This was a 9-year-old female patient referred from Kibuye Hospital in the Western province of Rwanda for further investigations and management of the left calcaneal mass suspected to be an osteosarcoma. The condition had persisted for 4 months before consulting our clinic at Kigali University Teaching Hospital CHUK for the left heel pain and swelling. The examination noted a history of fever, weight loss and swelling of the left foot extending to the whole lower limb without cough. Consulted, as structured health system, Birambo Health Centre, then Kirinda district hospital where she received different treatment (that we are unable to get their records for proper identification), without improvement. After 2 weeks, a pus discharging sinus appeared on the heel mass. Two months later, the patient noted right hip swelling with inability to stand and walk. She consulted Kibuye Referral Hospital, from where she was referred at CHUK on December 1, 2017, for further management of possible osteosarcoma of the left calcaneus. No history of trauma nor TB contact.
On physical examination: Temperature was 37.6 C, respiratory rate of 20 cycles/min, pulse of 97 beats/min; two ulcerated wounds on the lateral aspect of left ankle and heel, swollen and tender ankle joint, two mobile, non-tender, small inguinal lymph nodes on the left side, limited range of motion of right hip joint with tenderness and mild shortening of right lower limb.
COM of the left calcaneum with pus discharging sinuses
Left foot synovial sarcoma/Ewing sarcoma
TB of the left calcaneum and right hip.
As management, she received analgesics, daily wounds care and different clinical pathology tests were requested (Table 1). Imaging studies including computed tomography (CT) scan of the left foot (Fig. 1a, b and d) and pelvic X-ray (Fig. 1c).
CT scan results (December 8, 2017): Lytic and sclerotic calcaneal tumor consistent with osteogenic sarcoma, the differential diagnosis is COM.
She was admitted on December 14, 2017, on December 18, 2017, curettage and biopsy were performed under general anesthesia and pre-operative chest X-ray was normal. The patient was discharged home on December 20, 2017.
On January 10, 2018, microscopic examination of the calcaneal mass curettings (Fig. 2) revealed rare poorly formed granuloma, rare multinucleated giant cells, and mixed acute and chronic inflammatory cell infiltrates in favor of possible extrapulmonary TB. The special auramine-rhodamine stain was positive for acid-fast bacilli (Fig. 2).
On February 8, 2018, the patient was referred to pediatric outpatient department (OPD) seen in OPD for TB treatment, as follows: Rifampicin, isoniazid, pyrazinamid, and ethambutol (R75 mg H50 mg Z50 mg E100 mg) 8 tablets per dose for 12 days and then for 48 days. Rifampicin, isoniazid (R75H50) for the remaining period. Pyridoxine 25 mg/day was associated for the two 1st month.
On July 9, 2018, she was reviewed in OPD with persistent small sinus on the left heel. Walking with axillary crutches. The X-rays showed sequestrum and sclerosis of calcaneum, distal tibia, and fibula (Fig. 1d).
We did a sequestrectomy under general anesthesia at Kibuye Hospital in citizen outreach program. She was discharged and advised to continue anti-TB.
On November 29, 2018, she was reviewed and had significantly improved and gained weight; sinuses healed, mild limping with limb length discrepancy of around 1 cm (right being short) and she could stand and walk with the aid of one axillary crutch. Had a limb length discrepancy of around 1 cm (right being short). The liver function test, renal function test, and hemogram test were normal. Control X-rays and morphology picture of the limb were obtained at the same time (Fig. 3).