A Case Report on Disseminated Tuberculosis in an Immunocompetent Young Adult

VJM Spring Edition 2026

https://doi.org/10.18130/qq25-kd70

Authors: Olivia Spina, MPH¹ and Henry Fraimow, MD^1,2

Author Affiliation:

¹Cooper Medical School of Rowan University Camden, NJ 08103

² Department of Infectious Disease, Cooper University Hospital, Camden, NJ 080103

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Abstract

Disseminated tuberculosis (DTB) is a rare but life-threatening manifestation of Mycobacterium tuberculosis (MTB) infection characterized by hematogenous spread to two or more noncontiguous sites and often presents with nonspecific symptoms, contributing to delayed recognition and treatment. We report a 24-year-old immunocompetent  with a six-month history of recurrent, spontaneously resolving cutaneous abscesses and significant unintentional weight loss ultimately diagnosed with DTB. This case highlights the diagnostic complexity of disseminated TB in immunocompetent individuals, particularly when cutaneous manifestations predominate, and pulmonary involvement is subtle.

Introduction

Disseminated tuberculosis (DTB) is a severe form of tuberculosis defined by multiple noncontiguous infection sites due hematogenous spread of M.tuberculosis (MTB).¹  It may arise from primary infection, reactivation, or iatrogenic origins.¹  Although TB commonly affects the lungs,  extrapulmonary involvement can occur.^1,2 DTB accounts for approximately 20% of extrapulmonary cases globally, with an estimated 1-2% occurring in immunocompetent patients.³ In the United States specifically, 17% of tuberculosis cases in 2024 were extrapulmonary, with a minority being in immunocompetent patients.^2,4 Further, it is found that non-US born individuals make up the majority of DTB cases in the US and occurs more often in men than women.⁴

Clinical manifestations are nonspecific. Patients commonly suffer from constitutional symptoms such as fever, weight loss, and night sweats and have normal chest radiography (CXR).² This case highlights the challenges of DTB diagnosis in an immunocompetent patient presenting with atypical presentation.

Case Presentation and History

A 24-year-old male from rural Guatemala presented to the emergency department with a large, non-draining abscess on the right posterior trunk (Figure 1). He reported a six-month history of recurrent, spontaneously resolving abscesses on the hands, neck, back arms and legs, along with fatigue and 40-pound unintentional weight loss. He denied hemoptysis but endorsed a productive cough. The patient had immigrated to Camden, NJ three years prior and had no known past medical history. He denied intravenous drug use, HIV exposure, recent trauma, or contact with TB. Vaccination history, including Bacillus Calmette–Guérin (BCG), was unknown.

Figure 1: Painful, cold abscess on the right posterior trunk

Physical examination revealed multiple abscesses, including a draining right supraclavicular wound on the right posterior back. 5-10 cm lesions were noted on the chest wall, shin, and gluteal region. Pulmonary examination was unremarkable. Given the clinical presentation, the patient was admitted for evaluation. Empiric vancomycin was initiated, and incision and drainage were performed on select abscesses. Purulent drainage from the abscesses was sent for acid-fast bacillus (AFB) staining and culture.

Initial imaging revealed necrotic lymphadenopathy, multiple soft tissue abscesses, and hepatic lesions. While no diffuse pulmonary infiltrates were observed, cavitary lesions in the upper lobes were present, prompting TB workup. HIV testing and QuantiFERON-TB Gold test were negative. A sputum culture was AFB-positive, and GeneXpert MTB/RIF assay identified active MTB. These findings confirmed the diagnosis of DTB.

Magnetic resonance imaging (MRI) of the brain revealed bihemispheric ring-enhancing brain lesions consistent with tuberculomas, though neurologic exams remained normal (Figure 2). Spinal imaging demonstrated a thoracolumbar fluid collection suggestive of hematogenous spread. Abdominal MRI revealed hepatic tuberculomas and the AFB staining of abscess drainage was positive for MTB.

The patient was started on standard first-line therapy of isoniazid, rifampin, pyrazinamide, and ethambutol (RIPE) with pyridoxine. He demonstrated early clinical improvement, with reduced abscess size. After seven inpatient days, he was discharged for outpatient follow up with the county's TB Clinic. At follow-up, he reported weight gain and continued lesion improvement. After four months of well tolerated RIPE therapy, he transitioned to isoniazid and rifampin for an additional five months.

Figure 2: MRI of the brain reveals 4 ring enhancing lesions, each noted by its size marker, consistent with tuberculomas

Discussion

DTB carries a mortality rate of 25% to 30%.² It occurs more frequently in immunocompromised patients, particularly those with advanced HIV or on immunosuppressive therapy.^2,5 Studies have shown that disseminated, multi-organ involvement is significantly more common in immunocompromised individuals, whereas immunocompetent patients more often present with localized extrapulmonary disease.⁵ Pulmonary involvement remains the most common primary site in both groups.^2,5 Overall, DTB is rare in immunocompetent individuals, making this presentation unusual.²

Clinical manifestations are nonspecific and it is estimated that >50% of patients will delay care.^2,4 Many patients initially present to emergency departments with vague symptoms.^6,8 In this case, cutaneous involvement prompted care. This case highlights the need for emergency department providers to be aware of DTB symptoms, as most cases initially present to emergency departments.²  

Diagnosis relies on microbiological confirmation; AFB cultures remains the gold standard.  Imaging plays a critical role in identifying multisystem involvement. However, 10-15% of DTB cases present with non-specific CXR findings.^1,2,8 The consolidations seen in our patients CXR were non-specific and ultimately MRI confirmed DTB multisystem involvement.

This case underscores the rarity and diagnostic difficulty of DTB, particularly in immunocompetent patients who present with minimal pulmonary symptoms. It is important to maintain a high index of suspicion for DTB in patients with disseminated abscesses and constitutional symptoms.

Conclusion

DTB in immunocompetent patients is diagnostically challenging due to nonspecific symptoms, which leads to delayed care and diagnosis.  This patient presented with an atypical DTB presentation of cutaneous lesions but minimal pulmonary symptoms, further complicating diagnosis. This case underscores the importance of maintaining a high index of clinical suspicion for DTB in patients with systemic symptoms from TB endemic areas.

References

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