Tuberculosis continues to be a prevalent infectious disease in developing countries. This study indicated that isolated sacral tuberculosis predominantly affects young adults, with an average age of 37.6 years (ranging from 20 to 72). Notably, females are the most impacted group, accounting for 70% of the case [4].

Tuberculosis continues to cause significant morbidity and mortality, despite universal access to effective multidrug chemotherapy. The emergence of multidrug-resistant mycobacteria, coupled with a global rise in HIV infections, has led to a recent increase in the number of tuberculosis cases. This health issue remains one of the most urgent priorities in developing countries. Spinal tuberculosis presents several atypical characteristics, including isolated vertebral infection, skip lesions, involvement of neural arch, and unusual sacral lesions [4,8].

The sacrum and cervical spine are uncommon locations for spinal tuberculosis. This condition is almost always the result of hematogenous dissemination of mycobacteria from primary sites in the lungs and/or urogenital tract. The paravertebral venous plexus of Batson is typically regarded as the primary pathway for the spread of tuberculosis bacilli into the spine. Additionally, it is possible that lymphatic drainage from the pleura or kidneys influences the para-aortic lymph nodes, which may subsequently impact the vertebrae [4-7].

Clinical manifestations of sacral tuberculosis depend partly on the age of the patient. As noted by Pun et al and evident in our series, young individuals tend topresent with discharging sinuses and abscesses while backache and sciatic pain are a dominant clinical feature in adults [4,9]. Neurological symptoms occur infrequently in sacral tuberculosis because the sacral nerve roots are shielded by bone.

During laboratory tests, patients typically exhibit an elevated erythrocyte sedimentation rate and high levels of C-reactive protein due to the underlying infectious pathology. Additionally, leukocytosis may or may not be present in the patient, as noted by the authors. For instance, Chang et al. reported a case of sacral tuberculosis mimicking a neoplasm, with elevated carbohydrate antigen 19-9 levels. A chest X-ray is mandatory in all cases of sacral tuberculosis to rule out pulmonary tuberculosis.

An initial diagnosis can be made using an X-ray of the spinal region, but the definitive diagnosis and the extent of the disease are better understood through an MRI of the spinal region, as MRI is more sensitive than an X-ray of the spine and more specific than a CT scan of the same area.

MRI is considered the most sensitive technique for the early detection and complete differentiation of the disease. In cases of sacral tuberculosis, the radiological features of the mass lesion typically show low intensity on T1-weighted images and high intensity on T2-weighted images. Additionally, there is often an associated parasacral abscess. These findings align with the results reported by Patankar et al. [4]. Sacral tuberculosis is marked by the replacement of the normally bright sacral marrow, appearing hypointense on T1-weighted MRI images. The hyperintensity observed on T2-weighted images is likely due to marrow edema [4,5]. Using gadolinium-enhanced MRI with fat saturation is considered the most sensitive approach for diagnosing sacral tuberculosis. This technique strongly indicates isolated sacral tuberculosis when it reveals intraspongy formations of mixed intensity with peripheral enhancement in the vertebral bodies, which correspond to abscesses

MR imaging also provided us with an accurate depiction of the presacral abscess, its extension under the anterior longitudinal ligament and differentiation from a pyo-genic abscess due to its circumscribed nature [11]. Incontradistinction to pyogenic abscesses, which frequently transgress the ligaments to enter the retroperitoneum [10].

This examination is very useful in planning the diagnostic and therapeutic procedure in this type of pathology. As radiological characteristics of sacral tuberculosis may be confused with neoplasms diseases, fresh tissue should be collected for culture and biopsy.

The diagnosis of tuberculosis is confirmed by tissue aspiration and histopathological analysis of the tissue, showing the presence of a tuberculous granuloma, central caseous necrosis surrounded by epithelioid cells and giant cells of the Langhans type also by the culture of Lowenstein Jensen and PCR, revealing acid-fast bacilli and Mycobacterium TB in the lesion [10,11].

Adequate treatment for sacral TB includes primary therapy ATT, consisting of isoniazid, rifampin, pyrazinamide, and ethambutol. The World Health Organization (WHO) recommends ATT for a period of 9 months for patients who have TB in bones and joints, [13] while the American Thoracic Society (ATS) recommends ATT for 12 months for children and 6 months for adults  [14]. The duration of ATT can vary depending on the local guidelines, as well as the severity of the disease.

Without early diagnosis and appropriate treatment, complications can occur, including structural and postural deformities, permanent neurological damage, and spread of the disease to adjacent structures, which can lead to the formation of cold abscesses in the gluteal and piriformis muscles. Surgical intervention may be necessary in patients with structural complications, such as bone failure, abscesses, and spinal deformities.