title: Tuberculosis presenting as multiple intramuscular nodules in a child: a case report.
abstract: BACKGROUND
  Tuberculosis is a global health problem that mostly affects people in developing countries. Tuberculosis can occur in various organ systems and may present with diverse manifestations in the same system. Primary muscular tuberculosis is a very rare condition in both adults and children, and tuberculosis of various muscle groups presenting as intramuscular nodules is an even more uncommon presentation.
  
  
  METHODS
  A 9-year-old Asian girl presented with multiple painless, gradually progressive swellings over different parts of her body for 3 months with no history of contact with tuberculosis. A physical examination was normal except for multiple swellings in her right forearm, a single swelling in her interscapular region and multiple swellings in her right calf. Ultrasonography of swellings revealed multiple nodules in the intramuscular layer. Excisional biopsies performed from two different sites revealed swellings in muscular layers and histopathology showed granulomatous inflammation with caseous necrosis consistent with tuberculosis. The child was started on antitubercular therapy after which the swellings resolved; she was kept on regular follow up.
  
  
  CONCLUSIONS
  Intramuscular nodules in multiple muscular sites may be the presenting symptoms of tuberculosis of the muscles. Tuberculosis of skeletal muscles should be considered in a differential diagnosis when presented with single or multiple masses even when a chest X-ray is normal and there is no evidence of tubercular foci elsewhere in the body.
authors.affiliation: Department of Paediatrics, KIST Medical College Teaching Hospital, Imadol, Lalitpur, Nepal. ajayakdhakal@gmail.com.
authors.forename: Ajaya Kumar
authors.initials: AK
authors.lastname: Dhakal
authors.affiliation: Department of Paediatrics, KIST Medical College Teaching Hospital, Imadol, Lalitpur, Nepal. subashshah2012@gmail.com.
authors.forename: Subhash Chandra
authors.initials: SC
authors.lastname: Shah
authors.affiliation: Department of Paediatrics, KIST Medical College Teaching Hospital, Imadol, Lalitpur, Nepal. devendra.shrestha@gmail.com.
authors.forename: Devendra
authors.initials: D
authors.lastname: Shrestha
authors.affiliation: Department of Surgery, KIST Medical College Teaching Hospital, Imadol, Lalitpur, Nepal. nirojbanepali@yahoo.com.
authors.forename: Niroj
authors.initials: N
authors.lastname: Banepali
authors.affiliation: Department of Pathology, KIST Medical College Teaching Hospital, Imadol, Lalitpur, Nepal. geetikakc@hotmail.com.
authors.forename: K C
authors.initials: KC
authors.lastname: Geetika
mesh_terms: D000995:Antitubercular Agents / Q000627:therapeutic use; D002648:Child; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D018482:Muscle, Skeletal / Q000473:pathology* / Q000648:ultrastructure; D014376:Tuberculosis / Q000175:diagnosis* / Q000188:drug therapy
chemical_list: D000995:Antitubercular Agents