TIBIAL OSTEITIS CAUSED BY MYCOBACTERIUM TUBERCULOSIS A CASE REPORT
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Tuberculosis is a major scourge, posing a serious public health problem in countries where it is endemic. Osteoarticular involvement accounts for 3 to 5% of all tuberculosis cases and 10 to 15% of extrapulmonary tuberculosis cases. We report a case of tibial osteitis caused by Mycobacterium tuberculosis in a 52-year-old female patient who presented to the trauma department at the Mohammed V Military Teaching Hospital with a painful swelling of the lower part of her left leg. Standard X-rays and computed tomography (CT) scans revealed bone involvement, specifically in the tibia. In an endemic context, any persistent and atypical bone lesion should raise suspicion of osteoarticular tuberculosis to enable rapid diagnosis and appropriate therapeutic management. In the absence of other suggestive pulmonary or extrapulmonary lesions, the diagnosis also relies on the exclusion of other pathologies, such as malignant tumors, which may present with similar clinical and radiological features.
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The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
Abstract * The abstract gives a concise overview of the case but should be made more internally consistent. * Revision suggestions: o The statement in Lines 18-19 regarding "absence of other suggestive pulmonary or extrapulmonary lesions" contradicts later findings (i.e., pulmonary consolidation and splenic involvement). Please revise for consistency. o Maintain italics for Mycobacterium tuberculosis throughout the manuscript, including the abstract. ________________________________________ Introduction * The introduction provides a good starting point but lacks epidemiological grounding for the local context. * Revision suggestions: o Please include more epidemiological data specific to Morocco, such as TB incidence/prevalence, extrapulmonary TB trends, or skeletal TB burden. o Reconsider the phrase …
Comments to Author
Abstract * The abstract gives a concise overview of the case but should be made more internally consistent. * Revision suggestions: o The statement in Lines 18-19 regarding "absence of other suggestive pulmonary or extrapulmonary lesions" contradicts later findings (i.e., pulmonary consolidation and splenic involvement). Please revise for consistency. o Maintain italics for Mycobacterium tuberculosis throughout the manuscript, including the abstract. ________________________________________ Introduction * The introduction provides a good starting point but lacks epidemiological grounding for the local context. * Revision suggestions: o Please include more epidemiological data specific to Morocco, such as TB incidence/prevalence, extrapulmonary TB trends, or skeletal TB burden. o Reconsider the phrase "relatively common" in Line 31—3-5% of all TB cases may not be considered "common." Clarify or provide regional data to contextualize. o Ensure Mycobacterium tuberculosis is italicized throughout. ________________________________________ Case Report * This section is comprehensive but would benefit from clarification and additional clinical detail. * Revision suggestions: o Was the mass measured on physical examination or imaging? Please provide dimensions. o The patient received treatment by her rheumatologist—please specify what treatment was administered (e.g., NSAIDs, corticosteroids). o The patient had no symptoms of infection and no inflammatory signs at the ankle—please define what these signs are (e.g., erythema, warmth, tenderness) for the benefit of non-specialist readers. o Lines 61-63 mention "absence of typical malignant features"—please elaborate on what those features would be (e.g., periosteal reactions, cortical destruction). o Also clarify what is meant by "characteristic lesions" on imaging that suggested TB. o Line 65: Please confirm that the oxygen saturation of 94% was on room air. o From Line 71 onwards, there is an extensive list of blood test results—this can be abbreviated to relevant abnormal values only, particularly as most were normal. o Define all acronyms on first use: HBV (hepatitis B virus), HCV (hepatitis C virus), HIV (human immunodeficiency virus). o Lines 94-98: Imaging revealed consolidation, bronchiectasis, and splenic lesions. Yet the patient reported no respiratory symptoms—please clarify this. o The term "secondary involvement" of the spleen should be clarified—secondary to TB or another infectious focus? ________________________________________ Results * This section is clear but would benefit from precise language and consistency. * Revision suggestions: o Avoid stating that "AFB on ZN staining confirmed Mycobacterium tuberculosis"—this is presumptive. The presence of AFB suggests Mycobacterium species; confirmation came from culture and PCR. o Spell out MGIT on first use: Mycobacteria Growth Indicator Tube. o If abbreviations of anti-TB drugs are introduced (INH, RIF, PZA, EMB), ensure they are used consistently throughout, or consider omitting the abbreviations if unused elsewhere. o Italicize Mycobacterium tuberculosis throughout the section. ________________________________________ Discussion * The discussion contextualizes the case adequately but would benefit from expanded comparison with literature and minor structural edits. * Revision suggestions: o Consider citing additional similar case reports or small reviews of tibial osteitis or skeletal TB to strengthen generalizability and highlight rarity. o Avoid repeating extensive treatment details already covered in the Results—focus on clinical reasoning, challenges, and outcomes. o If available, comment on patient follow-up or clinical outcome, as this would enhance clinical relevance. o Maintain proper formatting of bacterial names. ________________________________________ Recommendation: Minor Revisions This is a well-constructed and interesting case report. With minor revisions for consistency, clinical clarity, and formatting, it will make a valuable contribution to the literature on extrapulmonary TB.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
The manuscript is well written and and presents an important case report of an often difficult to diagnose presentation of extra-pulmonary TB. Minor comments: Abstract: Please include that microscopy, culture, Xpert MTB and histology all retrieved positive results for Mycobaterium tuberculosis. Line 39 Symptoms -> please include a reference. Line 61 - what other non-specific infections were suspected? This can help clinicians facing similar cases. Line 109 - if available please include Cq values for the different GeneXpert MTB/Rif assays. Figure 4: not 100% convinced the red arrow points to an acid-fast bacillus. Everything in this image looks blue and I would expect the AFB to have a red/purple colour, since they resist the decolouration with acid ethanol after the carbolfuchsin stain. Since …
Comments to Author
The manuscript is well written and and presents an important case report of an often difficult to diagnose presentation of extra-pulmonary TB. Minor comments: Abstract: Please include that microscopy, culture, Xpert MTB and histology all retrieved positive results for Mycobaterium tuberculosis. Line 39 Symptoms -> please include a reference. Line 61 - what other non-specific infections were suspected? This can help clinicians facing similar cases. Line 109 - if available please include Cq values for the different GeneXpert MTB/Rif assays. Figure 4: not 100% convinced the red arrow points to an acid-fast bacillus. Everything in this image looks blue and I would expect the AFB to have a red/purple colour, since they resist the decolouration with acid ethanol after the carbolfuchsin stain. Since the culture, qPCR and histology results are very convincing, can the authors justify this? What was the counter staining time? is there a better image with more typical coloured AFB? Line 130-132 is repetition of line 122-126. I advise to remove it. It would be interesting to have a follow up on the outcome after completing the treatment regime. I appreciate this information might not be available, but it would make the case report more complete and helpful for other clinicians. Line 150 Xpert MTB/RIF has a very good specificity, but it is not 100%. Please present this with confidence intervals and cite your source as it varies depending on the population (high prevalence, low prevalence, HIV co-infection, etc). Line 154 ZN staining also needs a very trained technician and is quite labour intensive. You mentioned there was 1-10 AFB/100 field, which is not many at all. The AFB you present in Fig4 is also not typically pink coloured which would almost certainly evade a less trained analyst. These observations also showcase how challenging it is to diagnose extra pulmonary TB and enrich your discussion.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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