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Rohan Sardana1, Naresh Kumar Sardana2, Ashish Sharma3

Author Affiliations: 

1Senior Resident, Department of Pathology, All India Institute of Medical Sciences, New Delhi, India; 2Consultant Pathologist, Sardana Labs, Jalandhar, Punjab, India; 3Consultant Rheumatologist, Department of Rheumatology, Fortis Hospital, Noida, India

Correspondence to: 

Ashish Sharma, Department of Rheumatology, Fortis Hospital, Sector 62, Noida, Uttar Pradesh 201301, India


Journal Issue: 
Volume 50: Issue 2: 2020
Cite paper as: 
J R Coll Physicians Edinb 2020; 50: 168–70



Multifocal bony lesions involving vertebral bodies and cancellous bones commonly occur in metastases and haematological malignancies. However, tuberculosis being a ‘great mimic’, can have a similar presentation. We present a young Indian female who had bony lesions involving multiple cancellous bones, without constitutional features. Extensive search for a neoplastic cause revealed negative results. Histopathological examination of the involved tissue revealed diagnosis of tuberculosis, which was not suspected. The patient improved remarkably with antitubercular therapy. Tuberculosis of the spine commonly presents with destructive spondylitis (Pott’s spine), leading to spinal deformity. Multifocal involvement of the skeleton is an atypical presentation of musculoskeletal tuberculosis. This case highlights the fact that tuberculosis should always be considered in patients with multifocal bony lesions in countries where it is endemic, like India, even in the absence of constitutional features.

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A 29-year-old gynaecologist had pain in the lower back and neck for the previous month. The pain did not change with rest or activity, was poorly localised and dull-aching. She did not have fever or pain in peripheral joints. She had a normal appetite and stable weight. Physical examination was unremarkable. Laboratory results showed haemoglobin 8.9g/dl, total leucocyte count 5000/mm3 (70% polymorphs and 20% lymphocytes), erythrocyte sedimentation rate (ESR) 67 mm/hr and C-reactive protein (CRP) 48.5mg/l. Liver and kidney function tests were normal. Magnetic resonance imaging (MRI) of the spine was remarkable for focal areas of heterogeneous signals in the bodies of many vertebrae with surrounding oedema (Figures 1A and 1B). A similar lesion was present in the manubrium sterni (Figure 1C). Paravertebral lesions were noted adjacent to the intraosseous lesions at some vertebral levels (Figure 1D). Short-tau inversion-recovery (STIR) hyperintensities were seen in iliac bones and the sacrum; the sacroiliac joints were normal (Figure 1E). A suspicion of spinal metastasis or lymphoma was raised. Peripheral smear examination did not show atypical or immature cells. There was no breast lump; speculum examination was normal. Computed tomography (CT) of the abdomen did not reveal any abnormality. CT scan of the chest showed pretracheal, subcarinal and hilar lymph nodes; the thyroid, breasts and lungs were normal. Lytic lesions were noted in some of the thoracic vertebrae (Figure 1F).

Figure 1 Sagittal T2-weighted MRI of lumbar spine showing heterogeneous lesions with surrounding oedema in thoracic, lumbar and sacral vertebrae (1A). Sagittal T1-weighted MRI of cervical spine showing hypodense vertebral bodies of C7, T1 and T2 vertebrae (1B). Similar lytic lesion noted in manubrium sterni (1C). Paravertebral soft-tissue lesion adjacent to the intra-osseous lesion seen on axial T2-weighted MRI (1D). Coronal section of pelvis showing hyperintense lesions in sacrum and ilium on both sides on STIR (1E). Axial CT scan showing osteolytic lesion in the vertebral body (1F).

CA-125, CA-19-9 and alpha-fetoprotein were negative. She had normal thyroid function and serum thyroglobulin. CT-guided fine-needle aspiration cytology was performed from the paravertebral lesion along the fifth thoracic vertebra, which revealed viscous, purulent material. Histopathological examination showed necrosis and granulomatous inflammation; acid-fast bacilli staining was positive. Polymerase chain reaction of the pus revealed a positive result for Mycobacterium tuberculosis. There was no evidence of neoplasia. Serology for human immunodeficiency virus and cultures for pyogenic and fungal infections were negative. A diagnosis of multifocal skeletal tuberculosis was made and the patient was started on rifampicin, isoniazid, ethambutol and pyrazinamide. The pain in the neck and back improved significantly and ESR and CRP normalised by the fourth month of treatment. The treatment was continued for 12 months.