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Updated: Jun 5, 2025
Posterior Approach for Debridement of the Psoas Abscess
Published on: March 2, 2020
A Case of Pott's Disease Complicated by Tuberculous Meningitis and Psoas Abscess Diagnosed by Computed
Ko Miyakoda1,2, Ryohei Ono2, Izumi Kitagawa1
1Department of General Internal Medicine, Shonan Fujisawa Tokushukai Hospital, Fujisawa, JPN.
Abstract:
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (MTB). Disseminated TB can cause various types of complications. Extrapulmonary TB includes TB meningitis, abdominal TB, skeletal TB, Pott's disease (spine), scrofula, and genitourinary TB. In particular, TB meningitis is a lethal complication of TB with a high mortality rate. The patient was an 84-year-old Japanese man with a history of tuberculous pleurisy during childhood who presented with fever and altered mental status. Eight months prior, the patient was diagnosed with a urinary tract infection and treated with levofloxacin, but further investigation showed spondylitis. Although the causative microorganism was not identified as levofloxacin likely masked it, he was treated with linezolid and rifampicin for six weeks for the empiric diagnosis of bacterial pyogenic spondylitis; both medications are also antituberculous agents. At this visit, abdominal computed tomography (CT) revealed a left psoas abscess with calcification, and cerebral magnetic resonance imaging revealed multiple nodules with target signs. Cerebrospinal fluid (CSF) findings were consistent with TB meningitis, though the TB polymerase chain reaction, culture, and CSF cytology were all negative. He underwent CT-guided percutaneous drainage for the psoas abscess, and MTB was finally identified. Although he was treated with antituberculous agents including rifampicin, ethambutol, and isoniazid, the patient died seven months after admission as a result of the debilitating effects of tuberculous meningitis. In our case, we should have tried to identify the causative organism in the diagnosis of pyogenic spondylitis. Especially in patients with a history of TB, the possibility of TB should always be considered. In addition, the use of antituberculous drugs may mask the presentation; therefore, biopsy or CT-guided drainage, as used in this case, should be considered for diagnostic accuracy.
Insights
Tuberculosis meningitis is a severe complication of disseminated TB. Early identification of Mycobacterium tuberculosis is crucial, especially in patients with a history of TB, as standard tests may be negative and treatments can mask symptoms.
Area of Science:
- Infectious Diseases
- Neurology
- Radiology
Background:
- Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (MTB).
- Extrapulmonary TB, including TB meningitis, can lead to severe complications and high mortality.
- A history of prior TB infection increases suspicion for reactivation or disseminated disease.
Observation:
- An 84-year-old male with a history of tuberculous pleurisy presented with fever and altered mental status.
- Imaging revealed a psoas abscess with calcification and multiple cerebral nodules with target signs.
- Cerebrospinal fluid analysis was negative for TB, despite clinical suspicion of TB meningitis.
Findings:
- CT-guided drainage of the psoas abscess led to the identification of MTB.
- Despite treatment with antituberculous agents, the patient succumbed to complications of TB meningitis.
- Empiric treatment for bacterial spondylitis with antituberculous drugs likely masked the TB diagnosis.
Implications:
- Diagnostic challenges in TB meningitis necessitate considering MTB in patients with a history of TB, even with negative initial tests.
- CT-guided drainage can be crucial for accurate diagnosis when standard methods fail.
- Antituberculous drug use can obscure clinical presentation, highlighting the need for thorough diagnostic workups.
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