Active pulmonary tuberculosis with vertebra and rib involvement: case report.

Abstract: Multifocal skeletal tuberculosis is defined as osteoarticular lesions that occur simultaneously at two or more locations and is generally associated with disseminated disease. Although involvement of bones accounts for 1 to 5% of all tuberculosis cases, multifocal involvement of the skeleton is extremely rare. We present a case of active pulmonary tuberculosis (TB) with vertebral and rib involvement and multiple hypodense lytic lesions accompanied by a paravertebral mass lesion. In the differential diagnosis, metastases, lymphoma, multiple myeloma, chordoma sarcoidosis and rare spinal infections such as brucellosis and fungal disease were considered. The diagnosis was established by surgical biopsy, taken by video-assisted thoracoscopic surgery. Especially for patients from TB-endemic areas, tuberculosis must be considered in the differential diagnosis and treatment should be started without delay.

Key Words: tuberculosis, bone involvement

**********

The association between mycobacteria and humans has a long history and tuberculosis (TB) will undoubtedly continue to be a significant cause of mortality and morbidity. While TB most commonly affects the lungs, any organ can be affected. Tuberculosis lesions have been found in Egyptian mummies and it has been recorded as the most common infectious disease process in the spine. (1) Tuberculosis remains a major cause of skeletal infection in many parts of the world. With the advent of acquired immune deficiency syndrome (AIDS) and mass emigration from underdeveloped to industrialized nations during the past decade, a new patient population is being encountered in which extrapulmonary TB is not uncommon and atypical presentations may confuse the diagnosis. (2) Nearly 20% of patients with TB develop extrapulmonary manifestations and skeletal TB accounts for 10 to 20% of all tuberculosis infections. Of these infections, multifocal involvement is seen in less than 5%. (3) Rib tuberculosis is seen in only 0.1% of all tuberculosis infections. (4)

Case Report

A 26-year-old male presented with complaints of pain in the back and left shoulder, dry cough, fatigue and weight loss for three months. He denied smoking, risk factors for HIV and recent exposure to tuberculosis. He had no past history of tuberculosis. His vital signs were within normal range and his lungs were clear on auscultation. He had tenderness over his left chest wall and back on palpation. Erythrocyte sedimentation rate was 68 mm/h. Chest x-ray revealed a reticulonodular infiltration in the right upper zone with right hilar enlargement. He did not accept a bronchoscope and was unable to provide sputum for culture. Tuberculin skin test was positive (22 mm). HIV serology was negative. Computed thorax tomography of the left 8th rib, multiple thoracic and lumbar vertebrae revealed involvement with multiple hypodense lytic lesions accompanied by a paravertebral mass lesion. (Fig. 1, 2, 3, 4). These lesions were predominantly lytic with minimal soft tissue involvement. Video-assisted thoracoscopic surgery (VATS) and wedge biopsy of the lung revealed lymph node pathology, epithelioid granulomata with Langhans giant cells and lymphohistiocytic aggregates. Antituberculous treatment with four drugs was implemented and continued for 12 months with steady improvement in the bone lesions.

Discussion

The incidence of skeletal tuberculosis, which once accounted for a majority of cases of extrapulmonary tuberculosis, has fallen significantly in recent years with the advent of effective drug therapy. Disseminated bone involvement in TB is very uncommon, but it may still occur in countries where TB is endemic. The lesions in the spine are almost always secondary to a demonstrable primary focus elsewhere in the body and are mainly due to hematogenous dissemination. (5) Multifocal bone tuberculosis is more frequent in young adults of black race, who often present with an initial complaint of fistulas. Multifocal bone tuberculosis in this population is predominantly found in the flat bones, whereas in the white population, it is most often located in the long bones of the extremities. (3) The spine is the most frequent site of osseous involvement in tuberculosis, (6) with the upper lumbar and lower thoracic spine being involved most frequently. More than one vertebra is typically affected, and the vertebral body is more commonly involved than the posterior elements. (7,8) Our patient had involvement in four vertebral bodies, as well as the transverse processes. The average number of vertebrae that are seen radiologically has been found to be 3.0 in children and 2.5 to 3.8 in adults. (5) The ribs are very rarely involved and local pain is the most common symptom as a result of rib destruction. (9) Patients sought medical attention because of pain in 84% of the cases. (3)

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

The radiologic lesions are not specific. Rib tuberculosis shows nodular shadows which may mimick a metastatic tumor, eosinophilic granuloma, multiple myeloma or lymphoma (2) and it can be difficult to differentiate TB from bone tumor on x-ray. The diagnosis of certitude is based on histologic findings of the bone lesion. Computed tomography and bone scan are of great value in demonstrating a small focus of bone involvement.

[FIGURE 4 OMITTED]

Conclusion

A high index of suspicion is the cornerstone for diagnosis, especially for high risk populations and patients from endemic areas. Conservative, specific antituberculosis therapy leads to recovery in most cases.

References

1. Nerlich AG, Rohrbach H, Zink A. Paleopathology of ancient Egyptian mummies and skeletons. Investigations on the occurrence and frequency of specific diseases during various time periods in the necropolis of Thebes-West. Pathologe 2002;23:379-385 (Abstract).

2. Harisinghani MG, McLoud TC, Shepard JO, et al. I. Tuberculosis from Head to Toe. Radiographics 2000;20:449-470.

3. Moujtahid M, Essadki B. Lamine A, et al. Multifocal bone tuberculosis: apropos of a case. Rev Chir Orthop Reparatrice Appar Mot 1995;81:553.

4. Tatelman M, Drouillard EJP. Tuberculosis of the ribs. AJR 1953;70:923-935.

5. Sankaran B. Tuberculosis of bones and joints. Ind J Tub 1993;40:109-118.

6. Martini M, Quahes M. Bone and joint tuberculosis: a review of 652 cases. Orthopedics 1988;2:861-866.

7. Ahmadi J, Bajaj A, Destian S, et al. Spinal tuberculosis: atypical observations at MR imaging. Radiology 1993;189:489-493.

8. Azzam NI, Tammawy M. Tuberculous spondylitis in adults: diagnosis and treatment. Br J Neurosurg 1988;2:85-91.

9. Wiebe ER, Elwood RK. Tuberculosis of the ribs--a report of three cases. Respir Med 1991;85:251-253.</p> <pre> Do not let what you cannot do interfere with what you can do. --John Wooden </pre> <p>Duygu Ozol, MD, Asli Koktener, MD, and Mehtap E. Uyar, MD

From the Departments of Respiratory Medicine, Radiology, and Internal Medicine, Fatih University Hospital, Ankara, Turkey.

Reprint requests to Assistant Professor, Dr. Duygu Ozol, Fatih University Faculty of Medicine, Department of Respiratory Medicine, Ciftlik Street 57 Emek, Ankara, Turkey. Email: [e-mail]

RELATED ARTICLE: Key Points

* Differential diagnosis of multiple lytic lesions in vertebrae and ribs should include tuberculosis.