Bilateral tuberculous psoas abscess in an immunocompetent patient: a case report and literature review

  1. hamid laatiris
  2. hajar zouaki
  3. yassine benlahlou
  4. benaissa Elmostapha
  5. mariama chadli

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Abstract

L'abcès du psoas est une infection rare, historiquement associée à la tuberculose (TB), bien que les causes bactériennes non tuberculeuses soient de plus en plus fréquentes, Staphylococcus aureus étant le principal agent pathogène. Ce type d'abcès peut être primaire ou secondaire, et son diagnostic est compliqué par le manque de spécificité des symptômes cliniques. La radiologie et la biologie jouent un rôle clé dans le diagnostic. Le cas décrit concerne un patient de 22 ans, sans antécédents médicaux particuliers, présentant des lombalgies mécaniques depuis 18 mois. Les examens cliniques et un scanner ont révélé une protrusion discale non conflictuelle, ce qui a conduit à une prise en charge initiale par anti-inflammatoires non stéroïdiens (AINS), sans amélioration. Face à la persistance des symptômes, des investigations complémentaires ont révélé une localisation rachidienne extrapulmonaire de la tuberculose chez un sujet immunocompétent, présentant des abcès bilatéraux du psoas causés par Mycobacterium tuberculosis (MTB).

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  1. Version published to 10.1099/acmi.0.001003.v3 on Access Microbiology
  2. Access Microbiology

    Comments to Author

    Please ONLY put comments for the Author(s) in here 1. The authors have made corrections in the manuscript as per the editor's comments. 2. Can the authors mention in the discussion, previous case reports on psoas abscess infection with M.tuberculosis? How is this case unique in its presentation and management when compared to the previous literature? 3. Can the authors explain the national protocol for the treatment of psoas abscess due to M.tuberculosis in the case presentation?

    Please rate the quality of the presentation and structure of the manuscript

    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

  3. Access Microbiology

    Comments to Author

    1. There are many grammatical errors in the manuscript. 2. No mention about HIV status of the patient and renal findings, if any. 3. Its is not clear whether the final diagnosis according to the author is primary or secondary. 4. No mention of past history of tuberculosis. 5. Confounders like smoking not mentioned. 6. Status of BCG vaccine is questionable.

    Please rate the quality of the presentation and structure of the manuscript

    Satisfactory

    To what extent are the conclusions supported by the data?

    Partially 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

  5. Access Microbiology

    Comments to Author

    1. It would be nice to mention that the positive growth in the LJ medium confirmed TB by what assay. 2. Is there any phenotypic drug susceptibility testing done? 3. Any chest radiography done in this case? 4. It would be nice to include what test was perform to conclude 3 consecutive sputum were negative for TB.

    Please rate the quality of the presentation and structure of the manuscript

    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

  6. Access Microbiology

    Comments to Author

    Thank you for submitting this interesting and well-documented case. The case description and presentation of results are clear, informative, and logically structured. The manuscript is well organized and highlights the key clinical findings effectively. However, the Discussion section would benefit from further elaboration—particularly by contextualizing the current findings in relation to similar cases reported in immunocompetent individuals. It may also be valuable to address the possibility of undetected underlying pathologies and if this was documented in previously published literature. Additionally, I have a few minor comments for clarification: The term "biology" as used in line 15, and "biological tests" in line 49, require further explanation or more precise terminology to enhance clarity for the reader

    Please rate the quality of the presentation and structure of the manuscript

    Good

    To what extent are the conclusions supported by the data?

    Partially 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

  7. Access Microbiology

    Comments to Author

    The manuscript presents a rare case of bilateral tuberculous psoas abscess in an immunocompetent patient, contributing valuable insights into the atypical presentations of extrapulmonary tuberculosis. However, the manuscript would benefit from enhancements in several areas: Abstract: Comment: The abstract fails to highlight the microbiological diagnosis and the importance of TB in the differential for chronic back pain in endemic areas. misses the key point tuberculous psoas abscess in an immunocompetent host. Include "tuberculosis" and "psoas abscess" early. Briefly describe the diagnostic modality (GeneXpert, AFB staining) and treatment outcome. Introduction: Clear but generic. References are current, but lack depth in microbiological discussion. Expand on epidemiology: TB remains a leading cause of psoas abscesses in endemic countries despite rising pyogenic cases globally. Briefly introduce GeneXpert's role in rapid TB diagnosis. Specify incidence of bilateral cases and their typical association with immunosuppression. Case presentation: Timeline is fairly well presented, radiological findings well described. Follow-up Gap: The patient was lost to follow-up after NSAID therapy. Clarify why follow-up was missed for 18 months. Was there any access issue? Microbiological Diagnosis: Good inclusion of Ziehl-Neelsen and auramine stain. But add more details on culture media and incubation conditions. GeneXpert result lacks cycle threshold (Ct) values or bacterial load category (e.g., high/medium). If possible, mention them. Strong inclusion of contact screening; however, describe if latent TB screening was done (TST/IGRA). Discussion: Rich in anatomical and pathological insights, citing good literature base. Expand on false negatives in AFB smear and sensitivity comparison with culture vs PCR. Consider citing WHO recommendations on the use of GeneXpert in extrapulmonary TB (especially for pus samples). Comparative Review: Include previous case reports of bilateral abscesses in immunocompetent hosts and how this case aligns or differs. Immunocompetent Host: Immunocompetence was inferred, but include HIV, diabetes, renal function, and nutritional status to justify this claim. Treatment Regimen: 4-drug regimen well documented; specify whether DOT (directly observed therapy) was implemented. Title: Current: "The occurrence of bilateral tuberculous psoas abscess in an immunocompetent patient with low back pain unresponsive to non-steroidal anti-inflammatory drugs: A case report and literature review." Comment: The title is overly long and includes unnecessary clinical detail that does not enhance the main finding. Suggested Revision: "Bilateral tuberculous psoas abscess in an immunocompetent patient: a case report and literature review."

    Please rate the quality of the presentation and structure of the manuscript

    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

  8. Version published to 10.1099/acmi.0.001003.v2 on Access Microbiology
  9. Access Microbiology

    Many thanks to the authors for this interesting Case Report. On initial review, the Case Report is well written and presented. However, before I invite reviewers, I do believe some points need to be clarified and/or elaborated in order to improve the the quality of the script for peer-review. Firstly, the Abstract needs to be re-written entirely. On reading your Abstract, all I can ascertain is that a patient presented with back pain that failed to settle with analgesia. Your entire Case Report is based on extra-pulmonary MTB infection in an immunocompetent individual (as far as we know), but this is entirely missed in the Abstract. There is no mention that this patient was eventually diagnosed with bilateral psoas abscesses due to MTB. When reviewers are invited they would often read the Abstract before making a decision on whether the Case Report is worth their time, and your Abstract needs to be substantially improved to reflect your Case Report before being sent out for review. The rest of your manuscript is good. Though, more information on the employment of this individual would be welcomed, besides just 'heavy lifting'. You mentioned 'lumbar spinal syndrome' - for the non-medical reader, please clarify what exactly you mean by this term. The patient was treated with various classes of NSAIDs - NSAIDs are one class, what other medications were administered? Please annotate Figure 1 to highlight the disc protrusion. Regarding the management of this individual, he was prescribed analgesia and discharged despite no clinical improvement and re-presented 18 months later? No interim follow-up? His back pain persisted for more than a year before he re-presented? Were blood tests not performed on the initial visit? It would be nice if you can provide a hypothesis on how this patient contracted MTB. Were Public Health involved? Presumably this was assumed to be a Primary MTB infection and not a reactivation? Also, please italicize all bacterial species throughout the manuscript. Should you require any further clarification, please do not hesistate to reach out. I look forward to receiving your revised manuscript.

  10. Version published to 10.1099/acmi.0.001003.v1 on Access Microbiology