A rare presentation of multifocal tuberculosis in an immunocompetent patient

Abstract

Introduction: Multifocal tuberculosis (MT) is an uncommon presentation in immunocompetent patients. It’s associated more with an immune-depression like Human Immunodeficiency Virus infection. We report a case of MT with presternal cold abscess, mediastina and cervical adenopathy, bone, and vertebral location that occurred in an apparently immunocompetent patient. Case presentation: A 19-year old woman with no previous history of tuberculosis (TB) exposure was admitted for chronic chest pain lasting for 13 months. She presented with a history of fever, night sweat and weight loss (09 kg). The first clinical examination noticed a voluminous presternal abscess. The chest X-Ray showed an enlargement of the middle mediastinum associated to pleural effusion opacity, but any active pulmonary lesions. A computed chest tomography revealed the presence of a parietal mass centered on the sternum, with extension in the soft parts, bone lies of the sternal manubrium, lies of the vertebral hemi-bodies of T10 and T11, cervical lymph nodes, phrenic mediastina and sub-pectoral nodes with peritoneal and mesenteric involvement. Magnetic resonance imaging of the spine showed tiered thoracic lumbar and sacral spondylitis with paravertebral and anterior epidural collections responsible for spinal cord compression next D10 without signs of spinal cord pain. The draining of the cold abscess revealed some whitish pus, in which acid-alcohol resistant bacilli were identified. There was no history of diabetes, renal failure, or long-term treatment with corticosteroids or immunosuppressant’s: HIV serology and viral hepatitis were negative. The blood glucose was normal. The patient was treated with anti-tuberculosis regimen based on: Ethambutol, Rifampicin, Isoniazid, and Pyrazinamide for two months, and then rifampicin and isoniazid for seven months. The outcome was good with the disappearance of the abscess and all the radiological signs. Conclusion: Multifocal TB such as the case reported are uncommon and confined mostly to immunocompromised patients especially those with HIV infection. Because of the clinical polymorphic features of multifocal TB, the diagnosis is usually difficult to make, resulting into delay before beginning of the adequate treatment.