Tuberculous osteomyelitis of the foot in a haemodialysis patient

A 64-year-old woman with end-stage renal disease secondary to hypertension undergoing haemodialysis for 2 years was admitted with a history of fever, pain and swollen left foot lasting for 1 year. Clinical examination demonstrated localized erythema, warmness and swelling (Figure 1). The erythrocyte sedimentation rate was 122 mm/h and C-reactive protein was 12.6 mg/dL (normal <0.5 mg/dL). The tuberculin skin test revealed 26 mm enduration with bullous oedema. Thoracic computed tomography indicated only calcified lymph nodes in the left hilar region. Magnetic resonance imaging showed destruction in the navicular bone and widespread oedema in the adjacent bones and fluid collection (Figure 2). After surgical intervention, a diagnosis of tuberculosis (TB) was established with the histopathological examination of the tissue. Growth of mycobacterium tuberculosis complex was found in the culture obtained at the time of bone debridement.However, she was lost to follow-up without anti-TB treatment. After 10 months, she presented with fever, swelling and drainage in the left inguinal region. Ultrasonographic examination revealed enlarged inguinal lymph nodes. The diagnosis of TB lymphadenitis was made by demonstrating positive acid-fast bacilli in the drainage fluid. She was cured with standard anti-TB drugs for 9 months. TB osteomyelitis is one of the unusual manifestations of osteoarticular TB and comprises 2–3% of all cases [1]. Due to nonspecific presentation, symptoms together with frequent extrapulmonary localization, this rare condition is often misdiagnosed or the true nature of the lesion is identified late in the diagnostic process as in our case.