A 45-year-old HIV negative male immigrant from Mexico presented to our emergency department complaining of progressive bilateral lower extremity weakness for one month with increasing difficulty walking and decreased sensation below the nipple level over the preceding two weeks. He reported urine and stool retention over the preceding one week. He denied cough, shortness of breath, or fevers/chills but did complain of night sweats for the past one month. On physical exam he was found to have profound diffuse bilateral lower extremities weakness (2/5) and diminished sensation to light touch and pinprick below the level of T4-T5. There was no lymphadenopathy appreciated on examination. Initial work up included a white blood cell count of 12.6, platelet count of 494, C-reactive protein of 2.6 mg/dl, erythrocyte sedimentation rate of 20, and a positive QuantiFERON (cutoff value of 0.35 IU/ml). A set of blood cultures was negative. HIV immunoassay testing was negative. Gadolinium enhanced magnetic resonance imaging (MRI) of the thoracic spine demonstrated evidence of T3-T4-T5 osteomyelitis with epidural abscess and bony destruction of the T4 and T5 vertebral bodies, resulting in severe spinal canal stenosis and spinal cord compression (Figures 1 and 2).
The patient underwent emergency decompression of the epidural abscess with multi-level pedicle screw instrumentation for thoracic vertebral stabilization and interbody cage placement (Figure 3). Intraoperative findings were more consistent with a chronic fibrotic process with a solid mass adherent to the thecal sac with only a small amount of liquid abscess encountered. Epidural tissue biopsies showed caseating and non-caseating granulomas (Figure 4). Further pathology results showed no organisms on acid fast bacilli (AFB) and Grocott methenamine silver stains. M. tuberculosis was not detected on polymerase chain reaction (PCR) (GeneXpert assay) testing of the surgical specimen. The epidural abscess cultures were positive for pan susceptible Streptococcus anginosus at 48 h on multiple tissue samples. A transthoracic echocardiogram did not show evidence of endocarditis. A computed tomography chest showed clear lung parenchyma and multiple sputum samples were negative for AFB stain and culture. Genitourinary testing for TB was not performed given lack of genitourinary symptoms. Approximately 6 weeks after the tissue biopsies were obtained, mycobacterial cultures grew pan susceptible M. tuberculosis. The patient completed six weeks of intravenous ceftriaxone for treatment of S. anginosus and was initiated on rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy. At hospital discharge the patient had persistent bilateral lower extremity weakness requiring a walker for ambulation, and these deficits improved with outpatient physical and occupational therapy. He was lost to follow-up before completion of RIPE therapy.