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.
