A 16-year-old girl first presented to the otolaryngology outpatient clinic at Bagcilar Training and Research Hospital, Istanbul, Turkey, with painless swelling of the neck. She also presented to the physical medicine and rehabilitation clinic with complaints of hip and low back pain that mimicked spondyloarthropathy. She had been treated with nonspecific antibiotics for cervical lymph nodes, but the size of the lymph nodes did not change with this treatment. She was followed for hip and low back pain by the physical medicine and rehabilitation clinic for a while, until she was finally referred to our outpatient pediatric clinic for evaluation of systemic disease. She denied cough, night sweats, or weight loss over the prior two months. She was admitted to the pediatric clinic on May 20, 2014. Her family history revealed that her father had been treated for tuberculosis ten years earlier. The patient did not have any underlying disease. She had a crowded family and their socioeconomic level was low.
On physical examination, the patient was pale, with a temperature of 37.8 C, blood pressure of 120/80 mmHg, and a weight of 45 kg (3 - 10 percentile). Heart and lung auscultation were normal, and the patient had no hepatosplenomegaly. She had a 2 x 2 cm solid, painless lymph node in the right cervical region. Tenderness and limited range of motion were evident on hip joint examination, and a gait disorder was apparent. The laboratory findings were as follows: hemoglobin 10 g/dL; white blood cell count 5,800/mm3; platelets 704.000/mm3; C-reactive protein 104 mg/L; erythrocyte sedimentation rate (ESR) 74 mm/h; uric acid 5.2 mg/dL; and lactate dehydrogenase 192 U/L. Other laboratory data were normal. The Brucella agglutination test was negative and the peripheral smear revealed no pathology.
Cervical ultrasonography showed hypoechoic lymphadenopathy. Hilar lymphadenopathy was seen on chest x-ray (Figure 1). We performed thoracic computed tomography (CT), which revealed a Ghon complex in the right lung and was suspicious for a Pott's abscess. Thoracic magnetic resonance imaging (MRI) confirmed a Pott's abscess involving the T8, T9, and T10 vertebrae (Figure 2), and pelvic MRI showed medullary trabecular edema in the right femoral head and neck combined with lobular cystic lesions in the peripheral muscle groups. With these MRI findings, we diagnosed the patient with tuberculous arthritis. Her purified protein derivative (PPD) skin test was 16 mm in diameter. The patient's features are summarized in Table 1. Sputum samples that received three consecutive days of staining for acid-fast bacilli were negative. The contact history and clinical and radiological findings aided in the diagnosis of bone and vertebral tuberculosis. A four-drug antituberculosis regimen was initiated (isoniazid, rifampin, pyrazinamide, and ethambutol). Our patient began to gain weight, and her pain lessened on the seventh day. On the fifteenth day, ESR was 33 mm/h and CRP was 2.3 mg/dL. The patient continued to be followed by the pediatric and orthopedic clinics, and she completed 12 months of tuberculosis treatment. There was no compression or neurologic deficits as complications of the spinal tuberculosis. The 10-month follow-up MRI of the hip showed decreased fluid in the joint space and regression of the abscess formation. At 12 months, her ESR was 2 mm/h and CRP was 0.48 mg/dL. The patient completely recovered after antituberculosis treatment.