A young female patient reported to the dermatologist with a skin lesion that was diagnosed as tuberculosis verrucosa cutis (TVC) after skin biopsy. She did not continue antitubercular drugs as she was having vomiting due to pregnancy. She reported to our hospital with swelling and pain in the abdomen with 18 weeks of pregnancy. On imaging, she was diagnosed to have large iliopsoas abscess with tubercular spondylitis. She took antitubercular drugs after surgical drainage of the iliopsoas abscess. She delivered a healthy male baby. Follow-up imaging revealed resolution of the skin lesion, iliopsoas abscess, and tubercular spondylitis.
Keywords: Iliopsoas abscess, pregnancy, spine, tuberculosis (TB), verrucosa
Tuberculosis (TB), caused by Mycobacterium tuberculosis, is still dominating as a major global public health problem in spite of mass Mycobacterium bovis bacillus Calmette-Guιrin (BCG) vaccination and the development of newer antitubercular drugs.  According to the latest global TB report by the World Health Organization (WHO), an estimated 8.6 million people developed TB and 1.3 million died from this disease in 2012 alone. Though TB mostly affects the lungs, it can affect the spine in 3-5% of the people.  According to the TB INDIA 2014, Revised National TB Control Programme, annual status report -2014, India has 2.3 million reported TB cases that contribute one-fourth of the global burden.  According to accumulated study and data, it has been proved that pregnancy does not alter the course of TB. , Cutaneous TB has variable presentations because of wider differential diagnosis, and difficult microbiological isolation and continues to be the most challenging to diagnose in developing countries. Again spinal TB is rare during pregnancy and can be associated with psoas abscess, cord compression, paraplegia, or quadriplegia.  In this setting, we are reporting a case of tuberculosis verrucosa cutis (TVC) complicated with a large psoas abscess in a young pregnant woman and reviewing the literatures.
A 29-year-old female patient reported to our hospital with an itchy skin lesion over the right elbow. On clinical examination, the lesion showed an irregular, elevated skin lesion with a rough verrucous appearance. The skin biopsy of the lesion revealed tubercular infection [Figure 1]. She was seronegative for hepatitis-B, C, and human immunodeficient immunodeficiency virus (HIV) infection. She had no history of diabetes, TB, hypertension, or any chronic illness. There was no history of tubercular infection in her family. Previous menstrual cycles were regular. She was prescribed antitubercular drugs for the lesion. She did not take the antitubercular medicine on her own as she was 6 weeks pregnant and was having nausea and vomiting most of the time. She reported in the mid trimester again to our hospital with irregular low-grade fever, increasing abdomen abdominal pain, back pain, and rapid swelling of the abdomen. On clinical examination, her vitals were within normal limits. Central nervous system, respiratory, and cardiovascular examinations were unremarkable. Abdominal examination revealed two intra-abdominal cystic swellings with a disproportionately increased abdomen size with respect to gestational age. She was unable to extend the right lower limb. Ultrasound examination showed intrauterine pregnancy of 18 weeks and a large right-sided intra-abdominal cystic mass with particulate mobile contents. A large ovarian cyst/chocolate cyst of the right ovary was suspected. Magnetic resonance imaging (MRI) of the abdomen and pelvis revealed a large right-sided iliopsoas abscess of size about 193 × 97 mm with intraspinal extension at L3-4 level. The L4 vertebra shows right lateral wedging with decrease disc height at L3-4 level. The L3, L4, and L5 vertebral bodies showed T1 hypointense, short tau inversion recovery (STIR), and hyperintense signal within the right side of the vertebral bodies suggestive of marrow edema [Figure 2]. The gravid uterus is pushed toward the left side. No fetal anomaly was detected. Three samples of sputum test for acid-fast bacilli were negative. Results of chest radiography that was carried out with a lead shield over the abdomen were normal. The iliopsoas abscess was drained surgically by the extraperitoneal approach. She was advised to take antitubercular drugs regularly (rifampicin, isoniazid, pyrazinamide, and ethambutol combination as per dose and duration). After taking the medicines, her clinical symptoms improved gradually. She delivered a healthy male baby transvaginally, but unfortunately the baby died due to meconium aspiration complicated with respiratory infection in the neonatal intensive care unit. She reported after 5 months of antitubercular therapy (ATT) and her repeat contrast-enhanced MRI of the lumbosacral spine revealed complete resolution of iliopsoas abscess and the right lateral wedging of L4 vertebral body [Figure 3]. Her skin lesion had disappeared. She was advised to continue the ATT for 1 year. She was found to be asymptomatic on follow-up.
TVC is an indolent, warty skin plaque and is usually caused by M. tuberculosis, M. bovis, and sometimes by the attenuated BCG organism in a certain condition. It constitutes approximately 1-2% among all forms of TB. TVC is a paucibacillary form of cutaneous TB caused by exogenous reinfection in previously sensitized individuals with high immunity. ,
Evidence of tubercular infection is suggested by tuberculin skin test, routine chest radiograph study, demonstration of acid-fast bacilli in the pathological sample, culture for M. tuberculosis, and serological/molecular assay such as molecular line probe assay (LPA) and polymerase chain reaction (PCR). Tuberculin skin testing is safe and recommended for high-risk pregnant women.  Positive culture for M. tuberculosis is considered to be the gold standard for the diagnosis of cutaneous TB. The radiometric BACTEC 460 TB culture system (Becton Dickinson Diagnostic Instrument Systems, Sparks, MD, USA) is more rapid than the traditional Lowenstein-Jenson (L-J) medium culture procedures. Aggarwal et al. reported the sensitivity of the BACTEC system to be much higher (62.8%) compared to the L-J medium (25.7%), with a marked reduction in the mean detection time (17.3 vs. 39.4 days). Though deoxyribonucleic acid (DNA) amplification by PCR is a rapid and sensitive method to detect cutaneous TB using IS 6110 gene specific for the M. tuberculosis, it is associated with the false positive/negative result and moreover, with high cost that precludes its use in many a times. The diagnosis of TVC is based on history, evolution of the disease, cardinal morphological features, and histopathological characteristics. Presence of characteristic tubercular granulomas with epithelioid cells, Langhans giant cells, and lymphocytes are the most common findings in cutaneous TB though many other diseases can produce a tuberculoid granuloma.  In our case, the skin biopsy of the lesion and the culture of the sample revealed tubercular infection. Tuberculin skin test was not done for the patient as the histopathological report suggested features of cutaneous tuberculosis. The patient had undergone a tuberculin skin test after the histopathological report suggested symptoms of cutaneous TB.
According to the World Health Organization, 2009 (WHO) recommendation, cutaneous TB in HIV-negative individuals (adults as well as children) should be treated by directly observed treatment short-course (DOTS) course chemotherapy consisting of four drugs, isoniazid (H), rifampicin (R), pyrazinamide (Z), and ethambutol (E) given for 2 months (intensive phase), followed by isoniazid and rifampicin given for the next 4 months (continuation phase).  In our case, the patient was advised to take antitubercular drug according to the WHO regimen but she could not start the treatment because of frequent vomiting during pregnancy.
Researchers have demonstrated that pregnancy has no role to play in the progression of TB but frequent and consecutive pregnancies may promote recrudescence or reactivation of latent TB. Higher rate of spontaneous abortion, suboptimal weight gain in pregnancy, preterm labor, low birth weight, and increased neonatal mortality have been reported in pregnancy with TB.  Only few cases of Pott’s spine with psoas abscess in pregnancy have been reported. However, TVC complicated with spinal TB and large psoas abscess during pregnancy is rarely reported. The presentation of a pregnant patient with tubercular infection is nonspecific and routine radiograph of the chest or spine are is often not advised due to radiation risk to the embryo/fetus that delayed the detection of tubercular infection leading to further complication. , As pregnancy is associated with a relatively immune compromised state and with physiologically elevated serum cortisol level, skeletal TB may have an aggressive behavior with rapid and profound vertebral destruction.  Ultrasound detection of small psoas abscess in pregnancy is difficult. MRI is the investigation of choice for spinal infection in pregnancy.  In our case, the large psoas abscess was obvious in ultrasound examination.
Early diagnosis and appropriate intervention is critical. Tubercular spondylitis during pregnancy not complicated by neurological deficit or significant vertebral body destruction, conservative treatment in the form of multidrug antitubercular chemotherapy with pyridoxine supplement, and early mobilization in a suitable brace are appropriate. In case of neurological deficit and/or progressive deformity due to Pott’s spine, adequate decompression and stabilization with bone grafting and instrumented fusion is are required.
There are no strict guidelines about the best treatment option for psoas abscess.  Psoas abscess is now almost treated by radiologically controlled percutaneous drainage with administration of appropriate antibiotics. Surgical drainage is necessary when access is difficult. In case of psoas abscess due to secondary cause, surgical/medical intervention for the predisposing factor is necessary for better outcome. 
In our case, the large psoas abscess is drained surgically by a 14 gauge catheter drainage under local anesthesia following 1 week of the administration of antitubercular treatment. There was no significant neurological deficit in spite of intraspinal communication of psoas abscess. She delivered a term normal baby transvaginally but unfortunately the baby died due to meconium aspiration complicated with respiratory infection in the neonatal intensive care unit. Mother responded well to the treatment and showed near complete resolution of infection on follow-up MRI of the spine.
There is a certain limitation in our study. The imaging evaluation of the spine was not done for the spine during her the patient’s initial presentation with cutaneous tubercular infection as patient was not having any neurological deficit or severe backache. Risk of early spinal TB with concurrent TVC could not be ruled out. Further study is required to establish cutaneous TB complicating spinal infection and psoas abscess during pregnancy.
The Aantitubercular drugs should not be discontinued during pregnancy in case of cutaneous TB. Detailed clinical/radiological evaluation of the patient is required to rule out disseminated tubercular infection and for deciding the duration of the antitubercular drug regimen.
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[Figure 1], [Figure 2], [Figure 3]