The recognition of extrapulmonary tuberculosis can challenge the diagnostic skills of clinicians, often leading to delay diagnosis and treatment. Although, rare in immunocompetent patients, it is important to consider this diagnosis, especially in persistent infections. We are reporting a case of tuberculosis sinusitis documented 2 years after initial symptoms.
A 54-year-old male with history of tuberculosis treated twelve years ago for 6 months presented complaining of headache and fever for 2 days. For the past 2 years he suffered from brownish, nasal discharge attributed to maxillary sinusitis seen on computed tomography (CT). His symptoms were unresponsive to standard anti-microbial therapy, so myringomoty and antrostomy were performed one week prior. On this admission, he had a fever of 102°F with swelling and redness over the right periorbital area. Laboratory tests including antineutrophil cytoplasmic antibody and HIV were negative. The chest radiography and CT showed a patchy left upper lobe consolidation with bronchiectasis. A repeat CT of the sinuses showed opacification with air fluid levels in the right maxillary, sphenoid and frontal sinuses. Microscopic examination of maxillary sinus biopsy revealed numerous acid-fast bacillus (AFB), later identified as Mycobacterium tuberculosis, which was sensitive to isoniazide and rifampin. His sputum was negative for AFB. He was started on isoniazide, rifampin, pyrazinamide and ethambutol daily for 2 months; isoniazide and rifampin were continued for 7 months. Subsequent CT showed resolution of sinusitis.
Extrapulmonary tuberculosis presents a diagnostic challenge, in part, this relates to it being less common and, therefore, less familiar to most clinicians . The tubercle bacilli multiply in the alveolar macrophages forming either Simon or Ghon foci which act as seeds for dissemination or later reactivation. Infections at other organs may occur via hematological spread or by direct inoculation. The combination of small numbers of bacilli and inaccessible sites causes bacteriologic confirmation to be more difficult, thus invasive procedures are frequently required to establish a diagnosis. The diagnosis of TB sinusitis is usually based on: (1) the absence of clinical response to usual antibiotics (2) the presence of caseous granulomatous inflammatory lesion on histopathology, and (3) identification of Mycobacterium tuberculosis by bacteriological culture or polymerase chain reaction assay. Antineutrophil cytoplasmic antibody helps differentiate Wegener’s granulomatosis, although this test is negative in 15% of localized disease . TB sinusitis is a rare occurrence and like other extrapulmonary TB there is no well-conducted, controlled trials for treatment, hence the management principles of pulmonary TB are instituted. The most commonly used regimen consists of isoniazide, rifampin and pyrazinamide given daily for 8 weeks, followed by isoniazide and rifampin daily for 16 weeks. Unless the rate of resistance to isoniazide is known to be less than 4% in the community, ethambutol or streptomycin are added until susceptibilities are documented . Tuberculous sinusitis is uncommon, however limited clinical experience suggests that 6 to 9 months of treatment is effective. We treated for 9 months since our patient had prior TB infection. Patient improved clinically and follow-up CT showed improving sinusitis.
This case highlights the difficulty of diagnosing sinusal TB but must be considered in a patient with sinusitis resistant to common antibiotics, especially with a history of previous TB. Suitable imaging studies, bacteriological and histological examinations are essential to making the correct diagnosis, as response to treatment is usually good.
T. Yein, None.