A 25-year-old male originally presented with mid-back pain of 2 months duration. After a T8 thoracic CT-guided biopsy, he was diagnosed/treated for TB spondylitis with bed rest and appropriate antibiotic therapy. However, 1 month following his initial presentation, he developed worsening of his mid-back pain (VAS score 8), chest pain, shortness of breath, and a progressive lower extremity paraparesis (3/5 proximal and 4/5 distal).
The chest X-ray showed a pleural effusion, while the thoracic spine X-ray demonstrated T8 vertebral collapse. Further, the thoracic spine MRI showed a posterior epidural collection extending from T7 to T9 resulting in cord compression. Of interest, lumbar X-rays and lumbar MR scan both demonstrated an additional although smaller, asymptomatic L3 vertebral body lesion [Figures 1 and 2].
The patient's progressive myelopathy prompted a T8, T9 laminectomy that included a culture/biopsy of the lesion, epidural debridement, and T6-T10 pedicle screw fixation [Figure 3]. Notably, at the T8 level, there was a nonpurulent, soft, grayish-white material found in the center of the T8 vertebral body that appeared more consistent with tumor than tubercular infection.
The pathology showed only inflammatory granulation tissue, and the staining for all organisms, including Mycobacterium tuberculosis (MTB), was negative [Figure 4].
Postoperatively, the patient's back pain (VAS score 2) improved, and he showed significant neurological recovery (e.g., 4/5 function proximally, 5/5 distally). However, within 3 days, he developed an increased left-sided pleural effusion (1700 cc). Tissue culture and MTB DNA reverse transcriptase-polymerase chain reaction of the fluid were negative. Four weeks postoperatively, when he returned with dyspnea and cough, the PET-CT scan revealed a metabolically active osteolytic lesion predominantly involving the T8 vertebral body, with extension into the T7, T9, and T11 vertebral bodies, involving the left 7th rib, as well as multiple other sites [Figure 5a].
Biopsy of the left 7th rib and immunohistochemistry studies confirmed that the lesion was an EMS [Figure 5b]. At that point, the patient was referred for chemotherapy (e.g., cytarabine + daunorubicin). Now 1 year following the completion of chemotherapy, he remains asymptomatic, and the EMS has not yet recurred.
(a) PET-CT scan showed metabolically active osteolytic lesion predominantly in D8 vertebra and in multiple regions such as D7, D9, D11 vertebral bodies, left 7th rib, sternum, and right iliac bone along with bilateral pleural effusions, mediastinal, and left supraclavicular lymphadenopathy and soft-tissue lesions in the left orbit and left temporal region of brain.