Uncovering the Clinical Journey: A Single Case Study of Extrapulmonary Tuberculosis

Introduction: Tuberculosis is caused by Mycobacterium tuberculosis. The global burden of tuberculosis is high. In 2023, 10.8 million people fell ill with tuberculosis worldwide, and in India, around 28 lakh people fell ill with tuberculosis. Extrapulmonary tuberculosis (EPTB) also has a high global burden, with around 17% of cases being extrapulmonary tuberculosis globally, and in India, it's around 20%.

Spread: Pulmonary Tuberculosis (PTB) usually spreads by droplet infection, i.e., by coughing, sneezing, or speaking. Extrapulmonary Tuberculosis (EPTB) does not spread by droplet infection unless it is in the oral cavity or larynx.

Risk Factors for EPTB:

• Children: Weaker immune systems or macro and micronutrient deficiencies.

• HIV: Higher chances of getting EPTB or more serious forms like Tubercular Meningitis (TBM).

• Medications: Immunosuppressive therapies increase the risk.

• Living Conditions: Crowded areas and malnutrition.

• Health Conditions: Serious health conditions like cancer, ESRD (End Stage Renal Disease), and poorly controlled diabetes.

Diagnosis: Diagnosing EPTB can be challenging at early stages. Your doctor may advise several tests, including:

• Blood tests: Complete Blood Count (CBC), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Interferon Gamma Release Assay (IGRA), Liver Function Test (LFT), Renal Function Test (RFT)

• Imaging: X-Rays, Ultrasonography (USG), Computed Tomography (CT Scan)

• Specific tests: Acid-Fast Bacilli Staining, Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) also known as GeneXpert, Lowenstein-Jensen Test (LJ medium), Polymerase Chain Reaction (PCR)

Management: Management involves starting Anti-Tubercular Treatment (ATT). Many people have misconceptions about ATT and its side effects. Every drug has specific and non-specific side effects. Minor non-specific side effects can be managed easily through counseling, improving nutritional status, and supportive medications. Specific side effects, such as Antitubercular drug-induced hepatotoxicity, require modified ATT to avoid Drug-Induced Liver Injury (DILI), which can lead to hepatic failure. Drug resistance is also a major emerging issue.

Case Presentation: A 36-year-old female presented with pain and swelling in the right elbow joint for one and a half months, associated with mild intermittent fever. She was receiving treatment from a secondary care center.

Examination Findings:

• General: Conscious, alert, and afebrile at the time of examination. General physical examination was grossly normal.

• Local Examination: Significant fluctuant swelling with mild tenderness.

Image 1. Fluctuant swelling over right elbow joint of patient.

Image 2. Fluctuant swelling over elbow joint of same patient.

Investigations: X-Ray of the right elbow joint (AP and Lateral views) was normal.

Image 3. X Ray AP/Lat. View of right elbow joint of same patient.

Management Plan: Diagnostic aspiration of fluid from the swelling was done, which was straw-colored in appearance. The specimen was sent for culture and sensitivity (reported sterile) and GeneXpert (reported positive). The patient was started on ATT under the diagnosis of EPTB and responded well. Further dressings were done for around two weeks. The patient completed the ATT course for six months and is now doing well.