A 52 year old male patient was referred to our institute as a massive tumor of right thigh (Figure 1) for further management. There was no history of fever or loss of appetite; however history for night sweats and weight loss and low back pain was positive. He denied any history of cough, shortness of breath, hemoptysis or history of contact with a tuberculous patient or relative. There were no other medical illnesses.
Physical examination revealed normal vital signs. The right thigh was massively swollen and was non tender and was not associated with any inflammation. The patient looked ill and underweight, but there was no lymph node enlargement or clubbing. Chest and cardiovascular examination was unremarkable. Abdominal examination revealed soft, non-tender abdomen and no organomegaly. Palpation of lumbar spine revealed tenderness (Figure 1).
Laboratory investigations revealed normal full blood count, liver enzymes, electrolytes, urea and creatinine. ESR was 85 and HIV serology was negative. X-rays of the chest, pelvis and thigh was normal. X-rays of the lumbar spine (Figure 2) revealed decreased disc space between L1 and L2 vertebra along with collapse of L2. Magnetic resonance imaging of thigh (Figure 3) revealed large well encapsulated abscess in the back of thigh extending upto popliteal fossa, in continuation with ilio-psoas abscess (Figure 2 and Figure 3).
The abscess was aspirated under ultrasound guidance. Ziehl- Neelsen stain of the aspirate was positive for acid-fast bacilli. Culture of the aspirate revealed Mycobacterium tuberculosis resistant to isoniazid, and rifampicin, but sensitive to ethambutol, pyrazinamide, streptomycin, capreomycin, ofloxacin and amikacin. He was started on pyrazinamide, ethambutol, streptomycin, ofloxacin and amikacin. Isoniazid and rifampicin were discontinued. The abscess was then drained under ultrasound guidance and 650 ml of purulent fluid was obtained. Streptomycin was locally instilled and the drain was kept in place for seven days. A period of 18 months of therapy was completed. At the end of the treatment course, the swelling resolved completely, the patient improved clinically, gained weight and was walking normally.