary
diagnosed, a thorough evaluation must be done to tuberculous abscess of vastus lateralis muscle.
diagnose the primary focus of infection.2 JK Science 2011; 13(1): 37-38.
However, there may not always be a primary focus 6. Simon SP, Fodor D, Valasciuc R et al. A rare
in all cases as we could not find any other focus of case of primary tuberculous pyomyositis.
tuberculosis in our patient. All cases of tubercular Case report. Medical Ultrasonography 2011;
pyomyositis have to be treated with multidrug 13: 245-48.
antitubercular therapy (ATT). Surgical 7. Narang S. Tuberculous pyomyositis of
debridement may be necessary in patients not forearm muscles. Hand 2009; 4(1): 88-91.
responding to chemotherapy alone. Other 8. Krishnasamy V, Joseph M. Tuberculous
conditions where surgical option has to be used pyomyositis: A Rare but serious diagnosis.
include presentation as rapidly enlarging painful Case Report Med 2013: 126952.
mass lesion (causing compartment- syndrome like 9. Batra S, Naell MA, Barwick C et al.
condition); recurrence after aspiration or Tuberculous pyomyositis of the thigh
debridement; associated bony destruction and masquerading as malignancy with
sequestrum formation.7 concomitant tuberculous flexor tenosynovitis
and dactylitis of the hand. Singapore Medical
In conclusion, tubercular myositis should be Journal 2007; 48: 1042-46.
considered as one of the differential diagnosis in 10. Kim JY, Park YH, Choi KH. MRI of
patients presenting with a muscular or soft tissue tuberculous pyomyositis. Journal of Computer
swelling in an endemic country like India. Early Assisted Tomography 1999; 23: 454-57.

J. Adv. Res. Med. 2015; 2(2): 10-13. ISSN: 2349-7181