Tuberculosis - pleural, pulmonary, discitis

Case contributed by Dr Derek Smith

Presentation

New persistent cough and recurrent fevers. Migrated 10 years ago.

Patient Data

Age: 30 years
Gender: Female

Left midzone nodule and left sided pleural effusion / pleural thickening.

Imaged for RIF fullness and tenderness.

Normal uterus and left ovary.

Fluid filled structure around right ovary, probable hydrosalpinx.

No free fluid.

Small left basal loculated pleural effusion. Left pleural and pulmonary nodules (15 mm, 9 mm) with tree-in-bud opacification in left apex. Patchy air trapping. Calcified paratracheal lymph nodes.

Large right iliopsoas abscess, >20 cm in length extending into right femoral canal.

Destruction of L3/L4 endplate with surrounding sclerosis. Small anterior paraspinal collection. No definite epidural collection.

Partly enhancing fluid collection in right adnexa.

No subdiaphragmatic nodal enlargement or free fluid.

No other significant finding. Small right adrenal adenoma.

L3/L4 vertebral body and pedicle edema. Endplate destruction with loss of disc height. Paraspinal inflammation with anterior epidural collection. This inflammatory change is in communication with the large septated right iliopsoas abscess. This extends level with the right hip joint but no evidence of communication with the hip or of a joint abscess.

Normal included spinal cord, conus and cauda equina.

Right adnexal fluid collection.

Case Discussion

This patient was identified from the community as having symptoms and risk factors compatible with tuberculosis. The CXR findings prompted AFB testing which was positive, and she was commenced on anti-TB therapy. While on this, she developed RIF pain which was initially attributed to a TB hydrosalpinx but further assessment demonstrated a L3/L4 tuberculous discitis with anterior paraspinal and large complex right iliopsoas abscess.

This abscess was aspirated under ultrasound guidance (>500 mL) and positive for TB on culture.

The majority of changes showed improvement or resolution on follow up imaging.

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