A previously fit and well Pakistani-born 44-year-old male patient presented to the Royal London ED with a 3-month history of constant left-sided chest pain and swelling of the chest wall. He reported unintentional weight loss (approximating 15 kg over 2 months) associated with an enlarging left-sided chest wall mass, night sweats and postural dizziness. He denied cough, haemoptysis and dyspnoea. His initial vitals recorded a respiratory rate of 17 breaths/min, heart rate of 137 beats-per-minute, blood pressure of 154/106mmHg and a temperature of 37.2  C. Clinical examination revealed pain on palpation of the thoracic vertebral body at the level of T7. There was no associated or regional lymphadenopathy. Blood investigations revealed microcytic anaemia (HB of 117 g/L and MCV 75.7 fL), thrombocytosis (platelets 410 109/L) and lymphocytopenia (0.7 109/L). The patient's HIV status was negative. 
POCUS performed by an ED physician showed a collection of heterogenous material with fluid content (Figure 1) along with hyperechoic, thickened periosteum of the left first rib at the level of the pectoralis major muscle (Figure 2). Specks of hyperechogenic material with 'ring-like' structures were also noted. These structures had a hyperechoic, ring-shaped border surrounding a hypoechoic centre. Chest X-ray showed an abnormal opacification within the left apex and upper zone. Subsequent computerised tomographic (CT) scan of his thorax CT confirmed a 66 mm x 30 mm left upper chest wall abscess involving left costochondral junction and engulfing the distal left subclavian vein (Figure 3).
The patient was admitted under the medical team and treated for osteomyelitis with broad spectrum antibiotics and a high suspicion of EPTB. Aspirate from the abscess grew Mycobacterium tuberculosis, confirming the diagnosis. Full body CT scan further revealed thoracic and lumbar disseminated spinal TB alongside destruction of the left first rib at the T1 junction. He was started on anti-tuberculous medications and followed up by the TB outpatient and spinal clinics for a 12-month period.