Atypical disseminated tuberculosis with multi-organ involvement and secondary infertility in an immunocompetent female: a case report and review of the literature

Abstract

Introduction and importance:

Tuberculosis (TB), caused by Mycobacterium tuberculosis, is a widespread infection. While typically affecting the lungs, 10%–20% of cases involve extrapulmonary sites. Disseminated TB with involvement of multiple contiguous or non-contiguous organs is a rare phenomenon.

Presentation of case:

A 28-year-old female from Garbo, Ethiopia, presented with a 1-year history of lower back pain and chronic pelvic pain, amenorrhea, and secondary infertility. She also reported 6 months of progressive left middle finger swelling and constitutional symptoms. Examination revealed a chronically ill and tenderness in her left middle finger and lower back. Investigations showed mild iron deficiency anemia. X-rays of the left hand and lumbosacral region, along with abdominopelvic ultrasound, revealed osteomyelitis of the finger and lumbar endplate destruction with bilateral psoas abscesses. Aspirate from the psoas abscess was positive for M. tuberculosis by GeneXpert. The patient was treated with 2RHZE/10RH and showed improvement.

Clinical discussion:

Disseminated TB presents with varied symptoms and affects different sites outside the lungs. Rare in immunocompetent individuals, risk factors include malnutrition, malignancy, retroviral infection, substance abuse, and extremes of age. Lymphohematogenous spread is common. Disseminated TB can affect any organ system, and it rarely presents with the involvement of multiple organs simultaneously, as seen in our patient. Diagnosis relies on organ-specific imaging and bacteriological confirmation. Treatment adheres to updated World Health Organization and national guidelines to improve patient outcomes.

Conclusion:

Disseminated TB is rare but requires prompt diagnosis and treatment. Resource limitations hinder diagnosis and management, necessitating community awareness and infrastructure improvements.

Introduction

Tuberculosis (TB) is a chronic infection caused by Mycobacterium tuberculosis, with a global distribution but disproportionately affecting low- and middle-income countries, such as Ethiopia^[1,2]. In 2022, TB affected approximately 10.6 million people worldwide, resulting in 1.3 million deaths^[2]. These figures highlight the urgent need for intensified efforts to reduce TB-related morbidity and mortality^[2]. While TB primarily presents with pulmonary involvement, approximately 10%–20% of affected individuals experience extrapulmonary TB^[3]. Extrapulmonary TB can involve various organ systems, either in isolation or through simultaneous multisystem involvement^[3]. Disseminated TB arises from lymphohematogenous spread from primary, noncontagious sites; reactivation of latent infection; or, less commonly, from iatrogenic causes^[4]. The manifestations of disseminated TB range from nonspecific symptoms such as fever, loss of appetite, and weight loss to organ-specific manifestations depending on the organs involved^[5]. Diagnosing disseminated TB is challenging due to its nonspecific manifestations^[6]. Therefore, a high index of suspicion and appropriate organ-specific investigations are essential, particularly in high TB burden areas like Ethiopia^[6]. Adherence to updated World Health Organization (WHO) and national TB guidelines for prompt and appropriate management is crucial to improve patient outcomes and prevent mortality and morbidity^[2].

HIGHLIGHTS.

• Tuberculosis (TB) is a common disease with variable rare presentations.

• Simultaneous multi-organ involvement is a rare presentation of disseminated tuberculosis.

• Disseminated tuberculosis continues to pose a challenge in resource-limited settings, despite considerable efforts.

• Resource limitations can impact patient diagnosis and outcomes.

• A high index of suspicion is crucial for timely diagnosis and management, which can improve patient outcomes and prevent complications.

We present a case of disseminated extrapulmonary TB in a 28-year-old a para 1 female who presented with a 1-year history of nonspecific symptoms, lower back pain, left middle finger swelling, and amenorrhea. The patient was ultimately diagnosed with disseminated TB involving multiple noncontagious sites, including the spine with bilateral psoas abscesses, the left middle finger, endometrium, and adnexa, contributing to her amenorrhea and infertility. The patient was then successfully treated with anti-TB therapy. This case report has been reported in line with the SCARE 2025 guideline^[7].

Case presentation

A 28-year-old female patient from Garbo, Somali Region, Ethiopia, presented with a 1-year history of progressive lower back pain. The pain was described as a deep, aching sensation. She also reported an intermittent, foul-smelling vaginal discharge, for which she had been repeatedly treated for vaginal discharge syndrome at a local health center. The treatments provided only mild and temporary relief, with the discharge recurring. The patient is a para 1, having given birth 3 years ago, and reports secondary infertility (inability to conceive). She also experienced amenorrhea, despite not using any contraceptives. Additionally, she reports progressive swelling of her left middle finger for the past 6 months, accompanied by pain, but with no associated skin color change or discharge. Her other complaints include low-grade, intermittent fever, significant unquantified weight loss, and loss of appetite. She denies cough, chest pain, or other bone pain. She reports no other chronic medical illnesses. The patient’s male partner has two additional wives in accordance with local customs and has sired more than five children (two by one wife and three by the other). He has no scrotal swelling, and his other wives have no related complaints.

Physical examination revealed a stable patient who appeared chronically ill. No lymphadenopathy was noted. The left middle finger was swollen with mild tenderness, as shown in Figure 1. Lower back and deep pelvic tenderness were elicited on palpation. No other pertinent findings were noted.

Figure 1.

Gross left hand picture; the figure of the left middle finger displays significant swelling, along with an ulcerated area on its lateral side. The ulcerated area is red and raw, featuring some crusting or slough. The surrounding skin exhibits inflammation and potential scarring.

Investigations revealed: a normal white blood cell count; hemoglobin of 10 g/dL; mean corpuscular volume of 65 fL; normal other cell lines; erythrocyte sedimentation rate (ESR) of 100 mm/hr; serum creatinine of 0.9 mg/dL. Normal alanine transaminase, random blood sugar, aspartate transaminase, and bilirubin. Human immunodeficiency virus serostatus, Venereal Disease Research Laboratory test, and urine human chorionic gonadotropin were all negative. A biopsy of the left middle finger, performed at a private hospital, revealed fragments of tissue consisting of caseating epithelioid granuloma, multinucleated giant cells, chronic inflammatory cells, and pieces of dead bone. These findings are suggestive of tuberculosis osteomyelitis. No features of malignancy were identified. A chest X-ray was normal. A left-hand X-ray is shown in Figure 2.

Figure 2.

Left hand X-ray showed middle finger proximal phalanx: there is cortical destruction, increased cortical thickness, and sclerotic change also involving the medulla. Soft tissue thickening is seen. No sinus tract seen.

A lumbosacral X-ray is shown in Figure 3; MRI was unavailable.

Figure 3.

Lumbosacral X-ray revealed: L1 vertebral body asymmetry; a 7 mm discrepancy indicating height loss on the left side; lower endplate destruction on the ipsilateral side; narrowing of the L1/L2 disc space; and collapse of the L1 vertebral body with narrowing of the disc space. These findings are suggestive of TB spondylitis.

Abdominopelvic ultrasound findings revealed bilateral psoas abscesses measuring 11.6 × 5.4 cm on the right and 8.58 × 4.11 cm on the left, demonstrating complex fluid collections as shown in Figure 4. There is also an endometrial collection measuring 4.5 × 3.8 cm with an anechoic component; free fluid in the cul-de-sac; and a 4.4 × 3.7 cm echo debris collection with calcification in the left adnexa, leading to the overall conclusion of bilateral psoas abscesses, bilateral pyosalpinx with calcification, and an endometrial collection. An ultrasound-guided aspiration was performed, yielding 5 mL of purulent fluid from a right psoas collection, as shown in Figure 5. This fluid was sent for GeneXpert analysis, which was positive for M. tuberculosis, with no rifampicin resistance detected.

Figure 4.

Ultrasound showing bilateral psoas abscesses measuring 11.6 × 5.4 cm on the right and 8.58 × 4.11 cm on the left, demonstrating complex fluid collections.

Figure 5.

Ultrasound-guided sample from psoas abscess.

Based on these findings, disseminated TB involving left middle finger osteomyelitis, Pott’s disease, psoas abscesses, bilateral pyosalpinx, and endometrial TB with secondary infertility was diagnosed. The patient was started on a 2-month intensive phase of rifampicin, isoniazid, pyrazinamide, and ethambutol (2RHZE), followed by a 10-month continuation phase of rifampicin and isoniazid (10RH), adhering to WHO and national TB guideline recommendations.

The patient was seen for a follow-up appointment after 2 weeks, demonstrating adherence to her medication regimen and reporting no drug side effects, although the pain persisted. A subsequent follow-up appointment 1 month later revealed a decrease in the psoas collection and improvement in her constitutional symptoms. As of September, the patient is in her 6th month of anti-TB treatment and is doing well. The patient was advised to undergo further evaluation after completion of anti-TB therapy, including hysteroscopy to assess uterine and tubal status and to inform her conception prognosis.

Discussion

Disseminated extrapulmonary TB presents with variable manifestations and involvement of different extrapulmonary sites. Spinal involvement with bilateral psoas abscesses accounts for only approximately 5% of all extrapulmonary TB cases^[8], while isolated finger involvement occurs in less than 2%^[9]. Isolated involvement of the female genitourinary tract, specifically the ovaries, adnexa, and endometrium, is also a rare phenomenon, occurring in approximately 1% of cases^[10]. However, our patient presented with the combined involvement of the spine, bilateral psoas abscesses, left middle finger, and female genitourinary tract, a truly exceptional presentation.

Disseminated TB is rare in immune-competent individuals, accounting for less than 2% of all TB cases worldwide^[5]. However, it represents approximately 20% of extrapulmonary TB cases in this population^[5]. Although our patient lacks identifiable risk factors for disseminated TB, it’s important to note that this presentation is more commonly observed in individuals with malnutrition, malignancy, retroviral infection, substance abuse, or at the extremes of age^[11]. Disseminated TB can affect any organ in the body, including the eyes, pleura, peritoneum, liver, central nervous system, bones, kidneys, adrenal glands, and thyroid, either individually or simultaneously in multiple organs^[12,13].

The pathophysiology of disseminated TB, involving multiple organs, can result from contiguous spread or lymphohematogenous dissemination from distant sites^[4,5]. Given our patient’s involvement of multiple non-contiguous organs, hematogenous spread is the most likely source. However, the presence of Pott’s disease with a psoas abscess and genitourinary tract involvement raises the possibility of contiguous spread as well. The origin of the psoas abscess is uncertain. It could represent a primary site of tuberculous infection^[14]. Alternatively, given our patient’s spinal TB, the abscess is more likely to have developed as a result of spinal involvement^[14]. Furthermore, the genitourinary tract involvement in this patient could have resulted from the contiguous spread of the infection from the spine, particularly given the anatomical proximity^[15].

The clinical presentation of disseminated TB is highly variable and depends on numerous factors, including the patient’s age. Younger and older patients may exhibit nonspecific, chronic symptoms such as fever, loss of appetite, weight loss, and fatigue. Another key factor is the duration of illness; while most patients experience chronic symptoms for months to years, approximately 50% present after more than 1 month of symptoms^[1,4,6]. In addition to these nonspecific symptoms, patients with disseminated TB often develop organ-specific manifestations and complications^[1]. Our patient presented with a combination of chronic, nonspecific symptoms and organ-specific findings. Given that our patient exhibits both potentially contiguous and non-contiguous manifestations, it is challenging to determine the initial site of infection. While the patient reports noticing nearly all manifestations concurrently, with only slightly earlier onset of lower back pain, this complicates pinpointing the primary focus. Pott’s disease typically presents with chronic back pain and constitutional symptoms^[3], as seen in our patient. However, some patients may present with significant complications like vertebral fracture and paraparesis, which significantly impact their overall condition^[3]. A less common complication of Pott’s disease, as observed in our patient, is a unilateral or bilateral psoas abscess^[3,8]. Female genitourinary TB can present with nonspecific symptoms or menstrual irregularities^[16]. Our patient experiences amenorrhea and has a history of secondary infertility^[16]. Other potential manifestations, not observed in our patient, include vaginal discharge^[10,15]. The typical age range for female genital TB is 20–40 years^[17], consistent with our patient’s age of 28. Her secondary infertility, given her risk factors, is possibly caused by the genitourinary TB. Among the mechanisms of infertility in female genital TB, tubal disease is predominant^[18]: tuberculous salpingitis causes endosalpinx destruction, peri-tubal adhesions, and fibrosis that produce tubal obstruction (often seen as blocked tubes or hydrosalpinx on hysterosalpingography), while immune-mediated inflammation and granuloma formation damage the ciliated epithelium and impair tubal motility^[18,19]. Endometrial involvement is another important mechanism of infertility; our patient had an endometrial collection^[18,19]. Tuberculous endometritis can lead to intrauterine adhesions (Asherman’s syndrome), which are diagnosed and often treated by hysteroscopy^[18,19]. Although hysteroscopy was not performed in this case, all patients should be advised to undergo reassessment after completing anti-TB therapy to determine whether the uterine damage is reversible. Endometrial scarring may also cause implantation failure, further compromising fertility^[19]. Our patient’s adnexal collection suggests possible ovarian involvement, which can cause primary or secondary infertility through endocrine dysfunction or mechanical destruction of ovarian tissue, leading to impaired steroidogenesis and failure of ovulation^[18,19]. The cause of infertility in our patient may be from any one or from a combination of the fallopian tubes, endometrium, and ovaries involvement.

Finger involvement in TB can range from simple cutaneous (skin) manifestations to deep bone involvement^[20]. Our patient exhibits both types of manifestations in her fingers.

Diagnosing disseminated TB is often challenging due to its nonspecific manifestations and delayed presentation with complications^[4,5]. As exemplified by our patient, who suffered for over a year and visited local clinics multiple times with nonspecific symptoms, diagnosis can be significantly delayed^[11]. Resource limitations, such as the absence of advanced imaging modalities like magnetic resonance imaging (MRI) and hysteroscopy, as well as access to histopathologic examination, further compound these diagnostic difficulties, as seen in this case^[3,15]. Diagnosis depends on baseline and organ-specific investigations combined with microbiological confirmation^[6]. Accurate diagnosis of disseminated TB hinges on specific imaging techniques and biological confirmation^[14]. For genitourinary TB, the diagnostic process typically begins with imaging to localize the lesion and assess the extent of involvement^[15]. In our patient, imaging revealed endometrial, adnexal, and pyosalpinx involvement^[15]. Ideally, this would be followed by a laparoscopic-guided histopathologic examination demonstrating granulomatous inflammation with caseous necrosis^[15]. However, this procedure is not available in our setting. Alternative confirmatory tests, such as discharge and urine cultures for M. tuberculosis, are also unavailable^[11]. For spinal TB and psoas abscess, MRI is considered the gold standard diagnostic modality. In the absence of MRI, computed tomography (CT) scanning is the next best option^[3]. However, lacking access to both, we relied on abdominopelvic ultrasound, which revealed bilateral psoas abscesses, and a lumbosacral X-ray suggestive of TB. Ultrasound-guided aspiration of the psoas abscess yielded a purulent discharge, which tested positive for M. tuberculosis via GeneXpert, with no rifampicin resistance detected. Diagnosing finger TB presents additional challenges due to the overlap with other differential diagnoses, such as bacterial osteomyelitis^[20]. In resource-limited settings, X-ray imaging revealing bone necrosis can be suggestive. In settings with greater resources, hand MRI is considered the gold standard^[9,20]. Histopathologic examination demonstrating granulomatous inflammation, with or without caseous necrosis, further supports the diagnosis^[20]. Acid-fast bacillus staining of the sample provides another alternative confirmatory method.

Similar cases have been reported in the same center; Nur et al^[21] described a 30-year-old female with Pott’s disease complicated by bilateral psoas abscess during pregnancy at Garbo Primary Hospital in Somali, Ethiopia, in 2025. Similarly, Tebeje et al^[22] described female genitourinary tubo-ovarian TB in a multiparous 40-year-old female patient. In addition to these reports, we have previously reported a 32-year-old male with Pott’s disease and bilateral psoas abscess at our hospital, which was confirmed by GeneXpert analysis of collected material^[23]. We previously discussed the diagnostic challenges faced in this setup.

Following the diagnosis of disseminated TB, management adheres to the WHO and national guidelines^[2]. Given the patient’s bone involvement, treatment consists of 2 months of rifampicin, isoniazid, pyrazinamide, and ethambutol (2RHZE), followed by 10 months of rifampicin and isoniazid (10RH), along with pyridoxine supplementation^[3]. Close monitoring for drug side effects and adherence to medication is crucial. The patient has experienced no complications and demonstrates improved outcomes.

The overall conception rate generally ranges from 20% to 60%, depending on numerous factors^[24]. These include the degree of structural damage, the patient’s age, previous obstetric history, presence of comorbidities, the promptness of treatment, and the use of assisted reproductive technologies such as IVF^[24]. Given our patient’s adherence to medication, young age, absence of comorbidities, and history of a previous successful delivery, a good prognosis is anticipated. However, despite these positive indicators, a referral for a comprehensive gynecologic evaluation will be necessary at the end of treatment.

Conclusion

Disseminated TB, while a rare manifestation of a common chronic disease, requires a high index of suspicion for timely diagnosis. Early and appropriate anti-TB treatment significantly improves patient outcomes and prevents chronic complications. While anti-TB therapy is essential, it sometimes cannot reverse pre-existing structural damage to the fallopian tubes and endometrium. Therefore, further gynecologic evaluation is often required to determine subsequent treatment. However, diagnosis and management pose considerable challenges in resource-limited settings, due to factors such as limited access to advanced imaging and late patient presentation. Therefore, community awareness programs and improvement of diagnostic and treatment infrastructure are crucial.

Strength and limitation

This case report highlights the atypical presentation of disseminated TB with multi-organ involvement in a resource-limited setting, providing valuable insights for similar contexts. However, a limitation of this report is the absence of advanced imaging, such as MRI of the spine and CT of the abdomen for the psoas abscess, which are considered the gold standard for these conditions.

Ethical approval

Ethical approval for this study was provided by our institution’s ethical review committee.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

There is no source of funding found for this paper.

Author contributions

Conceptualization, design of the study, acquisition of data, drafting the article, revising it critically for important intellectual content, and approval of the version to be submitted: A.A.A.; analysis, interpretation of data, drafting the article, revising it critically for important intellectual content, and approval of the version to be submitted: W.A.N.; conceptualization, analysis, drafting the article, revising it critically for important intellectual content, and approval of the version to be submitted: M.A.I.; acquisition of data, analysis, revising it critically for important intellectual content, and approval of the version to be submitted: A.I.G.; acquisition of data, analysis, revising it critically for important intellectual content, and approval of the version to be submitted: M.M.H.; acquisition of data, analysis, revising it critically for important intellectual content, and approval of the version to be submitted: M.A.H.

Conflicts of interest disclosure

All authors declare that they have no conflict of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Addisu A. Ayen, MD.

Provenance and peer review

Not applicable.

Data availability statement

Not applicable.

Declaration of generative AI and AI-assisted technologies in the writing process

AI language modeling tools were utilized for the improvement of the English language only in this case report.