A 4-year-old boy was admitted with fever for more than 30 days, low back pain, peripheral and abdominal adenomegaly, hepatomegaly and splenomegaly. The abdominal ultrasound showed disseminated nodules in the liver and spleen. The chest X-ray showed a lytic lesion in the 11th right costal arch and a slight upper left pulmonary infiltrate. Tuberculin skin test (TST) with PPD Rt-23 was > 10 mm. He was not vaccinated with BCG. Anti-HIV serology was negative.
A cervical lymph node biopsy showed nonspecific inflammatory findings and granulomatous hepatitis was found in liver biopsy. Computed tomography (CT) and magnetic resonance imaging showed osteolytic lesions with partial destruction of C6 and C7 vertebral bodies and a paravertebral abscess.
Afterwards, he presented limited cervical movement, without neurological symptoms. A neck brace was prescribed and treatment for TB with rifampicin, isoniazid and pyrazinamide (RHZ) was started. During his hospitalization, it was found out that the patient had previously remained in a ward in contact with a patient undergoing TB treatment, about six months prior to the onset of his symptoms.
Sixty days after starting treatment, the patient no longer had fever and and hepatic and splenic granulomas were calcified. There was a progressive improvement in bone lesions, but a painless nodular lesion appeared in the skullcap, without neurological symptoms. A new cranial CT scan showed multiple lytic lesions on the external board of the left frontal region (Figure 1), left parietal and right occiput, with soft tissues edema, without subgaleal fat involvement. Another lesion with an extradural soft tissue component was identified in the right frontal region and reached both, the inner and the outer bone layers measuring 1 cm in diameter. Excisional biopsy of the frontal lesion showed AFB-positive granulomas (Figure 2). Mycobacterial cultures were negative in all analyzed materials. The patient underwent immunological investigation and the only alteration found was the lack of response to IL-12 and also to IFN-g in an in vitro functional assay with mycobacteria and BCG vaccine.