A 28-year-old male presented with a chronic dry cough and weight loss of 1-year duration, and 2 months of worsening mid-thoracic back pain accompanied by bilateral lower extremity weakness. Notably, there were no known TB exposure, recent travel, smoking, or history of intravenous drug use. On the initial physical examination, he had bilateral rales and left lower extremity weakness (4/5).
Magnetic resonance imaging revealed an epidural collection causing compression of the spinal cord from T5 to T6; this was accompanied by a moderate-sized, left-sided pleural effusion, a left lingular/lower lobe consolidation, and multiple cavitary lesions in the right lung [Figures 1-4]. The patient was initially diagnosed with pulmonary TB/Pott's disease and myelopathy, resulting in the standard TB regimen of rifampin, isoniazid, pyrazinamide, and ethambutol.
Surgery included a T5-T6 decompression (e.g., costotransversectomy); the largely ventral mass (e.g., anterior to the cord) was removed. This was followed by open reduction and a posterior T4-T8 fusion.
A 1.2 cm x 0.9 cm x 0.6 cm bone tissue fragment from the T6 lamina and 3.0 cm x 2.0 cm x 1.0 cm aggregate from the T6 epidural tissue demonstrated metastatic adenocarcinoma, likely primary from the lung.
The patient's postoperative course was complicated by an inability to be weaned off the ventilator; the high oxygen requirements were attributed to the left lung disease. A chest radiograph performed the day of surgery demonstrated an enlarging left pleural effusion and a left pneumothorax. There were also patchy right perihilar airspace opacities/scattered nodules, considered infectious/inflammatory [Figure 5]. The patient subsequently experienced acute hypoxemic respiratory failure, acute respiratory distress syndrome, shock, and cardiac arrest. Of interest, the TB polymerase chain reaction came back negative.