A 31-year-old male of Indian extraction was presented with a 2-month history of progressive nocturnal neck pain and 8 months of multiple skin lesions, but no neurological deficit. He had visited India 12 months previously and had received routine bacillus Calmette-Guerin vaccinations before immigrating to Australia at 21 years of age.
Skin examination revealed; a 4.5 cm solid mass overlying the right deltoid, a 1.5 cm mobile mass on the left chin, and a 1.5 cm mobile mass on the dorsum of the left foot. Although he had a positive QuantiFERON Gold assay (titer 11.68 IU/ml), his chest X-ray was normal. Cervical computerized tomography (CT) showed destructive bony changes at the left atlanto-occipital junction (between the left occipital condyle and superior articular facet of the left lateral mass of C1); there was a soft tissue mass between these plus left-sided lateral subluxation of C1-C2 [Figures 1 and 2].
He was immobilized in a halo vest. A CT of the chest, abdomen, and pelvis showed lytic and sclerotic bony lesions in the ribs, pelvis, sacrum, and right acromion [Figure 3]. As cervical CT angiogram precluded a biopsy of the cervical lesions (e.g., proximity of the vertebral artery), biopsies were obtained from the skin lesions (left pelvis and the right acromion). These revealed necrotizing granulomatous inflammatory changes (but no acid-fast bacilli on smear), while the TB polymerase chain reaction (PCR) was positive. Diagnosed with disseminated TB, he commenced a 1-year course of standard anti-tuberculous therapy (ATT): For example, rifampicin, isoniazid, pyrazinamide, and ethambutol; Lowenstein-Jensen culture confirmed mycobacterium TB with full drug sensitivities. At 2-month review, his neck pain and cutaneous lesions had resolved. Spinal immobilization was maintained for 6 months after which cervical CT and flexion-extension X-rays confirmed C1/C2 stability [Figure 4].