A 29-year-old woman, accompanied by her guardian, with a medical history of developmental delay and gastroesophageal reflux disease, presented to the emergency department (ED) for worsening right hip pain. Notably, she emigrated from Eritrea around ten years before this ED visit.
Two years prior to this ED visit, the patient's right SI joint pain was evaluated and admitted. When the patient initially presented, she had a six-week history of worsening right hip and buttock pain, which was concerning for a septic joint. The patient was examined and found to have a negative chest x-ray, an elevated erythrocyte sedimentation rate (ESR) of 44 mm/hr (reference range: 0-20 mm/hr), and a C-reactive protein (CRP) of 1.90 mg/dL (reference range: 0-50 mg/dL). Joint aspiration resulted in 1 cc of pus. However, blood cultures (Gram staining) were negative and did not grow any organisms. As such, the patient was discharged after four weeks of intravenous vancomycin and ceftriaxone. She still had chronic SI joint pain, which she managed with morphine or oxycodone. The patient was then seen by urgent care five months ago, where computed tomography (CT) of the right hip showed an abnormal fluid collection in the right piriformis extending to the right acetabulum and destruction of the SI joint (Figure 1). For that visit, she was recommended Tylenol for the pain and was referred to outpatient orthopedics; however, the patient did not follow up with orthopedics.
On the physical exam, the patient appeared uncomfortable from pain but was alert, oriented, and afebrile. The patient spoke slowly in broken English and had a childlike demeanor. On musculoskeletal examination, her right hip demonstrated swelling and tenderness from the lower buttock to the mid-thigh with a normal range of motion (ROM). She was able to bear weight, ambulate, and show normal sensory and motor exam findings. Labs were significant for low hemoglobin (9.7 g/dL) with a normal WBC count. A CT scan of her right hip and femur with contrast showed numerous rim-enhancing fluid collections about the right hip and thigh, with the largest rim-enhancing fluid collection measuring 11.9 x 8.7 x 22.7 cm along the lateral aspect of the thigh (Figure 2). This collection insinuated superiority between the right gluteus minimus and medius muscles (Figure 2). There were destructive changes on both sides of the right SI joint, similar to the CT scan taken five months prior. Blood cultures were negative after aspiration at the time of the ED visit; then, the ED providers noted a differential diagnosis for sacroiliitis. She was given ketorolac (Toradol) for pain and discharged with an orthopedic outpatient follow-up.
Over the course of the following month, the patient made outpatient visits to orthopedics, interventional radiology, and the ED. She endorsed a 40-pound weight loss over the past five months, further warranting a fluid aspiration and culture procedure in which three fluids were cultured, including two from the right hip and one from the right thigh. A CT of the right hip and femur with contrast taken at the subsequent ED visit approximately three weeks after the presentation showed a large fluid collection at the right hip region (Figure 3). Labs continued to show elevated ESR (66 mm/hr) and CRP (7.10 mg/dL).
Two weeks after the aspiration procedure, acid-fast bacilli cultures grew the Mycobacterium tuberculosis (MTB) complex without rifampin resistance. As such, the patient was seen by an outpatient infectious diseases specialist and was diagnosed with indolent extrapulmonary MTB. A contrast CT of the chest was obtained and revealed no communicable pulmonary MTB. Labs continued to be significant for elevated ESR (102 mm/hr) and CRP (2.78 mg/dL). The patient was not admitted to the hospital due to social issues and her inability to do well with new faces aside from her guardian. The patient was not started on MTB treatment right away due to concerns about drug-drug interactions with rifampin and rifabutin and the large number of pain and psychiatric medications that the patient was taking. These medications were prescribed by an outside psychiatry provider and included alprazolam, aripiprazole (Abilify), divalproex sodium (Depakote), fluphenazine (Prolixin), quetiapine (Seroquel), risperidone, sertraline (Zoloft), and trazodone. Psychiatry was consulted and was not concerned with toxicity; however, they noted the redundancy of medications at low, non-therapeutic doses and recommended their discontinuation. Ten days after the infectious disease visit, the patient was started on quadruple TB therapy of rifampin, isoniazid, pyrazinamide, and ethambutol; the patient was not started on pyridoxine. Per protocol, the patient was to be given intensive quadruple TB therapy for two months and assess the course (a total of six to nine months for treatment) at follow-up visits. The patient has been doing well clinically since this treatment.