A 50-year-old female from low socioeconomic background presented at Lok Nayak Hospital, New Delhi, India in 2011 with complaints of a dull aching suprapubic pain for the past six weeks. The pain was persistent throughout the day and increased further on standing and walking. Patient also had a history of low grade evening rise in temperature and weight loss of 8 kg since three months. There was no history suggestive of any trauma, athletic exertion, infection or surgical procedure in the patient. There was no history of tuberculosis in self or in contact with patient with tuberculosis. On examination, deep tenderness was localized to pubic symphysis. There was no localized swelling and palpation did not reveal any inguinal lymphadenopathy. Rectal examination was also normal.
Radiograph of the pubic bones showed bony erosion of the public symphysis [Figure 1]. An initial diagnosis of osteitis pubis was made and the patient was prescribed rest, hot water fomentation and non-steroidal anti-inflammatory drugs (NSAIDS) for three weeks. Patient continued to have pain even after six weeks of treatment. Laboratory tests done on follow-up revealed moderately increased white cell counts (14,300/mm3, Normal range: 4000-11000) and raised Erythrocyte Sedimentation Rate (54 mm/hr, Normal: <20 mm/hr). Mantoux test was non-conclusive. Chest radiographs were normal. MRI (Magnetic resonance imaging)/CT (computed tomography) scan of pelvis could not be done due to financial reasons, and so a decision was taken to do fine needle aspiration cytology (FNAC) from the affected region. Fine needle aspiration (FNA) from the pubic symphysis showed epithelioid cell clusters admixed with histiocytes in a background of caseous necrosis. In our case, patient had no active cough and no symptoms/sign of active TB and so no smear was taken. Based on these findings a diagnosis of tuberculosis of symphysis pubis was made and patient was started on multi drug anti-tubercular chemotherapy comprising of Rifampicin, Isoniazid, Ethambutol and Pyrazinamide. One month following the treatment, patient improved symptomatically and started to gain weight. Patient was kept on anti- tuberculous therapy for 12 months. A repeat radiograph did not show signs of progression. Finally, follow up after 12 months of chemotherapy, the patient was symptom-free with a normal activity level without any signs of recurrence.