International Journal of Surgery Case Reports 114 (2024) 109141

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Mistaken identity: Reporting two cases of rare forms of extrapulmonary

tuberculosis in Solomon Islands
Dylan Bush *, Florence Fiuramo, Jahrad Liligeto, Lydia Ipulu, Jason Diau, Rooney Jagilly
Ministry of Health & Medical Services, Honiara, Solomon Islands

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Extrapulmonary tuberculosis (EPTB) is a relatively rare and difficult-to-diagnose
Tuberculosis manifestation of Myobacterium tuberculosis (TB) infection.
Solomon Islands Case presentation: This study reports the cases of a 47-year-old male and a 35-year old female with rare forms of
Limited-resource
EPTB who sought medical care in Solomon Islands. Both patients presented with nondescript symptoms and a
Pott disease
chief complaint of pain. Initial diagnosis for the male and female patient was an abacterial colon polypoid mass
Case report
and a urinary tract infection (UTI) respectively. Following unsuccessful treatment for UTI and further investi­
gation, the surgical team diagnosed the female patient with a tuberculosis spondylitis and a bilateral psoas
abscess. The male patient was subsequently diagnosed with isolated colonic tuberculosis. After starting medi­
cation, the patients were discharged and prescribed 9-month treatment regimens. During outpatient treatment
both patients reported suboptimal adherence. The female patient resumed treatment and showed improvement
while the male patient discontinued treatment, experienced worsening symptoms, and ultimately died.
Clinical discussion: The nonspecific symptoms of extrapulmonary TB infection make it difficult to diagnose. Cases
of rare forms of EPTB are particularly challenging to identify. Misdiagnosis may further increase the likelihood of
mortality and morbidity in these cases. Intensive medication counseling, patient outreach, and regularly
scheduled follow-up visits may reduce the incidence of poor adherence and reduce the risk of developing drug-
resistant TB.
Conclusion: Medical practitioners in tuberculosis-endemic countries like Solomon Islands should maintain a high
clinical index of suspicion in diagnosing EPTB. Future research should investigate the prevalence of TB and EPTB
in the Solomon Islands.

1. Introduction underreporting of new TB cases [9].

Although extrapulmonary tuberculosis (EPTB) has historically been
a rarer manifestation of Myobacterium tuberculosis (TB) infection, its
relative frequency has increased in recent decades [1,2]. This condition
is primarily found in children and immunocompromised individuals and
is rarer in immunocompetent adults [3,4]. The threat of EPTB is
particularly great in tuberculosis-endemic countries and resource-
limited contexts where the high burden of disease combined with
limited health infrastructure can delay detection and treatment [5,6].
Solomon Islands, a medium burden TB country, has an estimated
incidence of approximately 72 cases of TB per 100,000 population [7].
Within the Pacific region, Solomon Islands is categorized as one of six
countries with a high burden of TB [8]. The limited health surveillance
and data collection infrastructure in Solomon Islands may contribute to
Although tuberculous spondylitis or Pott's disease is the most com­
mon form of extrapulmonary tuberculosis, Pott's disease with bilateral
psoas abscess is exceedingly rare [10,11]. Similarly, isolated colonic
tuberculosis is one of the rarest manifestations of the disease [12]. To the
author's knowledge these are the first reported cases of Pott's disease
with bilateral psoas abscess and isolated colonic tuberculosis in Solomon
Islands and more broadly in a Pacific Island country (PIC). We hope that
these cases will draw attention to the risk of EPTB in TB-endemic
countries like Solomon Islands and will encourage clinical consider­
ation of EPTB in cases of chronic abscesses.
This work has been reported in line with the SCARE guidelines [13].

* Corresponding author at: Surgical Department, National Referral Hospital, P.O. Box 349, Honiara, Solomon Islands.
E-mail address: dylanm.bush@berkeley.edu (D. Bush).

https://doi.org/10.1016/j.ijscr.2023.109141
Received 14 October 2023; Received in revised form 22 November 2023; Accepted 2 December 2023
Available online 10 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
D. Bush et al.
2. Case presentation
2.1. Case 1
A 34-year-old Melanesian female presented to the emergency
department with normal vital signs, flank pain, and low-grade fever. The
patient had a history of a Bartholin abscess, right ovarian cyst, and self-
resolved pleural effusion within the past year but no history of TB
infection. The patient was treated outpatient for a suspected UTI within
the past year with a standard regimen of nitrofurantoin (100 mg 2×/
day), metronidazole (400 mg 3×/day), with acetaminophen, and
ibuprofen for pain management. Nevertheless, back pain persisted for 7
months. On re-admission, the patient was referred to gynecology and
was again treated outpatient for a suspected UTI with trimethoprim
(300 mg 1×/day) and acetaminophen for pain. When the patient
returned 10 days later with persistent bilateral flank pain, her medical
team adjusted her treatment regimen to amoxycillin (500 mg 3×/day),
metronidazole (400 mg 3×/day), nitrofurantoin (100 mg 2×/day) and
acetaminophen. Additionally, an ultrasound of the abdomen and kid­
neys was ordered, and the patient was referred to the surgical team.
When the patient presented to the surgical ward to review her ul­
trasound results, her flank pain had spread to include the upper lumbar
region (L1 & L2). Ultrasound revealed complex collection (10.5 × 4.8 ×
7.4 cm) inferior to the right kidney with loss of the normal proximal
aspect of the right psoas muscle. A follow-up CT of the abdomen pelvis
was scheduled, and the patient was placed on a regimen of cloxacillin
(500 mg 4×/day), ibuprofen, and acetaminophen. The patient inde­
pendently sought out kastom medicine, a traditional set of herbal and
spiritual medical practices in Solomon Islands, before returning for her
CT two months later.
Radiologic imaging (Fig. 1) revealed bony destruction of the T8-T12
vertebrae with a loss of height and kyphosis of T11. Of further concern,
bone and inflammatory debris of T11 was noted to be encroaching into
the spinal canal at the T11-T12 level. Lytic lesions were also visualized
on the L1 and L2 vertebrae. A paravertebral abscess was seen extending
from T8 to L1 and a bilateral psoas abscess was visualized. The psoas
abscess was irregular in distribution, measuring 5 × 4.3 × 15.3 cm on
the right side and 1.1 × 1.3 × 3.4 cm on the left. Additionally, focal
omental lymphadenopathy was seen in the right lower quadrant. The
limited view of the lungs (below T6) showed septal thickening and
consolidation in the right middle lobe. A functional right ovarian cyst
(3.3 × 2.8 cm) was also noted.
A surgical registrar performed an incision and drainage (I&D) of the
psoas abscess with tubes inserted bilaterally for continuous drainage. A
total of 10 mL of straw-colored fluid were drained from the right side
with minimal collection (<2 mL) drained from the left abscess over two
days. The surgical team collected a sample of fluid from the right psoas
abscess for laboratory analysis. When this sample did not culture, the
surgical team suspected TB and screened the patient for TB exposure.
Further questioning revealed that the patient had been the primary
caretaker for her mother during an infection of pulmonary tuberculosis
four years prior. Subsequent mycobacterial testing was positive, and the
patient was diagnosed with Pott's disease involving a bilateral psoas
abscess. Importantly, chest x-ray was unremarkable in this case. The
patient was discharged and placed on a nine-month treatment of HRZE1
with pyridoxine. On six-week follow-up the patient reported moderate
resolution of flank pain and was observed to have permanent kyphosis.
The patient acknowledged occasionally forgetting to take her
medication.
1
Isoniazid (5 mg/kg), rifampicin (10 mg/kg), pyrazinamide (25 mg/kg),
pyridoxine (25 mg), and ethambutol (15 mg/kg) for 2 months followed by
isoniazid (5 mg/kg), rifampicin (10 mg/kg), and pyridoxine (25 mg) for 7
months.
2
International Journal of Surgery Case Reports 114 (2024) 109141
2.2. Case 2
A 47-year-old Melanesian male presented to the emergency depart­
ment following referral from a provincial hospital for symptoms
including moderate grade fever (39 ◦ C), decreased appetite, bloody
stool, severe and ascending abdominal pain, and generalized weakness
over the previous week. The patient reported inability to pass stool over
the previous two days. Two months prior, a colonoscopy had revealed a
right ascending colon mass that extended into the intestinal lumen
(Fig. 2). Biopsies were taken at that time, but the samples were lost in
transit to the Australia-based laboratory.
On readmission, a computerized tomography scan was performed
and showed a complex mesenteric mass of the ascending colon without
abdominal lymphadenopathy or metastasis (Fig. 3). The surgical team
was consulted and suspected that the mass was the result of colon can­
cer. Biopsies were collected and sent to Australia for histopathological
analysis. The patient was instructed to return in 4 weeks to the medical
ward to review results. Histopathological results indicated tissue
changes consistent with an inflammatory polyp including mild crypt
irregularity, an increase in mixed inflammatory cells in the lamina
propria, and some focal surface erosion. Notably, there was no evidence
of dysplasia or malignancy. At follow-up, the patient reported worsening
pain and was readmitted. Vitals were normal apart from a blood pres­
sure of 90/50 mmHg and a respiratory rate of 22 breaths per minute. On
palpation of the right iliac fossa, the patient exhibited abdominal
distension, a palpable mass, tenderness, and guarding. Bloodwork on
admission is listed in Table 1. The patient was admitted to the medical
ward and an intravenous (IV) saline drip was initiated along with
cloxacillin (1 g 4×/day), metronidazole (500 mg 3×/day), with oral
acetaminophen (1 g 4×/day) and morphine (3 mg pro re nata) for pain.
Given the patient's worsening symptoms, he was again referred to the
surgical ward for inpatient management and further investigation.
Considering the histopathological results and the patients' symptoms,
the surgical team suspected a colonic abscess of bacterial etiology and
thus added IV ceftriaxone (1 g 2×/day), oral Fefol2 (150.5 mg 1×/day),
and switched the patient to IV morphine (3 mg 4×/day). Further
bloodwork, ultrasound, I&D, and a repeat colonoscopy was ordered. Pus
collected during I&D cultured both gram positive cocci and gram-
negative bacilli. The laboratory identified clindamycin and
erythromycin-resistant staphylococcus aureus within the culture. Ultra­
sound confirmed the presence of a heterogenous right ilia fossa mass
(10.6 × 8.3x10cm). Repeat colonoscopy revealed a polypoid mass in the
ascending colon that obstructed the cecum (Table 1). The gastroscopy
team again sent samples for histology. A subsequent exploratory lapa­
rotomy allowed the surgical team to palpate a firm intra-abdominal
mass with attachment to the small bowel and greater omentum, mak­
ing surgical removal difficult. A surgical registrar placed a drain in situ
to remove fluid from the abscess.
When histology results from the colonoscopy showed no evidence of
granulomatous inflammation, dysplasia, or malignancy and instead
were consistent with an inflammatory polyp, pus was collected for
culturing and nucleic acid amplification TB testing. Microbiology results
cultured mixed enteric flora, Escherichia coli positive for extended
spectrum beta-lactamase, and klebsiella pneumonia that was resistant to
ampicillin, amoxicillin, Augmentin, ceftriaxone, cotrimoxazole, and
gentamicin. TB testing was positive. Following receipt of these results,
the patient was diagnosed with an extrapulmonary TB infection isolated
to the colon. The patient was placed on a nine-month HRZE regimen
with Fefol, vitamin B6, and acetaminophen for pain. The patient was
managed outpatient due to a limitation of bed space in the TB ward.
Despite initial improvement during inpatient treatment, the patient
returned within two weeks of discharge and reported defaulting on
2
Fefol is a brand name supplement that includes a mix of 150 mg ferrous
sulfate and 500 μg folic acid.
D. Bush et al. International Journal of Surgery Case Reports 114 (2024) 109141

Fig. 1. Computerized tomography scan of female patient showing bony destruction of the T8-T12 vertebrae as well as loss of height and kyphosis of T11. A par­
avertebral abscess can be seen extending from T8 to L1 level. The right psoas abscess is more easily appreciated on CT due to its large size (5 × 4.3 × 15.3 cm) as
compared to left-side psoas abscess (1.1 × 1.3 × 3.4 cm). Key features including bilateral psoas abscesses and bony destruction of the spinal column have been
identified with red and green arrows respectively. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of
this article.)

3
D. Bush et al.
Fig. 2. Colonoscopy of male patient showing a distal ascending colon polypoid mass extending into the lumen of the ascending colon.
medication. The patient was re-admitted with low-grade fever, nausea,
vomiting and reduced appetite. Despite attempted re-initiation of ther­
apy, the patient decompensated and died within one month of re-
admission.
3. Discussion
The cases presented above demonstrate the threat posed by extrap­
ulmonary tuberculosis. Not only are the diverse presentations of EPTB
difficult to diagnose, but its relative increase in frequency coupled with
the increasing rate of TB infection in the Pacific region make EPTB
particularly dangerous in Solomon Islands [14]. Furthermore, the
increased prevalence of diabetes in the region may increase the immu­
nosusceptibility of local populations to life-threatening infections like
EPTB [15,16].
Misdiagnosis was an important factor that delayed treatment in the
cases presented above. Importantly, misdiagnosis of rare forms of EPTB
occurs in both developing and developed nations [17–19]. EPTB infec­
tion in organs with a high normal burden of bacterial flora, like the
colon, can be particularly difficult to diagnose as samples may culture
pathogenic bacteria that disguise the mycobacterial tuberculosis infec­
tion, delaying diagnosis. Thus, prompt and aggressive management,
including early and minimally invasive abscess drainage as well as
mycobacterial testing when feasible, could contribute to more rapid
diagnosis in cases of EPTB.
In both cases presented here, patients had symptoms for longer than
4
International Journal of Surgery Case Reports 114 (2024) 109141
two months, with one patient suffering from severe pain for more than
one year. Importantly, both sociocultural and infrastructural factors also
contributed to delays in these cases. In the case of the female patient,
when conventional urinary tract infection treatments failed, she became
frustrated and sought out alternative, non-biomedical healing, delaying
the detection and treatment of her EPTB as the infection spread
dangerously close to her spinal cord.
The lack of a functional medical records system and laboratory
outsourcing further delayed treatment decisions and diagnosis. Without
accessible medical records, doctors were unable to comprehensively
review prior medical history in these cases. In the case of the female
patient, this led to repeated treatment for suspected UTI despite non-
response. Furthermore, histopathology specimens from Solomon
Islands must be sent to Australia for processing. Samples may be lost or
damaged during transit and wait times for results often exceed three
weeks. There is an urgent need to build infrastructure that enables local
histopathological processing.
Both patients demonstrated suboptimal medication adherence. In the
case of the male patient, therapy default resulted in the worsening of his
condition and ultimately to the patient's death. The unavailability of
inpatient beds in the TB ward made daily observed therapy impossible in
both cases. Further research should investigate alternative community-
based methods to ensure medication adherence.
In order to prevent such delays in effective anti-TB treatment in the
future, it will be important to rapidly recognize EPTB not only in tertiary
care centers, but also in the field. Point-of-care ultrasound has been
D. Bush et al. International Journal of Surgery Case Reports 114 (2024) 109141

Fig. 3. Computerized tomography scan of male patient showing a large complex mesenteric mass of the ascending colon that obliterates the appendix. Bowel wall
thickening in the lower abdominal quadrants can also be appreciated. The mass has been identified with red arrows. (For interpretation of the references to colour in
this figure legend, the reader is referred to the web version of this article.)

5
D. Bush et al. International Journal of Surgery Case Reports 114 (2024) 109141

Table 1 editor (case note interpretation, imaging data procurement).

Bloodwork on admission for male patient. Dr. Lydia Ipulu - Assisting surgeon on colonic tuberculosis case (case
Test type Result note interpretation, data procurement).
Dr. Jason Diau – Lead surgeon on bilateral psoas abscess case.
Hemoglobin (g/L) 109 (110–180)
Erythrocyte (x 1012/L) 4.36 (3.9–5.1) Dr. Rooney Jagilly – Consultant surgeon on both cases (Case analysis,
MCV (fL) 71.8 (84–94) revision of prior drafts, final approval of manuscript).
MCH (pg) 25.0 (27–34)
MCHC (g/L) 348 (300–350)
Research registration
White Blood Cell Count (x 109/L) 28.49 (4.0–11.0)
Neutrophil (%) 90.9 (40–75)
Lymphocyte (%) 3.3 (20–45) N/A.
Monocyte (%) 5.5 (2− 10)
Platelets (x 109/L) 581 (150–400) Guarantor
Sodium (mmol/L) 124 (135–146)
Potassium (mmol/L) 4.6 (3.5–4.6)
Dylan Bush.

shown to potentially offer an effective and feasible method to quickly
identify EPTB in resource-limited contexts [20]. In countries with
endemic TB like Solomon Islands, the implementation of community-
based screening and standardized clinical questionnaires to identify
TB risk may hold promise, especially in the identification of EPTB.
Furthermore, these cases demonstrate that the creation of locally-
tailored diagnostic guidelines for extrapulmonary masses of unknown
etiology, with particular attention to prompt mycobacterial testing, may
improve treatment outcomes in cases of EPTB. We hope these cases serve
to alert medical practitioners and researchers to the threat of EPTB in
Solomon Islands and in the Pacific region more broadly.
4. Conclusion
In conclusion, we presented two rare manifestations of EPTB in
which the infection was initially unrecognized, and the patients were
initially treated for other conditions. In both cases, a combination of
surgical, radiological, and laboratory investigations eventually led to a
conclusive EPTB diagnosis. A high clinical index of suspicion coupled
with more detailed history-taking and point-of-care diagnostics may
help to reduce morbidity and mortality in these cases.
Consent
Written informed consent was obtained from the patients for publi­
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Ethical approval
Ethical approval was provided by the Solomon Islands Health
Research Ethics Review Board (SIHRERB), Honiara, Solomon Islands
(Project number HRE025/23).
Funding
No funding received.
Credit authorship and contribution statement
Dylan Bush – Primary author of case report (Conceptualization,
drafting of manuscript).
Dr. Florence Fiuramo – Assisting surgeon on bilateral psoas abscess
case (case note interpretation, clinical data procurement,
interpretation).
Dr. Jahrad Liligeto - Lead surgeon on colonic tuberculosis case,
Declaration of competing interest
The authors report no declaration of competing interest.
Acknowledgement
The authors acknowledge Dr. Eileen Natuzzi for her critical contri­
butions to this case report.
References
[1] H.M. Peto, R.H. Pratt, T.A. Harrington, P.A. LoBue, L.R. Armstrong, Epidemiology
of extrapulmonary tuberculosis in the United States, 1993-2006, Clin. Infect. Dis.
49 (9) (2009) 1350–1357, https://doi.org/10.1086/605559.
[2] A. Sandgren, V. Hollo, M.J. van der Werf, Extrapulmonary tuberculosis in the
European Union and European economic area, 2002 to 2011, Euro Surveill. 18 (12)
(2013), 20431 (Published 2013 Mar 21).
[3] I.L. Leeds, M.J. Magee, E.V. Kurbatova, et al., Site of extrapulmonary tuberculosis
is associated with HIV infection, Clin. Infect. Dis. 55 (1) (2012) 75–81, https://doi.
org/10.1093/cid/cis303.
[4] A.A. Velayati, Tuberculosis in children, Int. J. Mycobacteriol 5 (Suppl. 1) (2016)
S1–S2, https://doi.org/10.1016/j.ijmyco.2016.10.038.
[5] S. Hassan, T. Mustafa, B. Robberstad, et al., 169:poster Gaps in healthcare services
leading to high extra-pulmonary tuberculosis un-addressed high economic burden
of extra-pulmonary tuberculosis patients, BMJ Glob. Health 7 (2022) A35–A36.
[6] T. Duke, S. Kasa Tom, H. Poka, H. Welch, Holistic care of complicated tuberculosis
in healthcare settings with limited resources, Arch. Dis. Child. 102 (12) (2017)
1161–1168, https://doi.org/10.1136/archdischild-2017-313095.
[7] World Health Organization, in: World Health Organization Staff (Ed.), Global
Tuberculosis Report 2019, World Health Organization, 2019. https://www.who.
int/publications/i/item/9789241565714. (Accessed 3 June 2023).
[8] J. O’Connor, A. Wiegandt, K. Viney, Tuberculosis surveillance in the Pacific Island
countries and territories 2010 report, in: Secretariat of the Pacific Community,
2010.
[9] N. Itogo, P.C. Hill, K. Bissell, A.D. Harries, K. Viney, S. Gounder, Tuberculosis
notifications, characteristics and treatment outcomes: urban vs. rural Solomon
Islands, 2000-2011, Public Health Action. 4 (Suppl. 1) (2014) S25–S28, https://
doi.org/10.5588/pha.13.0078.
[10] S. Ansari, M.F. Amanullah, K. Ahmad, R.K. Rauniyar, Pott’s spine: diagnostic
imaging modalities and technology advancements, N. Am. J. Med. Sci. 5 (7) (2013)
404–411, https://doi.org/10.4103/1947-2714.115775.
[11] J.S. Bresee, M.S. Edwards, Psoas abscess in children, Pediatr. Infect. Dis. J. 9 (3)
(1990) 201–206, https://doi.org/10.1097/00006454-199003000-00011.
[12] B. Nagi, R. Kochhar, D.K. Bhasin, K. Singh, Colorectal tuberculosis, Eur. Radiol. 13
(8) (2003) 1907–1912, https://doi.org/10.1007/s00330-002-1409-z.
[13] C. Sohrabi, G. Mathew, N. Maria, A. Kerwan, T. Franchi, R.A. Agha, The SCARE
2023 guideline: updating consensus surgical CAse REport (SCARE) guidelines, Int.
J. Surg. Lond. Engl. 109 (5) (2023) 1136.
[14] M. Yanagawa, F. Morishita, K.H. Oh, K. Rahevar, T.A. Islam, S. Yadav,
Epidemiology of tuberculosis in the Pacific island countries and areas, 2000-2020,
Western Pac. Surveill. Response J. 14 (1) (2023) 1–12. Published 2023 Feb 22, http
s://doi.org/10.5365/wpsar.2023.14.1.996.
[15] J.B. Mehta, A. Dutt, L. Harvill, K.M. Mathews, Epidemiology of extrapulmonary
tuberculosis. A comparative analysis with pre-AIDS era, Chest 99 (5) (1991)
1134–1138, https://doi.org/10.1378/chest.99.5.1134.
[16] D. Bush, E. Natuzzi, G. Koburu, M. Bana, F. Taki, A. Melly, Tropical diabetic hand
syndrome in a Solomons Islands adult: a case report of a rare complication, Int. J.
Surg. Case Rep. 105 (2023), 108042, https://doi.org/10.1016/j.
ijscr.2023.108042.
[17] S. Panthi, P. Khatiwada, S. Adhikari, et al., Intestinal tuberculosis masquerading as
carcinoma colon: a case report of diagnostic quandary in low-resource setting,
J. Surg. Case Rep. 2022 (5) (2022), rjac210. Published 2022 May 24, https://doi.
org/10.1093/jscr/rjac210.

6
D. Bush et al.
[18] R. Chandradevan, H. Takeda, T. Lim, N. Patel, Mycobacterium tuberculosis
concealed by enterococcal sacroiliitis, IDCases 21 (2020), e00858. . Published 2020
Jun 1, https://doi.org/10.1016/j.idcr.2020.e00858.
[19] S.E. Weinberg, A.M. Mughal, A case of intestinal tuberculosis mimicking Crohn’s
disease: a clinical and diagnostic dilemma, Eur J Case Rep. Intern. Med. 8 (11)
(2021), 002699. Published 2021 Nov 9, 10.12890/2021_002699.
International Journal of Surgery Case Reports 114 (2024) 109141
[20] E. Nacarapa, I. Munyangaju, D. Osório, et al., Extrapulmonary tuberculosis
mortality according to clinical and point of care ultrasound features in
Mozambique, Sci. Rep. 12 (1) (2022), 16675. Published 2022 Oct 5, https://doi.
org/10.1038/s41598-022-21153-z.