Scientific Letter
Skeletal Muscle Tuberculosis in an Immunocompetent Patient
Tuberculosis de musculatura esquelética en una paciente inmunocompetente
a Departamento de Neumología, Centro Hospitalar de São João-EPE, Porto, Portugal
b Departamento de Neumología, Centro Hospitalar de Lisboa Norte-EPE/Hospital Pulido Valente, Lisboa, Portugal
c Departamento de Medicina Interna, Centro Hospitalar de Lisboa Central-EPE/Hospital Curry Cabral, Lisboa, Portugal
d Departamento de Anatomía Patológica, Centro Hospitalar de Lisboa Central-EPE/Hospital Curry Cabral, Lisboa, Portugal
e Ribeiro Sanches Pulmonary Diagnostic Center, Lisboa, Portugal
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(C) Histopathological examination revealing an extensive mixed inflammatory infiltrate with numerous histiocytes and areas with epithelioid non-necrotising granulomas.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tuberculosis remains a major health problem and cause of death from infection worldwide. Musculoskeletal involvement occurs in only 3% of patients.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Primary skeletal muscle involvement without coexisting active skeletal or extraskeletal tuberculosis is extremely rare.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> We report the case of an immunocompetent patient with tuberculous pyomyositis of the primary dorsal muscles.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 38-year-old female immigrant from Cape Verde, living in Portugal (Lisbon), with an unremarkable medical history, presented with pain and progressively increasing swelling in the right dorsal region over the previous two months. She denied any perceived trauma. Pain continued to intensify, despite treatment with analgesics, and she began to lose weight and sweat excessively at night. Musculoskeletal examination revealed a firm, non-fluctuant, painful swelling on the right lower dorsal region. An ultrasound showed a predominantly solid, space-occupying lesion, considered to be of muscular origin. Chest computed tomography was inconclusive. Magnetic resonance imaging (MRI) showed an extensive space-occupying lesion in the muscles of the back, highly suggestive of abscess or tumoral lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B), with no evidence of bone involvement. Biopsies were inconclusive, suggesting lipoma, so the lesion was finally removed, about 14 months after initial evaluation. Histology revealed extensive mixed inflammatory infiltrate and areas with epithelioid non-necrotising granulomas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Resected tissue culture revealed <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> complex, showing susceptibility to all first-line drugs. Serology for HIV was negative. Tuberculosis treatment was introduced and maintained for 6 months, resulting in progressive clinical improvement. On follow-up, the patient remains asymptomatic.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Primary muscular tuberculosis is an extremely rare condition, mostly affecting individuals with altered immune status, especially patients with acquired immunodeficiency syndrome.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In a recent retrospective study, only 20 cases of muscular tuberculosis were reported during 2000–2010.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The rare occurrence of skeletal muscle tuberculosis has been associated with several characteristics of this highly differentiated tissue, such as high lactic acid content, high vascularity and blood flow, and the absence of reticuloendothelial and lymphatic tissue inhibiting mycobacterial growth. The pathogenesis is still uncertain. It may result from the hematogenous dissemination of pulmonary tubercular lesions, contiguous infection from an underlying structure or, in the absence of active foci of tuberculosis elsewhere, direct traumatic inoculation. In this patient, no clinical or radiological evidence of other structural involvement or traumatic episode suggested direct inoculation. However, this patient was an immigrant from Cape Verde, a country with a high tuberculosis burden. Furthermore, tuberculosis remains an important public health problem in some areas of Portugal, mainly in Lisbon were she resides. The clinical presentation is non-specific and may mimic other diseases, leading to misdiagnosis or delay in a diagnosis that warrants a high index of suspicion. In most cases, diagnosis is made months to years after the onset of symptoms: in our patient more than a year elapsed. The gold standard for diagnosis is histology, with mandatory microbiological confirmation from the aspirated/surgical material. Medical treatment is the first-line option although surgical intervention may be useful as an adjuvant treatment. The 6-month regimen is recommended.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although extremely rare, tuberculosis of the primary skeletal muscle should be considered in the differential diagnosis of painful back muscle swelling, particularly in patients living in or coming from tuberculosis endemic areas.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Dabó H, Mineiro A, Carmelino J, Carvalho A, Gomes C. Tuberculosis de musculatura esquelética primaria en una paciente inmunocompetente. Arch Bronconeumol. 2016;52:340–341.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2333 "Ancho" => 1977 "Tamanyo" => 551142 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial (A) and sagittal (B) T1-weighted magnetic resonance imaging of the chest, revealing an extensive space-occupying lesion in the back muscles, with contrast enhancement of the wall. (C) Histopathological examination revealing an extensive mixed inflammatory infiltrate with numerous histiocytes and areas with epithelioid non-necrotising granulomas.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary tuberculous pyomyositis of quadriceps femoris in an immunocompetent individual" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.A. Modi" 1 => "A.D. Mate" 2 => "A.M. Nasta" 3 => "A.K. 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Jassim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "2000" "volumen" => "59" "paginaInicial" => "164" "paginaFinal" => "165" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10700421" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005200000006/v1_201605260126/S1579212915003262/v1_201605260126/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005200000006/v1_201605260126/S1579212915003262/v1_201605260126/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915003262?idApp=UINPBA00003Z" ]
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| 2023 March | 39 | 5 | 44 |
| 2023 February | 146 | 15 | 161 |
| 2023 January | 103 | 29 | 132 |
| 2022 December | 120 | 35 | 155 |
| 2022 November | 195 | 28 | 223 |
| 2022 October | 145 | 35 | 180 |
| 2022 September | 144 | 22 | 166 |
| 2022 August | 156 | 40 | 196 |
| 2022 July | 115 | 43 | 158 |
| 2022 June | 127 | 36 | 163 |
| 2022 May | 144 | 36 | 180 |
| 2022 April | 108 | 32 | 140 |
| 2022 March | 110 | 42 | 152 |
| 2022 February | 101 | 21 | 122 |
| 2022 January | 126 | 37 | 163 |
| 2021 December | 122 | 33 | 155 |
| 2021 November | 109 | 48 | 157 |
| 2021 October | 132 | 38 | 170 |
| 2021 September | 113 | 41 | 154 |
| 2021 August | 117 | 36 | 153 |
| 2021 July | 64 | 24 | 88 |
| 2021 June | 90 | 30 | 120 |
| 2021 May | 109 | 49 | 158 |
| 2021 April | 167 | 90 | 257 |
| 2021 March | 124 | 28 | 152 |
| 2021 February | 84 | 25 | 109 |
| 2021 January | 89 | 17 | 106 |
| 2020 December | 90 | 25 | 115 |
| 2020 November | 82 | 17 | 99 |
| 2020 October | 71 | 13 | 84 |
| 2020 September | 83 | 20 | 103 |
| 2020 August | 85 | 11 | 96 |
| 2020 July | 68 | 22 | 90 |
| 2020 June | 105 | 8 | 113 |
| 2020 May | 101 | 14 | 115 |
| 2020 April | 125 | 24 | 149 |
| 2020 March | 140 | 21 | 161 |
| 2020 February | 158 | 14 | 172 |
| 2020 January | 147 | 25 | 172 |
| 2019 December | 138 | 19 | 157 |
| 2019 November | 116 | 18 | 134 |
| 2019 October | 137 | 13 | 150 |
| 2019 September | 147 | 16 | 163 |
| 2019 August | 103 | 21 | 124 |
| 2019 July | 103 | 21 | 124 |
| 2019 June | 83 | 9 | 92 |
| 2019 May | 120 | 17 | 137 |
| 2019 April | 142 | 15 | 157 |
| 2019 March | 100 | 26 | 126 |
| 2019 February | 79 | 14 | 93 |
| 2019 January | 114 | 20 | 134 |
| 2018 December | 50 | 21 | 71 |
| 2018 November | 61 | 27 | 88 |
| 2018 October | 106 | 24 | 130 |
| 2018 September | 47 | 13 | 60 |
| 2018 May | 35 | 0 | 35 |
| 2018 April | 43 | 7 | 50 |
| 2018 March | 80 | 4 | 84 |
| 2018 February | 55 | 3 | 58 |
| 2018 January | 131 | 9 | 140 |
| 2017 December | 54 | 6 | 60 |
| 2017 November | 26 | 4 | 30 |
| 2017 October | 32 | 9 | 41 |
| 2017 September | 29 | 6 | 35 |
| 2017 August | 32 | 14 | 46 |
| 2017 July | 28 | 17 | 45 |
| 2017 June | 41 | 15 | 56 |
| 2017 May | 47 | 7 | 54 |
| 2017 April | 32 | 9 | 41 |
| 2017 March | 20 | 40 | 60 |
| 2017 February | 13 | 6 | 19 |
| 2017 January | 10 | 8 | 18 |
| 2016 December | 30 | 14 | 44 |
| 2016 November | 54 | 23 | 77 |
| 2016 October | 45 | 19 | 64 |
| 2016 September | 33 | 7 | 40 |
| 2016 August | 4 | 0 | 4 |
Show all
