Navigating Extrapulmonary Tuberculosis: A Case Series from a Tertiary Care Facility Highlighting Rare Presentations, Diagnostic Challenges, Drug Resistance, and Therapeutic Complexities.

Abstract

Background: Extrapulmonary tuberculosis (EP-TB) constitutes one-fifth of all tuberculosis (TB) cases. EP-TB mimics common infections which pose diagnostic dilemma, requires extensive diagnostics that culminate into therapeutic delay often resulting in irrational and empirical institution of antitubercular therapy (ATT) in challenging cases. This supplemented by poor treatment compliance resulted in emergence of Drug-resistant (DR) strains of EP-TB which further impedes the path to recovery. The aim of the present series is to study the rare and diverse presentations of EP-TB caused by drug-sensitive (DS) and DR mycobacterium that require a multi-modal diagnostic approach and appropriate treatment.

Methods: This observational retrospective series incorporated six rare EP-TB cases, excluding those with solitary lung affection and underwent comprehensive diagnostic tests aimed at microbial isolation from affected tissues with subsequent drug resistance testing. They were treated by integrative approach, standard (first/second/third line) ATT while few required emergent surgical interventions. Patient outcomes were evaluated based on clinicoradiological improvement and microbiological clearance determined in follow-up.

Results: Out of six cases (four males and two females; age range: 14-62 years), pleural linings, kidneys, brain and its lining, skin, and axial skeleton were directly affected, while superior mesenteric artery (SMA) syndrome was an indirect consequence of infection. Elective thoracic and urosurgical interventions supplemented medical management in two cases while urgent neurosurgical decompression improved outcomes in Pott's spine case that exhibited drug resistance. Notably of five DS EP-TB, one patient showed poor clinical response necessitating treatment escalation while nutritional rehabilitation was key in SMA syndrome.

Conclusions: EP-TB requires high clinical suspicion and a multidisciplinary approach for diagnosis and treatment. Addressing treatment adherence, with emphasis on good nutrition to tackle cachexia, is necessary for favorable outcomes.