Tuberculosis of the ischiopubic ramus. A report of five cases

A 6500-year-old Middle Neolithic child from Pollera Cave (Liguria, Italy) with probable multifocal osteoarticular tuberculosis

Clear skeletal evidence of prehistoric tuberculosis (TB) is rare, especially in children. We describe and differentially diagnose the pathological changes displayed by a five-year-old child, Pollera 21 (PO21) dated to the Middle Neolithic of Liguria (Italy), or 5740±30 BP (Beta-409341; 6635-6453cal BP, 2σ, OxCal 4.2). PO21 shows a number of osteoarticular lesions, mainly of a lytic nature with very little bone proliferation: the vertebral column, the shoulder and pelvic girdles, and the ribcage are involved. Given the nature and pattern of the lesions, we propose a diagnosis of multifocal (or multiple) bone TB. Attempts to detect TB aDNA through molecular analysis gave negative results, but this alone is not sufficient to prove that PO21 was not infected with TB. The lesions observed in PO21 share similarities with other published evidence, such as spinal and joint involvement, and disseminated cyst-like lesions. Conversely, PO21 does not show diffuse bone deposition, such as hypertrophic osteoarthropathy (HOA) or endocranial modifications such as serpens endocrania symmetrica (SES). PO21 adds to our knowledge of patterns of TB manifestation in archaeological skeletal remains, which is especially important considering the variability in types and patterns of osteoarticular lesions seen today in people with TB.

Tuberculosis of the pubic symphysis

Tuberculosis is one of India's public health problems. It involves various systems of the body, including the skeletal system. Osteoarticular tuberculosis is the second most common form of extrapulmonary tuberculosis next to lymph nodes and constitutes about 13% of all extrapulmonary cases. It is generally accepted that osteoarticular tuberculosis is the result of a haematogenous or lymphatic spread from a reactivated latent focus, usually pulmonary; however, previous infection is not always encountered, and in only 40-50% of the cases, it is possible to demonstrate another active infection site. The commonest site for skeletal tuberculosis is the spine followed by the hip, knee and ankle joints. Tuberculosis can involve literally any bone or joint. Pubic symphysis is an uncommon site for tuberculosis in the case of the skeletal system. We present a rare case of pubic symphysis tuberculosis in a 25-year-old woman presented to the general surgical department with a swelling in the right thigh region.

Tuberculosis of the pubic symphysis: four unusual cases and literature review

BACKGROUND

The incidence of extrapulmonary tuberculosis (TB) has increased in the chemotherapeutic era owing to the increasing presence of immunodeficiency disorders. Pubic symphysis TB, although uncommon, is again important as these infections once were in the prechemotherapeutic era.

CASE DESCRIPTION

We present the cases of four patients with pubic symphysis TB in which one patient had a horseshoe-shaped abscess in the pubic region and another had a double lesion of the pelvis leading to vertical shear-type pathologic displacement. Three patients were diagnosed by cytology and PCR. These patients were treated successfully with antituberculosis treatment with or without minimal surgical intervention despite their late presentation and advanced disease. The fourth patient remains under treatment and followup.

LITERATURE REVIEW

We identified 40 patients with TB of the pubic symphysis in the English language medical literature. Of these 40 patients, only five are from India despite TB being endemic in this country. Followup information is available for 32 of the 40 patients with followups ranging from 1 to 84 months (mean of approximataly 20 months).

PURPOSES AND CLINICAL RELEVANCE

We suspect TB of the pubic symphysis is increasing in frequency owing to drug resistance, use of biologics, immunomodulating drugs, and anticancer drugs. Therefore, it is important for clinicians to have a high index of suspicion in patients at risk. Initially patients may be asymptomatic or present with adductor region pain or spasm, sacroiliac strain, limp, or a hypogastric, inguinal, or thigh mass that mimics an inguinal hernia, genitourinary, abdominal, or thigh tumor.

CONCLUSION

It is important to diagnose and treat pubic TB early in the course of the disease before the destructive stage. After relevant investigations most patients can be treated with antitubercular drugs with or without a minor surgical procedure.