Not All Epstein–Barr Virus Infections End Well: Tuberculous Osteomyelitis Mimicking a Post-Viral Complication in a Toddler
Tallal Tntoush, MRCPCH, FRCPCH *1, Ramadan Salem, MD 1,
Adham Alhaji, MD 1, Amjad Tonbari, MD 1
*Correspondence to: Tallal Tntoush. Department of Pediatric Emergency Medicine, Sidra Medicine, Doha, Qatar.
Copyright
© 2026: Tallal Tntoush. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 20 July 2026
Published: 01 September 2026
Background
Tuberculous osteomyelitis (TB-O) is a rare manifestation of extrapulmonary tuberculosis in children, accounting for fewer than 3% of pediatric tuberculosis cases. Diagnosis is frequently delayed because of its insidious presentation, nonspecific clinical features, and overlap with more common viral and bacterial infections. Delayed diagnosis may result in progressive bone destruction, pathological fracture, growth disturbance, multiple surgical procedures, and long-term functional impairment. Early recognition requires a high index of suspicion, particularly when symptoms persist despite an apparent alternative diagnosis.
Methods/Case Presentation
A previously healthy 15-month-old boy presented with prolonged fever of unknown origin. Extensive investigations identified primary Epstein–Barr virus (EBV) infection, and he was discharged following partial clinical improvement. One month later, his parents noticed progressive swelling of the left upper arm associated with reduced limb movement. Plain radiographs demonstrated a multilobulated lytic lesion involving the proximal humerus (Figure 1A). MRI demonstrated extensive osteomyelitis with intramedullary involvement and multiple intramuscular abscesses (Figure 1B). The patient underwent incision, drainage, curettage, and surgical debridement (Figure 2), followed by a planned second-look procedure and wound closure. Bone tissue polymerase chain reaction (PCR) was positive for Mycobacterium tuberculosis complex despite negative QuantiFERON-TB Gold testing, mycobacterial cultures, and gastric aspirate investigations. He was commenced on rifampicin, isoniazid, pyrazinamide, and ethambutol with pyridoxine for two months, followed by continuation therapy with rifampicin and isoniazid for at least 12 months. He was discharged afebrile with multidisciplinary follow-up involving pediatric orthopedics, infectious diseases, and immunology.
Results/Findings/Recommendations
This case illustrates how tuberculous osteomyelitis can masquerade as a post-viral complication following confirmed EBV infection. Attribution of persistent symptoms to EBV infection and transient clinical improvement reduced clinical suspicion, delaying definitive investigation and allowing progressive bone destruction. The case also highlights the limited sensitivity of interferon-γ release assays in young children, demonstrating that a negative QuantiFERON-TB test does not exclude active tuberculosis. Clinicians should maintain a high index of suspicion when fever persists or focal musculoskeletal symptoms develop following an apparent viral illness. Early MRI, tissue biopsy with molecular testing, and multidisciplinary management are essential to prevent pathological fracture, chronic osteomyelitis, growth disturbance, and long-term disability.
Conclusion
Tuberculous osteomyelitis should remain an important differential diagnosis in young children presenting with persistent fever or evolving focal musculoskeletal symptoms despite an apparent viral diagnosis. Prompt imaging, microbiological confirmation from tissue specimens, and multidisciplinary intervention are critical for early diagnosis, reducing morbidity, and optimizing long-term functional outcomes.
Keywords
Ethical Approval
Written informed consent for publication, including clinical images, was obtained from the patient's parents. Institutional approval was obtained in accordance with local policy.
Conflict of Interest
The authors declare no conflicts of interest.
Funding
No external funding was received for this work.
Acknowledgements
The authors thank the multidisciplinary teams from Pediatric Orthopedic Surgery, Pediatric Infectious Diseases, Radiology, Pathology, and Immunology at Sidra Medicine for their contribution to the diagnosis and management of this patient.
Author Contributions
Tallal Tntoush: Conceptualization, patient management, literature review, manuscript drafting, and final approval.
Ramadan Salem: Clinical supervision, critical revision of the manuscript, and final approval.
Adham Alhaji: Radiological interpretation, data acquisition, manuscript review, and final approval.
Amjad Tonbari: Orthopedic surgical management, operative data acquisition, manuscript review, and final approval.
All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.
References