A 30 year old non-smoking male patient presented with intermittent, high-grade nocturnal fever with night sweats of one year. He also had low back ache over his right hip. Prior to hospitalization, he had received four-drug anti-tubercular therapy (ATT) based on right sacro-ileitis seen on magnetic resonance imaging (MRI). No change in symptoms was observed during one year of therapy and he lost 10 kg weight. He also developed a tender swelling over sternum about a month before presenting to us. We found him febrile, pale and his long bones, ribs and pelvis were tender. He had a 3 x 4 cm tender and hard swelling over the upper part of his sternum. Another firm, non-tender swelling about 4 x 5 cm was seen in the right iliac region. He had mild anaemia with normal liver/renal functions, serum calcium and alkaline phosphatase.
Radiographs of the skull (Fig 1a and 1b), spine (Fig 1c) and pelvis (Fig 1d) revealed multiple variable sized lytic lesions affecting all visualized bones. T1 weighted MRI images of pelvis (Fig 2a) revealed a hypointense mass lesion involving the right iliac bone extending into the sacrum (arrow). T2 weighted MRI images (Fig 2b) revealed that the lesion in right iliac bone was hyperintense (double arrows).
Plain chest radiograph (Fig 3a) of the patient revealed an ill-defined mass in the left mid and lower zones, along with multiple patches of consolidation in the right lung. Multiple lytic bony lesions were also seen (arrows). CT scan of chest (Fig 3b and 3c) showed the lung masses (solid arrows) and lytic lesions were observed in the sternum and the vertebra (double arrows).
A metastatic malignancy or disseminated tuberculosis was considered. His anti-tubercular therapy was intensified by addition of a quinolone and aminoglycoside to the existing regimen. Pain was controlled with NSAIDs. Fine needle aspiration performed from sternal lesion showed inflammatory cells. A bone marrow biopsy was taken from iliac crest and this showed infiltration of marrow spaces by tumor cells as shown in figure 4. The tumor was present in acinar architecture. The cells were polygonal in shape. The nuclei were hyperchromatic and showed moderate degree of nuclear pleomorphism. They had moderate amount of cytoplasm. The section also showed areas of procedural haemorrhage. These features are suggestive of metastatic adenocarcinoma. Patient's condition continued to deteriorate and he died within a fortnight of his hospitalization.