Primary Tubercular Abscess of Thigh in an Immunocompetent Individual

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

Abstract
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,

Pyomyositis.

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

*
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-
110005.
E-mail Id: drnareshmamc@gmail.com

© 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
swelling of thigh, provisional diagnosis of
pyogenic muscular abscess was made and patient
was started on broad spectrum antibiotics. MRI
revealed 18x7x3 cm large heterogeneous thick-
walled collection predominantly within vastus
lateralis which was hypointense on T1W image
and hyperintense on T2W images along with
surrounding muscles also showing edematous
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.
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
spines showed normal morphology and signal
pattern. Patient did not respond at all after three
days of antibiotic therapy. Abscess was drained
and the cytological examination revealed mainly
necrosis. Pus culture was sterile for pyogenic
organism and AFB stain was also negative.
Mantoux test was also negative. However, TB
PCR from the aspirated pus came out to be
positive and then patient was started on 4 drug
Anti Tubercular therapy (ATT) (HRZE). Patient
started improving after initiating ATT and after 2
months his swelling completely regressed. His
ATT was modified to 2 drug regimen and was
given for a year in total. He did well with the anti-
tubercular therapy alone.
Discussion
Musculoskeletal tuberculosis occurs in 3% cases
of all tuberculosis and presents mainly as arthritis,
osteomyelitis and spondylitis.1 Pyomyositis
usually describes bacterial infection of skeletal
muscles with formation of abscess within it.2
Infection of muscle with tubercular bacilli is
extremely rare with reported incidence of 0.15-2%
of extra- pulmonary tuberculosis.4 The possible
reasons for the resistance of skeletal muscles to
tubercular infections include poor oxygen content,
high lactic acid concentration and paucity of
reticuloendothelial cells in it.2 Tubercular myositis
is generally seen in immunocompromised
individuals although few cases have been reported
in immunocompetent patients as well.5,6 Thigh
muscles are rarely involved by tubercular bacilli
SSN: 2349-7181
12
but then it usually involves a single large muscle
with quadriceps femoris being the most common
muscle.6
Pathogenesis of tubercular pyomyositis is still not
clear. Tubercular pyomyositis is usually caused by
invasion from the adjacent structures e.g.,
underlying bone, tendon sheaths of adjoining
joints rather than as primary infection or by
hematogenous spread from a distant primary
lesion.7 In a series, it was observed that tubercular
myositis occurred due to contiguous spread in
more than 60% of patients, hematogenous spread
in approximately 30% cases and 8% of cases were
due to direct inoculation.1 We could not find any
adjoining or distant focus of tuberculosis in our
case. The underlying bony structure was normal in
our case as there was no marrow edema or
periosteal reaction on MRI and radiographs. The
pyomyositis typically progresses in three stages.8
However, tubercular pyomyositis does not follow
those classical three stages of pyogenic
pyomyositis.7 Also, tubercular bacilli do not
produce any proteolytic enzymes, so it is not a
pyogenic infection.2
Pyomyositis typically presents with fever and pain
localized to a muscle group. Clinical features of
tubercular abscesses are generally nonspecific.
Typical constitutional symptoms like fever, weight
loss, and loss of appetite may not be seen in many
cases and hence this can often be misdiagnosed as
sarcoma, parasitic infection or hematoma with
secondary infection.7 Usually, the presentation of
tubercular pyomyositis is subacute or chronic, but
in our case, the presentation was more acute like
J. Adv. Res. Med. 2015; 2(2): 10-13.
13
that of a pyogenic infection. So, high index of
clinical suspicion in an endemic country like India
is the key to the early diagnosis.
Work- up of the patients include blood parameters
which may exclude other causes and the only
consistent finding in tuberculosis may be
increased ESR. Other features may be anemia,
leukocytosis and increased creatine phosphokinase
(CPK) levels. Tuberculin test may guide in
making diagnosis but it is not always positive.
Initial radiological work- up includes X-ray of
local part, CT scan and MR imaging which can
detect the underlying bony pathology, if present.
MR imaging is more accurate in evaluation of
loco- regional extension of pyomyositis.9 MRI,
especially with gadolinium enhancement, is very
helpful in diagnosis as it can differentiate between
tubercular and pyogenic abscess.10 Diagnosis is
usually confirmed by tissue diagnosis. Needle
aspiration from the lesion shows necrosis with or
without granuloma. Yield of AFB is not so high in
these cases. Incisional biopsy may be helpful if
needle aspiration fails to establish the diagnosis.
Polymerase chain reaction (PCR), a very sensitive
test, is a tool for rapid confirmation of diagnosis.
However, biopsy and culture may further confirm
the diagnosis.8 Once soft tissue tuberculosis is
diagnosed, a thorough evaluation must be done to
diagnose the primary focus of infection.2
However, there may not always be a primary focus
in all cases as we could not find any other focus of
tuberculosis in our patient. All cases of tubercular
pyomyositis have to be treated with multidrug
antitubercular therapy (ATT). Surgical
debridement may be necessary in patients not
responding to chemotherapy alone. Other
conditions where surgical option has to be used
include presentation as rapidly enlarging painful
mass lesion (causing compartment- syndrome like
condition); recurrence after aspiration or
debridement; associated bony destruction and
sequestrum formation.7
In conclusion, tubercular myositis should be
considered as one of the differential diagnosis in
patients presenting with a muscular or soft tissue
swelling in an endemic country like India. Early
J. Adv. Res. Med. 2015; 2(2): 10-13.
Kathuria P et al.
diagnosis and treatment with ATT may alleviate
the need for surgical interventions and the
prognosis is good.
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