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Appendix 1. Reported cases of tuberculosis of the pubic symphysis in the world literature.

Study Number Language Age Clinical Diagnostic History Other Treatment Followup Outcome Path- Remarks of features imaging of TB ology/ patients (years)/ site TB culture sex

Thilesen 1 Other NA/M Sinuses Bone NA NA Sequestrec- 4 weeks Healed NA Old sequestrum tomy standing [49] fistula in groin extruding into hip the bladder disease

Chauvel 1 Other 23/M NA NA NA NA Surgical NA Not [16] removal of known symphysis as sequestrum

Mario [35] 1 Other 18/F Loss of appetite, NA NA NA Surgical Positive Family weakness, drainage of guinea history of pallor, loss of pus pig TB weight, and inocula- suprapubic lump tion

Büngner 1 Other 57/F Large swelling NA NA NA Surgical NA Dis- Pus [13] mons vernis, drainage of charged, cavity pubis and pus with doing lined by inguinal region, removal of apparent- granula- fistula symphysis ly well tion pubis tissue Chaaveau 6 Other 5-16 Abscess and Radiographs of NA NA All had NA Good NA [15] fistula all surgery

Rendu and 1 Other 9/M Swelling thigh Osseous lesion NA NA Curettage NA Recover- NA Wertheimer internal part of ing [44] ramus

Reich 1 Other 53/F Diarrhea and NA NA NA Refused NA Died of At severe weight surgery pneu- autopsy, [43] loss, swelling monia caries symphysis area spine, and pain TB of symph- ysis

Jackson 1 English 11/F Unusual gait Radiograph NA NA Aspiration NA Good NA [29] with difficulty of abscess in walking several followed by times swelling thigh

Swynghe- 1 Other NA NA NA NA NA NA NA NA dauw and Druon [48]

Clairmont 1 English 28/F Pain and NA NA NA Excision of NA Good Pus [17] swelling pubic right pubic mixed S area, sinus symphysis aureus formation, swelling over mons

Joachimouits 2 Other NA NA NA NA NA NA NA NA NA [30]

Blair 1 English NA/F Groin lump with Radiograph NA NA Plaster 2 years Healed NA pain spica [11] followed by fusion of SI joint

Quaini [40] 1 Other NA/F NA NA NA NA NA NA NA NA Pregnancy

Bean 1 English 23/F Back pain, Shadow, Dorsal NA Curettage, 3 years Symp- TB on Unre- sciatica with erosion spine sequestrec- tom free HPE cognized [7] lower tomy, bone for several abdominal pain graft and years corset application

Sorrel and 26 French NA NA NA NA NA NA NA NA Sorrel- Déjerine

[47]

Greger [25] 5 English 21/F Swelling Indistinct Hand, None Exploration 2 years Symp- Guinea outline initially knee of swelling tom free pig with hip pain followed by and inocula- “mouse-eaten” pleuri- tion border and sy showed sequestrum MTB

7/M Limp after Rarefaction of Tongue None Rest , 18 Died trauma followed symphysis traction, months by swelling repeated aspiration

49/ F Pain in Destruction and None None Incision Im- Granula symphysis with and proved -tion an abscess in diastasis drainage tissue labia sinus and fistula formation plaster cast later

36/M Pain in pelvis Destruction Wrist, None Sequestrec- 6 years Healed NA Died and fistula symphysis spine, tomy, pubis with hip sequestrum, incision of involvement of fistula ischia

33/M Pain leg and Defect of os None None Aspiration, 5 months Im- NA groin, swelling, pubis, sequestrec- proved tomy fistula followed sequestra by swelling that perforated

Alpert [1] 1 English Low back pain NA NA NA NA NA NA NA None

Bevan 1 English 23/F Lump in upper Radiograph None None Streptomy- N A Healed Positive thigh shows erosion cin and acid fast [10] of R pubis PAS for 3 bacilli; months stain, and culture grew bacilli

Fairbank 2 English NA NA NA NA NA SI joint NA NA NA None [22] fusion, curettage

Kirker [33] 1 English NA NA NA NA NA NA NA NA None Barnett 2 English 24/M Chest pain and Erosion and NA NA Débride- NA Symp- Caseous lower sequestra ment and tom free granulo- abdominal pain ATT ma on HPE [5]

48/M Hypogastric Erosion NA NA ATT NA Symp- NA mass and groin tom free pain

Nicholson 11 English 7/M Groin pain and Radiograph of None None ATT for 6 3 years Symp- Inguinal Recur- lump erosion of months tom free lymph rence [37] pubis followed node by repeated positive aspiration, for curettage, tubercle and ATT bacilli

19/M History of fall , Radiograph Lung None Aspiration 7 years Symp- Aspira- swelling in showed of pus; tom free tion thigh symmetric cyto- erosion of ATT for 8 logy body of pubis months, rib showed graft fusion of tubercu- symphysis lar pus

18/M Groin swelling Radiograph None None Curettage 1 year Symp- Tuber- shows erosion and tom free cle of both pubis drainage of bacilli abscess, on PAS and culture streptomy- cin for 3 months

Pain followed Erosion of Lung None Sequestrec- 5 years Symp- NA by lump over and tomy and tom free 22/M pubis followed pubis and large elbow curettage by sinus sequestra formation

Pain over pubic Erosion of None None Aspiration, 3 years Symp- On region with curettage; tom free culture 26 /F abscess left pubis with with showed labium after 2 rarefication streptomy- radiolo- tubercle months cin for 5 gic bacilli weeks and healing streptomy- cin and PAS for 3 weeks

24 /M Groin pain and Erosion of both None None Curettage 6 months Symp- On lump pubis and tom free culture sequestra showed tubercle bacilli

29 /F Groin pain and Erosion of both None None Streptomy- 3 years Symp- On lump with pubis and cin 2 tom free culture weakness and sequestra months, showed limp extending curettage, tubercle to labia majus sequestrec- bacilli tomy

30 /M Groin and thigh Erosion of both TB None Curettage , 2 years Symp- On swelling inner pubis peritoni sequestrec- tom free, culture aspect -tis tomy persis- showed tence of tubercle sinus bacilli

36 /F Pain less groin Erosion of both None Lung Drainage of 3 years Symp- Tuber- swelling pubis and abscess , tom free cular sequestra plaster cast pus

68 /F Groin pain and Erosion of both None None Streptomy- 1 year Symp- HPE inability to pubis and cin and tom free sugges- stand sequestra PAS for 2 tive of weeks and TB excision of symphysis

55/M Groin pain and Erosion both None None Drainage of 3 years Symp- NA lump abscess tom free pubis,

sequestra

Fares and 27 Italian NA NA NA NA NA NA NA NA NA Pagani [23]

Cadili [14] 2 Italian NA NA NA NA NA NA NA NA NA

Usandizaga 1 Spanish NA NA NA NA NA NA NA NA Labor [54]

Ellis [21] 1 English 14/M Erosion None Spine, skull, ATT and Died HPE Pubic mandible, SI surgery giant bone joint, lung cell, involved avian as a part type of of myco- multifocal bacteri- process um

Dybowski 32 Polish NA NA NA NA NA NA NA NA NA and Makuchowa [20]

Vogelzang et 1 English NA NA On CT bony NA NA NA NA NA NA al. [55] erosion and destruction with peripherally enhancing soft tissue mass

Ker [31] 1 English 41/F Multiple sinus Radiograph None none Débride- 18 All Histo- in groin showed bone ment months sinuses logy destruction, curettage, healed nonspe- diastasis and ATT for 12 cific, several months culture sequestra growth tubercle bacilli

Bronner et 1 Swedish NA NA NA NA NA NA NA NA NA al. [12]

Moon et al. 3 English 5 /M Limp Erosion of None none Curettage 3 years Healed NA and ATT [36] pubis for 18 months

8 /M Groin pain and Erosion of L None None Curettage 2 years Partial HPE lump pubis, diastasis and ATT healing showed for 24 on radio- TB months graphs

26 /M Groin pain after Destruction and History None Fusion with 2 years Healed NA 6 months disruption of of TB, plate and postpartum symphysis and peri- bone SI joint tonitis, grafting, and ATT for 18 cervi- months cal lymph- adeno- pathy

Rozadilla et 1 English 58/M Groin pain Erosion Spine Lung Conserva- NA Healed HPE tive ATT showed al. [45] TB

Manzaneque 1 English 79/F Cystic Cystic mass, None None Aspiration NA NA HPE Known et al. [34] hypogastric destruction L followed showed case of mass 15 months pubis with by surgical epithe- primary involvement of excision of lioid Sjogrens the symphysis mass, granu- syndrome and erosion of curettage lomata and the R pubis and ATT with immune culture thrombo- tubercle cytopenia bacilli

Khazov [32] 1 Russian 62/F Groin swelling Erosion Lung None Conserva- NA NA NA tive ATT

Tsay et al. 1 English 57/F Limp, pain, and CT showed None SI joint, elbow ATT for 1 8 months Symp- HPE Multiple [50] fever erosion year tom free showed bone caseous lesions granulo like ma ; metastatic culture disease tubercle bacilli

Benbouazza 2 French 21/F Groin pain after Osteolysis of Lymph Lung ATT 6 months Good HPE of et al. trauma, limp, pubic rami node lymph weight loss, and node [ 9] two inguinal showed lymph nodes giant follicles

19/F Pubic and knee Irregular None Cervical lymph ATT 6 months Healed Cervical pain with osteolysis of node lymph weight loss the pubic node symphysis, biopsy bone scan showed showed caseous increased granu- uptake loma

Rama- 1 English 29/F Discharging Osteolysis None SI joint Abscess NA Healed, HPE Massive krishnaiah sinus pubic bone and drainage, showed et al. sacrococcygeal L SI joint; conserva- doing granula- retroperi- region tive well tion toneal ab- [42] CT showed tissue scess massive pus with collection retro- foreign peritoneal area body type of giant cell Devarajan et 1 English 33 /M Sterile pyuria Erosion seen on Tubercular Nephrec- . Healed HPE al. radiograph with pyonephrosis, tomy, showed 3-cm echogenic epididymitis excision of caseat- [19] mass in the epididymis ing retropubic and ATT granu- region on US loma, acid- fast bacilli on culture

Hunter and 1 English 58 /F Pain in R hip Radiograph Lung None ATT NA NA HPE Sim [28] and vulval lump showed erosion showed caseous granu- loma ;

culture showed tubercle bacilli

Balsarkar 1 English 28/M Hypogastric Erosion seen on None None ATT Six Good CT and Joshi mass, chronic radiograph, CT months -guided [4] cough, and showed intra- aspira- weight loss parietal tion of swelling and pus erosion showed pres- ence of acid fast bacilli Ohkouchi et 1 Japanese 56/M Inguinal pain Erosion None Lung, Curettage 6 months Improved HPE Misdiag- al . [38] pericarditis and ATT showed nosed as TB, bacterial culture osteomy- showed elitis tubercle pubis; bacilli pericardi- tis developed during ATT

Bayrakci et 1 English 36/F Moderate lower Sclerosis, bony None None Necrotic 25 Well Culture Misdiag- al. [6] abdominal pain destruction of part months showed nosed as followed by the margins and symphysis MTB osteitis waddling narrowing of and abscess pubis and antalgic gait symphysis excision 6.5 pubis; bone and months of scan showed arthrodesis conserva- increased of the tive uptake; CT symphysis treatment showed pubis fixed failed sclerosis, with subchondral reconstruc- cyst tion plate

Aswathaman 1 English 32/M Pain, swelling, Radiograph Pubic Curettage, NA Sinus HPE Patient and Devasia and discharging showed bone endoscopic healed 8 showed presented [2] sinus suprapubic destruction of TB 6 removal of weeks TB with region with few the pubic bone years bone, osteuria solid pieces of with before spicules tissue in the sequestrum, CT from urine showed bladder, multiple bone ATT spicules in bladder Gulia et al. 1 English 74/F Pain and Wide None None Surgery Symp- Culture Diagnosed [26] swelling groin, symphysis and ATT tom free positive as sinus fistula, pubis seen on for bacterial and weight loss radiograph, CT MTB osteomy- showed bony elitis or destruction and cellulitis; sclerosis, started on intraven- symphysis ous pubis with a antibiotic fistula in groin with no region relief,

initial culture did not grow MTB,

delay of several months

Qassemyar 1 French NA/F Swelling, fistula Sequestrum and NA NA Surgery NA NA NA Cold et al. [39] erosion and ATT absc ess and Bazi n's indur ated eryth ema

Bali et al. 1 English 17/M Suprapubic Osteolysis, None None ATT 12 Symp- Needle Misdiag- pain, fever, bone scan months tom free cytol- nosed [3] weight loss showed ogy osteitis increased consis- pubis uptake tent with TB,

acid fast bacilli positive

Singh et al. 1 English 35/M Suprapubic Erosion, None None ATT 12 Symp- Cytol- History of [46] pain, fever, irregular months tom free ogy trauma , swelling 6 consis- misdiag- month later and wide tent nosed as followed by symphysis, with osteitis sinus rarefaction TB, pubis acid fast adjacent rami; bacilli sinogram positive confirmed smear, origin of fistula PCR from was symphysis, MTB MRI showed positive soft tissue collection and osseous debris

Current 4 English 49/ F Large swelling Erosion pubic None None Repeated 36 Healed Pus Delay in study and pain in left rami on both aspiration months aspirate diagnosis groin, sides, wide and ATT and for 1 year intermittent symphysis, followed PCR with large fever and by surgical positive horseshoe weight loss MRI showed drainage for abscess large soft tissue MTB, mass with cytol- osseous ogy destruction showed granu- loma- tous lesion with epithe- lioid cells

31/M Difficulty Osteolysis of None None ATT 21 Healed Needle Vague walking, pain in both pubic months cytolo- com- pelvic region bones , wide gy plaints and pubic showed delay in symphysis, granu- diagnosis loma- for 3 years MRI showed tous collection in lesion, soft tissue with PCR erosion of positive pubis internally for MTB 18/F Pain, Erosion None None Sequestrec- 78 Healed HPE Delay in discharging tomy, months showed diagnosis sinus pubis excision of TB, for 10 followed by sinus and acid fast months vulval swelling, débride- bacilli fever, weight ment, ATT positive loss

32/F Lower back Osteolysis TB SI joint On ATT 6 months Doing Cerebro As a part pain and pain with rarefaction menin- well, spinal of pubic region with disruption gitis appetite fluid multifocal and difficulty in of symphysis, im- examin- process, walking with erosion of L SI proved, ation abnormal gait 4 joint, pain de- sugges- months creased, tive of under MRI showed gait TB followup destruction, improved subluxation with irregular articular margins

ATT = antitubercular therapy; HPE = histopathology examination; L = Left; R = right; MTB = Mycobacterium tuberculosis, NA = not available; PAS = para-aminosalicyl ic acid; SI = sacroiliac; S aureus = Staphylococcus aureus; TB = tuberculosis; US = ultrasonography.

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