Recurrent tubercular gluteal abscess in an adolescent: a rare manifestation

Abstract Background Extra-pulmonary tuberculosis presenting as a gluteal abscess is uncommon in children and poses diagnostic and therapeutic challenges. The emergence of drug-resistant tuberculosis further complicates management, leading to recurrent abscesses and bone involvement such as sacral osteomyelitis. Case Presentation A 16-year-old female presented with a two-month history of painful swelling over the left gluteal region and difficulty in walking, without fever, trauma, or TB contact. She had weight loss and poor appetite. Examination revealed a firm, tender swelling with dilated veins. Ultrasonography showed a large multiloculated collection, and MRI of the pelvis revealed a thick-walled abscess extending into the presacral region with sacral nerve root enhancement. Aspiration yielded 300 ml of pus, and the Xpert/Rif assay detected Mycobacterium tuberculosis with rifampicin resistance; subsequent testing confirmed INH and fluoroquinolone resistance, consistent with Pre-XDR-TB. The patient was initiated on a second-line antitubercular regimen including bedaquiline, linezolid, clofazimine, and cycloserine. Despite initial improvement, she developed recurrent abscesses requiring multiple drainage procedures. An MRI of the spine later showed sacral osteomyelitis with presacral and epidural extension. Ethionamide and Delamanid were sequentially added, leading to gradual clinical improvement with continued follow-up. Discussion This case illustrates the diagnostic complexity and therapeutic difficulty of pre-XDR-tubercular abscess with sacral osteomyelitis in an adolescent. Conclusion Early imaging, microbiological confirmation, individualized multidrug therapy, and vigilant monitoring are crucial for favorable outcomes in recurrent extrapulmonary tuberculosis. Learning points