A 33-year-old man presented with a 6-month history of insidious low back pain intermittently. Twenty days before admission to our hospital, his back pain was significantly aggravated, which caused him to have difficulty in walking and sleeping. He denied the history of systemic disease and trauma. Recently, the pain severely affected his life and work especially when movements. There was no history of exposure to TB, including his family. The patient had systemic TB symptoms and signs including night sweats and decreased appetite with weight loss and progressive low-grade fever. He admitted a history of smoking, alcohol consumption without drug abuse. Physical examination demonstrated there was no visible or palpable spinal deformity, but definite tenderness could be elicited over the spinous processes of the extensive lower thoracic vertebrae. Neurologic examination represented no specific findings including that his reflexes of knee and ankle were normal. Subsequently, muscle strength and tension of lower limbs were also normal, and the straight leg raise test was negative in bilateral lower limbs. No other positive findings were found on physical examination. Laboratory investigations revealed red blood cells count, hemoglobin level, and white blood cells count were all within a normal range in spite of high erythrocyte sedimentation rate (ESR, 48 mm/hour), high C-reactive protein (66.9 mg/L). TB antibody and purified protein in derivate of tuberculin (PPD) test and human immune deficiency viral infection (HIV) were negative, but the TB spot (T-Spot) test was positive. Besides, the result of bone marrow puncture and serum protein electrophoresis (SPE) were all negative. Other laboratory tests were within reference range.
During the hospitalization, the patient underwent thorough radiographic examinations.
Routine image analysis demonstrated normal chest X-ray and abdominal ultrasound evidenced normal findings. A thoracolumbar spine X-ray was unremarkable. Whereas further computed tomographic of whole spine images surprizing us, indicated multifocal diffuse lesions located in cervical, thoracic, lumbar, and sacral vertebrae showing multiple level worm-eaten and osteolytic bony destruction, including C5, T1-T5, T7-T12, L1-L5, and S1 (Fig. 1). At the bodies of C5, T1, T2, T4-T5 (spinous processes and adjacent ribs), T8-T11, L1-L5, and S1 vertebrae, osteolytic bone lesions were noted along with the similar lesions at the transverse process of T7 (neural arch), T11-T12 (spinous processes, neural arch, and adjacent ribs), L1, and L4. Intervertebral discs spared. There was a paravertebral mass at the T9-T10 level (Fig. 2). On whole spinal magnetic resonance imaging (MRI) examination, there were heterogeneous mixed high-intensity changes at C3, C5, T1-T5, T7-T12, L1-L5, and S1 segments on T2 weighted images and decreased signal intensity on T1 weighted images. Besides, the epidural abscess at the posterior of the spinal canal at T7 and T12 compressed the dural sac distinctly and a fusiform paraspinal abscess located at T9-T10 without obvious collapse of the adjacent vertebral body (Fig. 3).
According to the constitutional symptoms of TB and all imaging and laboratory findings of this patient in our department, we hold a multidisciplinary conference including oncologists, radiologists, and orthopedists. Eventually, differential diagnoses such as lymphoma, multiple myeloma, and metastatic disease were suspected. Considering the risk of spinal cord compression and pathologic fracture, which may cause progressive severe neurological symptoms and deformity, could happen at any time. An open biopsy rather than computed tomography (CT)-guided needle biopsy was conducted by our experienced surgeon at the T11 level to make a clear diagnosis. Intraoperatively, we located at the spinous process of T11, then resected the partial lesion of the right transverse process. The excised specimen resembled a kind of cheese with necrosis material.
Pathological examination indicated a chronic granulomatous inflammation with abundant caseous necrosis, considering tuberculous inflammation (Fig. 4). And, negative microscopy for acid-fast bacilli from the specimen. However, in some cases, it was difficult to distinguish the lesions caused by Mycobacterium tuberculosis from other bacterial granulomas that may be still misdiagnosed. Meanwhile, we acquired the consent from the patient and his family to start on anti-TB trial chemotherapy, including rifampicin (450 mg/day), isoniazid (300 mg/day), ethambutol (750 mg/day), pyrazinamide (750 mg/day), and levofloxacin (500 mg/day), paying attention to nutrition supplement at the same time. The treatment turned out to be successful based on the lab test results, showing his ESR is reduced to 18 mm/hour, CRP to 11.3 mg/L, and significant improvement of systemic TB symptoms within 8 weeks of starting antitubercular trial therapy. Then the final diagnosis was an unusual presentation of skipped multifocal extensive spinal TB. As a consequence, we switched to a standard anti-TB chemotherapy without levofloxacin for a total duration of 12 months. Furthermore, the patient had achieved complete recovery without any complications. At 18-month follow-up, all the worm-eaten and osteolytic bony lesions were healed apparently, showing the disappearance of paravertebral and epidural abscess, and there was no evidence of recurrence on CT scan (Figs. 5 and 6).