Delay in Diagnosis of Extra-Pulmonary Tuberculosis by Its Rare Manifestations: A Case Report

Introduction: Tuberculosis is now more frequently observed in older individuals, often with underlying illnesses or conditions that may confuse diagnosis. Rapid diagnosis is mandatory. However, treatment should be initiated immediately based on strong clinical suspicion, because mortality from tuberculosis is most often due to delays in treatment. Case presentation: A 68-year-old male was admitted to our hospital with fever. He had splenomegaly, ascites and right-sided psoas abscess. Chest X-ray was normal. Although the vertebral column was intact, he had asymptomatic sacroiliitis. Bony changes of the right sacroiliac joint seemed to be chronic on computerized tomography (CT) scan. Lack of associated clinical symptoms strengthened this assumption. However, signal alterations of respective areas on magnetic resonance imaging (MRI) suggested active inflammation. Analysis of aspirated pus was positive for acid-fast bacilli and the culture depicted mycobacterial growth. The patient was not cirrhotic yet he had high serum-ascites albumin gradient ascites. He had two hypodense lesions in his liver with a cholestatic pattern in the liver test. He had pancytopenia. Biopsy from his liver and bone marrow showed multiple granulomas. Treatment was started with an anti-tuberculosis regimen of four drugs. He responded well to our therapeutic protocol. Conclusions: Tuberculosis is still a diagnostic challenge, especially when the presentation is atypical and extra-pulmonary.