Tuberculous bursitis of the greater trochanter mimicking ankylosing spondylitis

Abstract

Tuberculous trochanteric bursitis (TTB) is a rare condition that accounts for 1% of musculoskeletal tuberculosis cases. Extrapulmonary TB is usually diagnosed late because of reduced diagnostic suspicion, particularly in the absence of signs of systemic infection. Herein, we report a case of right hip pain that was misdiagnosed as ankylosing spondylitis. The patient had a history of inflammatory back pain with morning stiffness. However, HLA-B27 was negative. Sacroiliac magnetic resonance imaging (MRI) revealed a giant multiloculated collection (27×16×10 cm). Percutaneous drainage was performed and Mycobacterium tuberculosis was observed in fluid culture. The patient was treated by drainage along with antituberculosis therapy. After 1 year of antituberculosis therapy, control MRI revealed total resolution of the large fluid collection. It is important to emphasize that fever or general symptoms are absent in patients with TTB, as observed in the present case. In endemic countries, TTB should be kept in mind in the differential diagnosis of a patient presenting with chronic hip pain without fever, weight loss, and constitutional symptoms.

Tuberculous trochanteric bursitis in an immunocompetent patient

“…Initially it was thought that TTB mainly affected young adults, however, more recent studies indicate that it can occur at any age, with a higher incidence in the elderly (average age 57 years). 3 No gender predilection has been documented. 2 The clinical presentation of TTB is often vague, characterized by chronic symptoms, such as pain and joint stiffness.…”

“…1 Some studies advocate starting antibacillary medication before a definitive diagnosis is made in order to reduce the risk of mycobacteria spreading during surgery. 3,6 Several studies reported the reactivation of trochanteric tuberculosis after surgical drainage in the pre-chemotherapy era, also justified by the lack of knowledge about tuberculosis infection. 5 In this case, and as in many others, the difficulty in establishing this diagnosis was implicit, not only due to the vague, nonspecific and only local symptoms, but also because he was an immunocompetent patient, due to the initial AFB research, motivated by the histology of chronic necrotizing granulomatous bursitis (also present in brucellosis, coxiella, sarcoidosis), was negative and the patient suffered significant clinical improvement over 6 months.…”

“…1 Of these, arthritis and spondylitis are the most common, with bursitis and tenosynovitis being exceptional. 2 Tuberculous trochanteric bursitis (TTB) is responsible for 1% of all cases of musculoskeletal tuberculosis, 3 a rare clinical condition, having been described for the first time in 1870 by Teale. 4 Its symptoms are usually mild with an insidious evolution, delaying diagnosis and treatment until a later stage, 2 especially if we do not see systemic signs of infection.…”

“…4 Its symptoms are usually mild with an insidious evolution, delaying diagnosis and treatment until a later stage, 2 especially if we do not see systemic signs of infection. 3 Tuberculous lesions usually develop in immunocompromised patients and rarely in immunocompetent patients. 5 With the decline in the incidence of tuberculosis, the number of clinical cases of TTB described in recent literature has decreased considerably, and the reporting and sharing of TTB cases is of particular interest, with the aim of keeping this diagnosis in perspective when discussing and guiding cases of trochanteric bursitis.…”