We report a 19-year-old African-American male admitted to the hospital a year into his incarceration in prison. He described 6 months' history of progressively worsening back pain, weight loss, fatigue, anorexia, decreased mobility (making him wheelchair-bound), and associated low-grade fever with night sweats. He denied history of cough or hemoptysis, though family history included pulmonary tuberculosis. Prison TB skin test (PPD) was negative. He denied history of smoking, alcohol consumption or drug abuse.
Upon physical exam, the patient appeared malnourished, tachycardic, and had a low-grade fever. He was reluctant to move due to severe pain, with extreme cervical tenderness and tender swelling at the lumbosacral region. Chest was clear with normal breath sounds; cardiovascular exam was unremarkable. Abdomen was soft with no organomegaly.
Other significant findings included straight leg-raising was positive on right. Review of CNS was normal with no neck stiffness. Sensory system and reflexes were normal but motor system had reduced power of right lower extremity. Lab findings were significant for high erythrocyte sedimentation rate (120), high C-reactive protein (12), negative blood cultures, negative PPD, and negative HIV antibody tests. Chest X-ray was normal. MRI of spine showed destructive lesions involving the body of C5, T6 (right pedicle), T8 (left pedicle) and adjoining posterior ribs, L5, S1, S2, and left iliac bone (Figures 1, 2, and 3). Intervertebral discs spared. Bone scan revealed multiple areas of increased radiotracer activity in midthoracic spine and adjacent ribs, lumbar spine, and left ileum. 
At this time, differential diagnoses included lymphoma, eosinophilic granuloma, myeloma, and metastatic disease. Then, serum protein electrophoresis revealed polyclonal gammopathy; Bence Jones proteins were negative. A CT-guided biopsy of the left iliac bone lesion showed granulomatous inflammation with giant cells and rare acid-fast bacilli. Final culture report was positive for mycobacterium tuberculosis. 
Patient was diagnosed with multifocal tubercular osteomyelitis and was started on quadruple antitubercular treatment, including rifampicin, isoniazide, ethambutol, and pyrazinamide. Patient then underwent surgical decompression of cervical spine. Finally, he was transferred to University of Michigan for surgical decompression of lumbosacral spine. He was transferred back to prison, where he completed the course of anti-TB treatment. According to prison officials two years after the first presentation, he was doing better and was mobilizing without any support.