Case Report of a Patient With Tuberculous Osteomastoiditis

Tuberculosis (TB) is one of the main causes of global morbidity and mortality, with high incidence in immunosuppressed patients, especially people living with HIV (PLHIV). Extrapulmonary forms, such as tuberculous osteomastoiditis (OT), are rare and difficult to diagnose, given their nonspecific clinical manifestations, often mimicking chronic otitis media. We report the case of a 55-year-old man, HIV positive with CD4 of 152 cells/μL, coinfected with hepatitis C, who presented purulent right otorrhea, otalgia, and hearing loss for two months, without response to conventional antibiotic therapy. Cranial CT showed filling of mastoid cells and bone erosions, with confirmation of exacerbated mastoiditis on magnetic resonance imaging. Pulmonary investigation, prompted by complaint of dry cough, showed a tree-in-bud pattern and a cavitary lesion, with bronchoalveolar lavage positive for Mycobacterium tuberculosis . Mastoid biopsy confirmed OT. RIPE regimen and corticosteroid therapy were started, given suspicion of neurotuberculosis due to mental confusion, brain microabscesses, and lymphocytic pleocytosis in cerebrospinal fluid. The differential diagnosis of neurotoxoplasmosis was also considered, and subsequent empirical treatment was instituted with good evolution. The patient showed progressive clinical improvement, being discharged after 47 days. This case highlights the need for high clinical suspicion for extrapulmonary TB forms in immunosuppressed patients, especially when there is refractoriness to conventional treatment. OT should be considered in the differential diagnosis of chronic otitis in PLHIV. Diagnostic confirmation by biopsy, investigation of systemic involvement, and multidisciplinary management were fundamental for the favorable outcome.