Patient is a 25-year-old woman from Guinea-Bissau, West Africa, and was admitted with an 18-month history of dorsal back pain, asthenia, and significant weight loss followed in the last 8 months by loss of the ability to walk.
On her physical examination she presented with three skin lesions (two ulcerated and one nodular) involving the right subclavicle region and other two lesions on her left thigh (one ulcerated and the other in a healing phase) (Figures 1 and 2); her neurological exams exhibited an ASIA A paraplegia with a sensory level at D4. Patient was anaemic with hemoglobin of 11,2 g/dL with an erythrocyte sedimentation rate of 75 mm/h and a C-reactive protein of 5,26 mg/dL. Gamma globulin level was 44 g/dL and blood chemistry evaluation was normal. HIV and primary immunodeficiency testing were negative. A chest X-ray revealed an enlarged mediastinal shadow (Figure 3), and the spinal computed tomographic scan showed a large anterior and paravertebral abscess from D1 to D10 with significant compression and osteolytic lesions of vertebral bodies with a kyphotic deformity (Figure 4). Spinal magnetic resonance revealed significant compression of the spinal cord at the kyphotic apex and angulation of the column, anterior and paravertebral epidural abscess consistent with spondylodiscitis (Figure 5).
Bone biopsy revealed granulomatous inflammation with few acid-fast bacilli. Skin biopsy of the lesions (Figure 6) revealed acanthosis and pseudoepitheliomatous, hyperplasia of the epidermis, and necrosis foci surrounded by a histiocytic and lymphocyte infiltrate with giant cells on the dermis, consistent with tuberculosis with negative Ziehl-Neelsen stain. The patient was started on quadruple antituberculosis drug regimen together with pyridoxine and steroids, with a progressive clinical improvement, including healing of the skin lesions. One month later, anterior surgical debridement and posterior arthrodesis of the spine were performed. Blood and urine cultures including cultures for mycobacteria all proved negative. Cultures of the material collected through bone biopsy revealed M. tuberculosis. The patient fulfilled 15 months on antituberculosis medication and a favorable outcome was reported with complete recovery of neurological deficits.