Unusual Presentation of Isolated Sacral Tuberculosis

A Rare Case of Tuberculosis with Sacrococcygeal Involvement Miming a Neoplasm

Infection of the lumbosacral junction by tuberculosis is quite rare and occurs in only 1 to 2% of all cases of spinal tuberculosis; moreover, isolated sacrococcygeal or coccygeal tuberculosis is much rarer. Failure to identify and treat these areas of involvement at an early stage may lead to serious complications such as vertebral collapse, spinal compression, and spinal deformity. In the present paper, we report an uncommon case of spinal tuberculosis with sacrococcygeal location revealed by a chronic low back pain that was successfully managed. Computed tomography scan and magnetic resonance imaging of the pelvis revealed a lytic lesion affecting both of sacrum and coccyx causing osseous destruction and suggesting a malignant process. A surgical biopsy was performed to establish the tissue diagnosis. Histopathological report confirmed the diagnosis of skeletal tuberculosis. The patient was treated with antibacillary chemotherapy for a period of 9 months. The follow-up period was of 36 months. There was a full recovery and the patient was asymptomatic.

A case of perianal and gluteal scrofulodefma

A 47-year-old male presented with multiple perianal and gluteal pus discharging sinuses. On examination, undermined sinus edges, thick and hyperpigmented surrounding skin, sacral tenderness and a lax anal sphincter were noted. Based on clinical, radiological and histopathological evaluations, patient was diagnosed to have sacral tuberculosis with perianal and gluteal scrofuloderma and he was started on anti-tuberculosis treatment.

A rare location of sacral tuberculosis: A report of three cases

Tuberculosis remains one of the most common infectious diseases in the world. Vertebral tuberculosis is the commonest form of bone and joint tuberculosis; however, isolated sacral tuberculosis is rare. This atypical presentation may lead to a delay in diagnosis and treatment. We report three cases of sacral tuberculosis diagnosed in young women, aged 30, 23, and 35 years old, respectively. Lombosciatic pain was the main symptom in all cases. All patients had a biological assessment, plain radiographs, and CT scan. However, magnetic resonance imaging was done in only two cases. All patients underwent surgical sacral biopsy, and the diagnosis of tuberculosis was confirmed by histology in all cases. The evolution was satisfactory with the adjunction of antituberculous chemotherapy in all cases. Spinal tuberculosis should be the first and foremost differential diagnosis in the presence of atypical clinical and radiological features of a sacral lesion, particularly in developing countries. Early diagnosis and treatment could prevent or minimize the neurological morbidity in such cases.

Management of metastatic sacral tumours

PURPOSE

Metastatic involvement of the sacrum is rare and there is a paucity of studies which deal with the management of these tumours since most papers refer to primary sacral tumours. This study aims to review the available literature in the management of sacral metastatic tumours as reflected in the current literature.

METHODS

A systematic review of the English language literature was undertaken for relevant articles published over the last 11 years (1999-2010). The PubMed electronic database and reference lists of key articles were searched to identify relevant studies using the terms "sacral metastases" and "metastatic sacral tumours". Studies involving primary sacral tumours only were excluded. For the assessment of the level of evidence quality, the CEBM (Oxford Centre of Evidence Based Medicine) grading system was utilised.

RESULTS

The initial search revealed 479 articles. After screening, 16 articles identified meeting our inclusion criteria [1 prospective cohort study on radiosurgery (level II); 2 case series (level III); 4 retrospective case series (level IV) and 9 case reports (level IV)].

CONCLUSION

The mainstay of management for sacral metastatic tumours is palliation. Preoperative angioembolisation is shown to be of value in cases of highly vascularised tumours. Radiotherapy is used as the primary treatment in cases of inoperable tumours without spinal instability where pain relief and neurological improvement are attainable. Minimal invasive procedures such as sacroplasties were shown to offer immediate pain relief and improvement with ambulation, whereas more aggressive surgery, involving decompression and sacral reconstruction, is utilised mainly for the treatment of local advanced tumours which compromise the stability of the spine or threaten neurological status. Adjuvant cryosurgery and radiosurgery have demonstrated promising results (if no neurological compromise or instability) with local disease control.

Tuberculosis of sacrum mimicking as malignancy

Tuberculosis has always been a menace for both clinicians and radiologists due to its often non-specific and protean manifestations. Isolated tubercular involvement of sacrum is very rare. The authors present the case of a 38-year-old man with history of low-grade fever, pain and swelling in the sacral region. Skiagram revealed an osteolytic lesion of sacrum leading to the provisional diagnosis of chordoma and osteoclastoma. However, MRI was suggestive of a chronic infective condition like tuberculosis and fine needle aspiration cytology was positive for acid-fast bacilli and revealed epitheloid granulomas with caseous necrosis. Culture was positive for Mycobacterium tuberculosis. Antitubercular therapy was commenced and surgical decompression of cold abscess was done and with good clinical response. This case highlights the importance of remaining cognisant of the manifestations and the importance of considering tuberculosis as a diagnosis at unusual sites of involvement.

Sacral tumors and management

The evaluation and complex treatments of sacral tumors require a multidisciplinary approach. Because of the complex anatomy conditions and biomechanics of the lumbo-pelvic junction, surgical treatment of sacral neoplasms is one of the most challenging fields in spine. Here, diagnostic process and surgical and nonsurgical treatment options for sacral tumors are summarized based on the literature and on the authors' own experiences.