title: Tuberculosis of the pubic symphysis: four unusual cases and literature review.
abstract: BACKGROUND
  The incidence of extrapulmonary tuberculosis (TB) has increased in the chemotherapeutic era owing to the increasing presence of immunodeficiency disorders. Pubic symphysis TB, although uncommon, is again important as these infections once were in the prechemotherapeutic era.
  
  
  METHODS
  We present the cases of four patients with pubic symphysis TB in which one patient had a horseshoe-shaped abscess in the pubic region and another had a double lesion of the pelvis leading to vertical shear-type pathologic displacement. Three patients were diagnosed by cytology and PCR. These patients were treated successfully with antituberculosis treatment with or without minimal surgical intervention despite their late presentation and advanced disease. The fourth patient remains under treatment and followup.
  
  
  METHODS
  We identified 40 patients with TB of the pubic symphysis in the English language medical literature. Of these 40 patients, only five are from India despite TB being endemic in this country. Followup information is available for 32 of the 40 patients with followups ranging from 1 to 84 months (mean of approximataly 20 months).
  
  
  CONCLUSIONS
  We suspect TB of the pubic symphysis is increasing in frequency owing to drug resistance, use of biologics, immunomodulating drugs, and anticancer drugs. Therefore, it is important for clinicians to have a high index of suspicion in patients at risk. Initially patients may be asymptomatic or present with adductor region pain or spasm, sacroiliac strain, limp, or a hypogastric, inguinal, or thigh mass that mimics an inguinal hernia, genitourinary, abdominal, or thigh tumor.
  
  
  CONCLUSIONS
  It is important to diagnose and treat pubic TB early in the course of the disease before the destructive stage. After relevant investigations most patients can be treated with antitubercular drugs with or without a minor surgical procedure.
authors.affiliation: Department of Orthopaedics, PGIMER, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India, drhiteshlall@gmail.com.
authors.forename: Hitesh
authors.initials: H
authors.lastname: Lal
authors.forename: Vijay Kumar
authors.initials: VK
authors.lastname: Jain
authors.forename: Sudhir
authors.initials: S
authors.lastname: Kannan
mesh_terms: D000293:Adolescent; D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011631:Pubic Symphysis / Q000473:pathology*; D016896:Treatment Outcome; D014394:Tuberculosis, Osteoarticular / Q000175:diagnosis* / Q000188:drug therapy / Q000601:surgery
chemical_list: D000995:Antitubercular Agents