Tuberculous osteomyelitis diagnosed following an incidental finding on bone scintigraphy.

1 of 2 DESCRIPTION A 47-year-old Sri Lankan man was diagnosed with diabetic neuropathic ulceration of the left hallux. Technetium-99m scintigraphy showed increased uptake corresponding to the ulcer. However an incidental fi nding of increased uptake was also noted in the right distal tibia ( fi gure 1 ). The patient had no localising symptoms on the right. His medical history was signifi cant for type 2 diabetes requiring insulin and vasculitis (managed with prednisone 8 mg daily and mycophenolate 250 mg twice daily). The patient immigrated to Australia 1 year prior to presentation. The right distal tibia was non-tender with minor soft tissue swelling and erythema. T1-weighted post-Gadolinium contrast MRI of the right ankle showed a hyperintense collection in the medial malleolus involving the tendon sheath of tibialis posterior and subcutaneous tissues ( fi gure 2 ). Biopsy showed granuloma with central necrosis and multinucleated giant cells ( fi gure 3 ). Ziehl-Neelsen stain and PCR for Mycobacterium tuberculosis were negative from the direct sample. A fully sensitive Mycobacterium was Images in...