Isolated Coccygeal Tuberculosis
A 35-year-old man presented with a three month history of coccygeal and gluteal pain. Furthermore, the pain was associated with numbness in the same region and difficulty walking. The pain had been gradual in onset and was worse on sitting and walking. There was no bowel or bladder incontinence. He reported no recent weight loss, reduced appetite, cough, or night sweats, and his respiratory, cardiovascular, and abdominal system examinations were normal. No paresthesia or muscle weakness was evident in the legs, which he was able to straighten and raise his legs. However, mild perianal and perineal anesthesia were present. The Mantoux test and radiographs of the chest were negative, and hematological studies, including erythrocyte sedimentation rate and C-reactive protein were normal. A computed tomography (CT) scan of the lumbosacral spine revealed lytic destruction of the coccyx with sporadic calcification (). Magnetic resonance images (MRI) of the lumbosacral spine depicted a coccygeal mass involving the anterior and posterior extension (). Under a preliminary diagnosis of a primary bone tumor or metastasis, radionuclide bone scintigraphy (99m TC MDP) and positron emission tomography-CT were performed, but both failed to depict any lesion in addition to the lesion in the coccygeal area. A CT-guided biopsy of the sacral lesion was performed, and the patient was given anxiolytic and analgesic injection before and during the procedure. After infiltrating the skin and soft tissues with 2% lidocaine, a 14-gauge biopsy needle was advanced into the lesion and soft tissue and involved bone were aspirated. The solid material aspirated was dark brown in appearance and was forwarded for cytologic and microbiological examinations. The pathologic examination revealed caseating granulomas containing multinucleated giant cells (). Acid-fast bacilli cultures were positive for tuberculosis. The patient was given anti-tuberculosis treatment for 9 months based on four drugs (isoniazid, rifampin, pyrazimide, and ethambutol), which is the standard anti-tubercular regimen used at our institute. Patient made a rapid pain relief under this regimen and was asymptomatic at his last follow-up at 9 months.