Femoral head aseptic necrosis is a common complication after HSCT. In allogeneic HSCT recipients, hip tuberculosis on top of aseptic necrosis is infrequent and the mortality is high.

We present a case of hip joint tuberculosis in a 57-year-old man with acute myelomonocytic leukemia (M4) treated with HSCT. The patient developed extensive chronic graft versus host disease (cGVHD) five months after transplantation and was treated with cyclosporine and corticosteroids. Eight months after the transplantation because of low-grade fever, elevated ESR and abnormal chest CT scan findings, empirical anti-TB treatment started despite negative tuberculin skin test. Three weeks later anti-TB treatment was stopped because of hepatic enzyme elevation. One year after the transplantation he complained about bilateral hip pain. MRI revealed bilateral femoral head aseptic necrosis. One year later, the right femoral head collapsed, and suddenly, rapid hip joint destruction occurred. He was planned to have total right hip arthroplasty. During the operation an abscess was evacuated and biopsy showed tuberculosis. Necrotic tissues and bone were removed and suction drainage was applied. Diagnosis was confirmed by acid-fast stain, PCR and cultures. In BACTEC MGIT 960 culture system and on Löwenstein-Jensen Mycobacterium tuberculosis was isolated, which was sensitive to all first line anti-TB drugs. After one year of anti-TB treatment (HRZE for 2 months followed by HRE for 10 months), synovial fluid samples were negative for tuberculosis. The patient was submitted to cementless total left hip replacement. Three months later, the right hip was allografted on the acetabular side and a reinforcement ring was used in order to perform a successful total hybrid arthroplasty. Nine months postoperatively the patient is symptom free and able to walk.

Tuberculosis should be considered in the differential diagnosis when rapid joint destruction occurs. Early diagnosis improves response to anti-TB therapy and surgery.

A 51-year-old Caucasian woman was admitted to the Rheumatology Department of our hospital due to a 3-week history of diffuse neck, shoulder and upper torso pain, exacerbated by movements. An outpatient trial of non-steroidal anti-inflammatory medications had been unsuccessful. A few days later, the pain was localised above the manubrium, the left clavicle and sternomastoid muscle and fever up to 39.5°C was reported. The patient had no significant past medical history and lived in a suburban area. She did not work and liked to do gardening in her spare time. There was no history of local trauma or any medications. On examination, there was intense redness, tenderness and swelling of the manubrium and the left sternoclavicular joint. Chest CT revealed osteolytic changes of the manubrium and presence of inflammatory tissue surrounding the manubrium and extending posteriorly. The lung parenchyma was unaffected. Brain and abdominal CT were unremarkable. A triple-phase bone scan was indicative of sternal osteomyelitis without other bone involvement. Blood and urine cultures remained negative. The patient was empirically treated with high-dose intravenous vancomycin and ciprofloxacin with no response. Antibody testing to human immunodeficiency virus and hepatitis viruses was negative. An open biopsy was performed 1 week later, revealing persistent inflammatory tissue around the sternum and fluid collection posteriorly. Multiple bone specimens were sent for histological examination and cultures. Histology showed acute and chronic granulomatous inflammation, while both cultures of the bone marrow and the fluid revealed Nocardia nova. No other pathogen was identified. The patient responded to high-dose intravenous trimethoprim-sulfamethoxazole, which was continued on an outpatient basis for 1 year without further sequelae.

This is the first reported case of primary sternal osteomyelitis due to Nocardia species. The possibility of nocardiosis needs to be included in the differential diagnosis of sternal osteomyelitis, even for apparently immunocompetent adults.