Fifty-four years old female, without any medical history, suffered from a bilateral mechanical and inflammatory pelvic and lumbar pain, developing since the last 2 years. Firstly, lumbar arthritis or ankylosing spondylitis were suspected.
The patient was treated with non-steroidal anti-inflammatory drugs, with minor improvement but persistence of the symptoms.
The clinical evolution resulted on a profound asthenia which also suggested tuberculosis given the high incidence on local context.
Biological tests results showed a normal C-Reactive-Protein, without hyperleukocytosis, which excluded an inflammatory syndrome. Sputum samples analysis to identify mycobacterium tuberculosis complex has been done, and completed by an RT-PCR which were negative.
On the first line of investigation, a CBC test, Protein electrophoresis, vitamin D dosage, and serology were done without abnormality.
On the second line of investigation, since lumbar pain has not resolved by the treatment, imaging was carried out.
A whole body computerized tomography (CT)-scan showed para aortic and retro peritoneal lymphadenopathy with no other abnormalities (Figure 1) suggesting a secondary lymphatic node localization or lymphoma. A 18F-fludeoxyglucose positron-emission tomography showed a nodular uptake in adenopathy and a diffuse non-specific uptake in iliac bone (Figure 2).
In the other hand, magnetic resonance imaging (MRI) showed a pelvic bone lesions in T1 contrast sequence and diffusion perfectly correlated to the bone uptake zones which were accessible to osseous biopsy (Figure 3).
The histological results revealed the presence of intense lymphoid infiltrates, possibly of a reactive nature, associated with a few epithelioid cells without caseous necrosis compatible with a granulomatous lesion (Figure 4).
The treatment decision was a long-term systemic corticosteroids (prednisone) combined with an adjuvant treatment based on vitamin D and calcium with biological supervision. A 6-month treatment has been initiated, it is still in progress. A spectacular recovery was noted within the first month.