Rodrigo Chaturaka, Atukorala Inoshi
Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka.
J Med Case Rep. 2011 Oct 10;5:512. doi: 10.1186/1752-1947-5-512.
Diagnosis of atypical tuberculosis is difficult. Therefore, it is important that physicians are aware of rare presentations of tuberculosis to avoid diagnostic delays.
We present the case of a 17-year-old Sri Lankan man who presented to our facility with an ill-defined large induration over the skin of his left buttock and thigh. A cause could not be found despite extensive investigations. He also complained of chronic knee pain, but this was not investigated further at the time due to spontaneous resolution. Three years later his knee disease flared up again, with pain, swelling and restriction of movement. A synovial biopsy was suggestive of tuberculosis. He was started on antituberculosis therapy, to which he responded well. Our patient was asymptomatic two months after completion of therapy without any subsequent flare-ups. A chest roentgenogram taken on his second presentation showed evidence of tuberculosis sequelae in his lungs. The most likely diagnosis for the buttock and thigh swelling, when considering the entire clinical picture, is a tuberculous abscess. The constellation of skin and skeletal symptoms and pulmonary tuberculosis is a rare occurrence in an immunocompetent individual, but cases have been reported.
This case demonstrates the different presentations and the diagnostic difficulties posed by atypical manifestations of tuberculosis. It also demonstrates the value of maintaining a high degree of suspicion in endemic areas, even in the absence of microbiological evidence.
非典型结核病的诊断较为困难。因此，医生了解结核病的罕见表现以避免诊断延误非常重要。
我们报告一例17岁斯里兰卡男性患者，他因左臀部和大腿皮肤出现边界不清的大片硬结前来我院就诊。尽管进行了广泛检查，但仍未找到病因。他还主诉慢性膝关节疼痛，但当时由于疼痛自行缓解，未进一步检查。三年后，他的膝关节疾病再次发作，出现疼痛、肿胀和活动受限。滑膜活检提示为结核病。他开始接受抗结核治疗，治疗反应良好。治疗完成两个月后，患者无症状，此后未再发作。他第二次就诊时拍摄的胸部X线片显示肺部有结核病后遗症迹象。综合整个临床情况考虑，臀部和大腿肿胀最可能的诊断是结核性脓肿。在免疫功能正常的个体中，皮肤和骨骼症状与肺结核同时出现的情况较为罕见，但已有病例报道。
该病例展示了结核病非典型表现的不同呈现方式及诊断困难。它还表明，即使在缺乏微生物学证据的情况下，在结核病流行地区保持高度怀疑态度也具有重要价值。
