Isolated tuberculosis of the vastus lateralis muscle: A case report

VIVEK TRIKHA, MANISH KUMAR VARSHNEY & SHISHIR RASTOGI

From the Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India

AbstractTuberculosis is 1 of the most deadly diseases in the world. With an increase in the incidence of HIV worldwide, tubercularinfections at unusual sites are being reported. Skeletal muscle tuberculosis without bony involvement is an extremely rarepresentation of tuberculosis. A case of isolated tuberculosis of the vastus lateralis muscle without any evident primary focusin a 30-y-old immunocompetent female is presented.

Introduction

Tuberculosis remains a feared disease of mankind

even in the 21st century. Musculoskeletal tubercu-

losis accounts for nearly 3% of all cases of

tuberculosis [1]. Tuberculosis of skeletal muscle

without coexisting skeletal lesion is extremely rare

with only few cases existing in English literature

[2�/8]. Most of these cases have been reported in

patients in an immunocompromized state or having

chronic illness. We report a rare case of tuberculosis

of the vastus lateralis muscle in an immunocompe-

tent female without any primary or contiguous

source of infection or any history of antibiotic

therapy.

Case report

A 30-y-old female presented with progressively

increasing swelling in the lateral aspect of distal right

thigh for the previous 4 months along with pain for

the last week. There was no history of trauma,

injection/ inoculation at the local site, intravenous

drug abuse or any blood transfusion. On examina-

tion a tender, firm mass of the size of small lemon

fixed to the underlying muscle of the distal lateral

thigh was found. There was no local redness or

warmth. The movements at knee and hip were full

with painful terminal flexion at the knee joint. No

associated inguinal lymphadenopathy or discharging

sinus was noted. There was no history of any

infectious condition or previous antibiotic therapy

in the previous 6 months. Her past medical and

surgical history was non-contributory with no family

history of tuberculosis or any history of contact.

CBC was normal with ESR being 24 mm/1st hour.

Radiographs of chest, knee joint including femur and

tibia were normal. Ultrasound revealed an oval

hypoechoic mass seen on lateral aspect of distal

left thigh with homogenous internal architecture

with associated adjacent muscle heterogenecity and

oedema (Figure 1), which was suggestive of infective

abscess or a parasitic cyst. Magnetic resonance

imaging (MRI) with multiple pulse sequences of

T1 and T2 relaxation demonstrated soft tissue

intensity lesion and areas of liquefaction and necrosis

on a localized area of lower thigh in the region of the

lower part of the vastus lateralis muscle without any

osseous or joint involvement. The size of lesion was

approx. 48 mm x 34 mm (Figure 2).

Drainage of the abscess was performed and the

tissue obtained was sent for bacterial, fungal and

AFB staining along with examination for parasite,

which all reported negative. The histopathological

examination revealed the presence of necrotizing

epithelioid granulomas compatible with tuberculo-

sis. The radiometric AFB culture report for tuber-

cular pathogen was positive. Myco-3 DNA PCR

identified the species to be Mycobacterium tubercu-

losis . The patient was started on standard multi-

drug anti-tubercular therapy (ATT) with 4 drugs

(EHRZ) for an initial 3 months followed by 2 drugs

(RH) alone for next 9 months. The swelling

disappeared after drainage and there was no pain

at the local site. Two years later, the patient remains

asymptomatic with pain-free full movements at the

knee.

Discussion

Tuberculosis has staged a remarkable comeback

today following HIV infected cases. Around 8.8

million new cases of tuberculosis were diagnosed

in 2003 and there were 1.7 million deaths making

it 1 of the largest killers [9]. Unusual presentations

of tuberculosis are being increasingly diagnosed in

both immunocompromized and immunocompetent

hosts. Soft tissue infection, defined as the involve-

Correspondence: V. Trikha, L-381, Sarita Vihar, New Delhi 110076, India. Tel: �/91 11 26951052. E-mail: vivektrikha@rediffmail.com

304 Case Reports

(Received 19 August 2005; accepted 22 August 2005)

ISSN 0036-5548 print/ISSN 1651-1980 online # 2006 Taylor & Francis

DOI: 10.1080/00365540500353267

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ment of tenosynovium, bursa, muscle or deep fascia,

is an uncommon form of musculoskeletal tuber-

culosis [6]. It is usually associated with immunosup-

pressed patients.

There are very few reports in the English literature

of primary muscular tuberculosis without any in-

volvement of bone or in immunocompetent patients,

and its manifestations may mimic malignant or other

inflammatory diseases, leading to a faulty diagnosis

[2�/8]. Petter [10] recorded only 1 case of primary

muscular tuberculosis in over 6000 cases of all types

of tuberculosis giving an incidence of 0.015%.

Hence, as such isolated primary skeletal tuberculosis

without any associated involvement of the adjacent

bone or viscera is considered only a diagnosis of

exclusion over a soft tissue tumour or a pyogenic

abscess.

It is of interest to note that most of the reported

cases of extra-osseous muscular tuberculosis have

been reported adjacent to the joints or bursae

[2,6,7,10] or in immunocompromized individuals

[10,11]. The natural history of muscles primarily

involved in the disease process remains elusive [12];

however, extension from adjacent joint, bone, bur-

sae, tenosynovium and even direct inoculation have

all been proposed [2]. The primary focus subse-

quently heals leaving the evident infection in the

muscle. The exact cause of the tuberculous abscess

in our case remains unclear. The involvement of the

vastus lateralis in the presented case could be

ascribed to haematogenous spread or by extension

from nearby bursae. Haematogenous spread may

seem likely, as the prevalence of tuberculosis is fairly

high in our region, with nearly 40% of the total

population being infected with tubercle bacilli in

1 form or another. However, primary haematogen-

ous spread to muscles is an unlikely proposition

owing to previously presented reasons [12]. The

possibility of the infection arising in the adjacent

bursae around the knee and then becoming localized

to the vastus lateralis muscle hence appears to be the

more likely cause. This gains credence in the

presence of nearly 13 bursae around the knee

joint and absence of any adjacent skeletal involve-

ment or previous history of pulmonary or other

form of tuberculosis, or any history of trauma or

direct inoculation.

In the present world, an atypical presentation of

tuberculosis is on the increase. The ongoing pan-

demic of HIV/AIDS further contributes to the ever-

increasing incidence of this disease. The once

forbidden tissues/organs for tuberculosis are no

longer immune from the vagaries of atypical tuber-

culosis. All physicians should have adequate knowl-

edge of tuberculosis and awareness of its atypical

Figure 2. MRI shows altered signal intensity in soft tissue in

lateral aspect of the lower part of the left femur, involving the

vastus lateralis muscle. These appear hyperintense on T2/STIR

and hypointense on T1W images. A few areas of liquefactive

necrosis are also seen within the lesion. No osseous involvement is

seen. Visualized parts of lower femur/patella, upper tibia are

normal

Figure 1. Ultrasound of the distal thigh reveals a hypoechoic

region in the lateral muscle group of the thigh with homogenous

internal architecture. The possibilities of infective lesion or

parasitic cyst can be made on the ultrasound.

Case Reports 305

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presentations to ensure proper management of such

patients.

References

[1] Enarson DA, Fujii M, Nakielna EM, Grzybowski S. Bone

and joint tuberculosis: a continuing problem. Can Med

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[2] Abdelwahab IF, Kenan S. Tuberculous abscess of the

brachialis and biceps brachii muscles without osseous

involvement. A case report. J Bone Joint Surg Am 1998;/80:/

1521�/4.

[3] Abu-Salem OT. Tuberculous abscesses of the quadriceps

femoris muscle without osseous involvement. East Mediterr

Health J 2000;/6:/1136�/8.

[4] Bakshi G, Satish R, Shetty SV, Anjana J. Primary skeletal

muscle tuberculosis. Orthopedics 2003;/26:/327�/8.

[5] Haycock JB, Noble TC. Four cases of syringe-transmitted

tuberculosis. Tubercle 1961;/42:/25�/7.

[6] Puttick MPE, Stein HB, Chan RMT, Elwood RK, How AR,

Reid GD. Soft tissue tuberculosis: a series of 11 cases.

J Rheumatol 1995;/22:/1321�/5.

[7] Seber S, Kose N. Tuberculous abscess of the brachialis and

biceps brachii muscles without osseous involvement. A case

report. J Bone Joint Surg Am 1999;/81:/1788.

[8] Trikha V, Gupta V. Isolated tuberculous abscess in biceps

brachii muscle of a young male. J Infect 2002;/44:/265�/6.

[9] Global tuberculosis control: surveillance, planning, finan-

cing. WHO report 2005. Geneva, World Health Organiza-

tion (WHO/HTM/TB/2005.349)

[10] Petter CK. Some thoughts on tuberculosis of fascia and

muscle. Lancet 1937;/57:/156�/9.

[11] Wang JY, Lee LN, Hsueh PR, Shih JY, Chang YL, Yang PC,

Lu KT. Tuberculous myositis: a rare but existing clinical

entity. Rheumatology 2003;/42:/836�/40.

[12] Gahlaut DS, Nath K, Sikka KK, Singh KN, Samuel KC.

Generalized skeletal muscle tuberculosis. J Indian Med

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Severe disseminated tuberculosis in a 4-month-old infant initiallypresenting with multiform cutaneous lesions

NIKOS SPYRIDIS1,2, HELENI GEORGOULI2, THEANO TSOUKATOU2, IRINI SAKOU2,

MARIA TSOLIA2, NIKOS MIRIOKEFALITAKIS2 & PANAYIOTIS SPYRIDIS2

From the 1Department of General Paediatrics, St Thomas’ Hospital, London, UK, and 2Second Department of Paediatrics of

the University of Athens, TB Clinic for Children, Aglaia Kyriakou Children’s Hospital, Athens, Greece

AbstractA 4-month-old female infant presented with 1 month history of horizontal nystagmus and discrete multiform skin lesions.The patient was initially diagnosed with congenital nystagmus and staphylococcal skin infection not responding toantimicrobial agents. The development of severe systemic symptoms led to extensive investigations and the diagnosis ofdisseminated tuberculosis. Mycobacterium tuberculosis (MTB) was isolated from the skin and cerebrospinal fluid. Thepatient was treated with isoniazid, rifampicin, pyrizinamide, streptomycin and dexamethasone. Skin lesions resolvedcompletely but severe neurological deficits persisted.

Case report

A 4-month old female infant born in Athens

of Sudanese parents presented with a 1- month

history of horizontal nystagmus and multiform skin

lesions involving the entire body. She was born at 40

weeks gestation after an uncomplicated pregnancy,

labour and delivery. The baby had not received

any vaccination and no other significant past medical

or family history was noted. Skin lesions were

initially popular, then vesicular with serous fluid

production and were diagnosed as staphylococcal

skin infection by the local hospital. She was also

seen by a paediatric ophthalmologist who considered

the nystagmus to be congenital and a follow-

up appointment was offered. Two weeks after

the initiation of anti-staphylococcal treatment no

significant improvement was noticed and a second

course was given. The development of more

systemic symptoms led to the referral to our

clinic.

Correspondence: N. Spyridis, 46 St Petersburgh Place, London W2 4LD, UK. Tel: �/00 44 2072290898. E-mail: niksp@netbreeze.co.uk

306 Case Reports

(Received 10 July 2005; accepted 9 August 2005)

ISSN 0036-5548 print/ISSN 1651-1980 online # 2006 Taylor & Francis

DOI: 10.1080/00365540500361310

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