Atypical skeletal tuberculosis mimicking neoplasm

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Abstract
Although the radiographic features of skeletal tuberculosis are well described, little has been written regarding tuberculous involvement of the shaft of tubular bones. In general, para-articular regions are mainly affected. Only 10% of cases spare the joint, and the majority of these are metaphyseal. Diaphyseal disease is rare and the radiographic features are variable and at times confusing. Pulmonary tuberculosis with subsequent skeletal tuberculosis is being encountered with increasing frequency (DHHS, 1988). Our recent experience with two unusual presentations prompted this report. Two patients, both women, were diagnosed with focal bone tuberculosis. The lesion involved the left tibia in a 40-year-old woman of Chinese extraction and the pubic ramus in a 46-year-old black woman. Conventional radiography, bone scanning and computed tomography (CT) were performed on both patients. In addition, angiography and magnetic resonance imaging (MRI) were also performed on the second patient. The diagnosis was established in both patients by open biopsy. Paraffin sections were stained with haematoxylin and eosin as well as with acid-fast and fungal stains. Smears were made of the fresh material in each case for both Gram's and acid-fast staining. Some of the fresh material from each case was cultured for organisms, including acid-fast bacilli and fungi. Although the sections did not reveal acid-fast organisms, culture for acid-fast bacilli was positive in the two patients. Physical examination revealed a woman in severe distress, limping and having difficulty walking. There was swelling with skin erythema over the anteromedial aspect of the middle part of the left leg.

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