A 77-year-old African American female with hypertension and rheumatoid arthritis on chronic prednisone therapy presented to the hospital with fever, weakness, and unsteady gait. The patient had a history of latent tuberculosis infection reportedly treated over 15 years ago, and abdominal lymphadenopathy with granulomatous histology of unknown etiology three years ago. Laboratory testing showed normal hemoglobin, elevated leukocyte count of 35,000 cells/muL, and normal C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Her liver and kidney function were normal, and electrolytes were within normal limits. Physical examination revealed high fever and limited left hip mobility due to weakness and pain. Computed tomography of the hip joint revealed progressive destruction of her sacroiliac joint and a 10 x 8 x 7-centimeter (cm) fluid collection in front of her left iliopsoas muscle (Fig. 1, Fig. 2). A presumptive diagnosis of pyogenic sacroiliitis and psoas abscess were made and the patient was placed on broad-spectrum antimicrobials.
The patient underwent saucerization and partial excision of her left ilium and sacrum, surgical placement of antimicrobial beads, and drainage of the psoas abscess. Biopsy from the bone and drainage from the psoas abscess were also sent for further evaluation. The bone biopsy revealed ill-defined granulomas and the gram stain, AFB stain, GMS stain. and bacterial cultures of the psoas drainage were negative. Samples were sent for tuberculosis and fungal cultures. One out of four blood culture bottles grew Enterococcus faecalis sensitive to ampicillin. Given that all other testing was negative, the patient was sent to a nursing home with intravenous ampicillin therapy for a six-week course. Two days after completing treatment, the patient presented to the hospital again with recurrence of symptoms especially with nightly high fevers and weakness. Laboratory findings were only significant for an elevated WBC of 12,000 cells/muL. CT revealed healing sacroiliitis, no obvious new abscess, and post-surgical placement of antimicrobial beads (Fig. 3). Initial consideration was incomplete treatment given the timing of the symptoms after cessation of antimicrobials; however, the previous AFB culture coincidentally was found to be positive in the seventh week, and TB was confirmed by PCR from the culture positive samples. During the initial encounter,the patient underwent a CXR as a routine work up which didn't show any infiltrates; however during further work up after the AFB culture, a CXR was repeated and revealed new right upper lobe infiltrates suggestive of pulmonary tuberculosis (Fig. 4).
The patient did not present with respiratory symptoms; however, she was placed in respiratory isolation and sputum was tested for AFB. She was started on rifampin, isoniazid, pyrazinamide and ethambutol (RIPE) therapy, with the addition of moxifloxacin to also cover for multi-drug resistant tuberculosis (MDR-TB). The patient's fever subsided after one week of treatment, and after two weeks of treatment she markedly improved and had negative AFB smear and PCR on induced sputum. She was released from isolation precautions and discharged with follow up with the public health department. At the time of discharge, the patient exhibited functional decline and deconditioning due to prolonged hospital stay as well as chronic debilitating illness. She was assessed by physical therapy using Barthel Index score which is a measurement of activities of daily living and revealed a value of 45 points and partially independent. She was placed in a sub-acute rehabilitation facility after inpatient hospital discharge.