Extrapulmonary Tuberculosis Mimicking an Iliac Bone Lytic Lesion: A Case Report

TL;DR

A case of tuberculosis mimicking a bone lesion in a Sudanese man shows the importance of considering TB in lytic bone lesions, even without positive cultures.

Contribution

Highlights the diagnostic value of histopathology and clinical response in TB diagnosis when cultures are negative.

Findings

The patient showed improvement with anti-TB therapy despite negative cultures.

Histopathological evidence of granulomas supported a TB diagnosis.

TB should be considered in lytic bone lesions in patients from endemic regions.

Abstract

Lytic bone lesions pose significant diagnostic challenges due to their varied causes, ranging from malignancies to infections and benign conditions. Tuberculous osteomyelitis, though rare in non-endemic regions, remains an important consideration, particularly in patients from high-burden areas. A 35-year-old Sudanese male with a family history of tuberculosis (TB) presented with chronic left iliac pain that did not respond to nonsteroidal anti-inflammatory drugs (NSAIDs). Imaging revealed an expansile lytic lesion with cortical breaching, initially raising suspicion for malignancy. However, a biopsy showed necrotizing granulomatous osteomyelitis, though cultures - including those for Mycobacterium tuberculosis - were negative. Despite the lack of microbiological confirmation, the patient showed clinical and radiological improvement after starting empirical anti-TB therapy. This case highlights the need to consider tuberculous osteomyelitis in the differential diagnosis of lytic bone lesions, even in the absence of positive cultures, especially in individuals from endemic regions. Histopathological evidence of granulomas and a positive response to anti-TB therapy can support the diagnosis when microbiological tests are inconclusive. Greater awareness of this possibility is essential to prevent delays in treatment and unnecessary invasive procedures.

Figures