Mycobacterium tuberculosis infections remain a significant cause of morbidity and mortality worldwide. Extrapulmonary infections are less common, and skeletal tuberculosis accounts for about 5–20% of all cases. Skeletal tuberculosis cases often pose diagnostic challenges due to its insidious onset, non-specific clinical presentation and radiographic findings similar to other diseases. Multifocal skeletal tuberculosis is an extremely rare clinical entity, and is defined as an infection that affects two or more non-contiguous bony structures. This clinical entity can mimic bony metastasis and may lead to delays in diagnosis and treatment.
We present a case of multifocal skeletal tuberculous infection mimicking widespread bony metastasis, occurring in an immunocompetent 28-year-old male, and discuss the diagnostic challenges faced and management strategies. The patient successfully underwent instrumentation and stabilization of a pathological T11 vertebra fracture and treatment of tuberculosis infection.
While TB infections remain less common in developed countries, they can still cause significant morbidity. Multifocal skeletal tuberculous infections can resemble spinal or bony metastasis on various imaging modalities. Care must be taken when interpreting such imaging results, with histopathology and mycobacterial cultures remaining the gold standard to determine the presence of active TB infections.
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Garg B, Mehta N, Mukherjee RN, Swamy AM, Siamwala BS, Malik G. Epidemiological insights from 1,652 patients with spinal tuberculosis managed at a single center: a retrospective review of 5-year data. Asian Spine J. 2021. http://www.asianspinejournal.org/journal/view.php?doi=10.31616/asj.2021.0137. online ahead of printed.
Liu B, Dong L, Wang X, Han T, Lin Q, Liu M. Tuberculosis mimicking metastases by malignancy in FDG PET/CT. QJM. 2017;110:173–4.
Ye M, Huang J, Wang J, Ren J, Tu J, You W, et al. Multifocal musculoskeletal tuberculosis mimicking multiple bone metastases: a case report. BMC Infect Dis. 2016;16:1–5. https://doi.org/10.1186/s12879-016-1376-7.
Go SW, Lee HY, Lim CH, Jee WH, Wang YP, Yoo IR, et al. Atypical disseminated skeletal tuberculosis mimicking metastasis on PET-CT and MRI. Intern Med. 2012;51:2961–5.
Mulleman D, Mammou S, Griffoul I, Avimadje A, Goupille P, Valat JP. Characteristics of patients with spinal tuberculosis in a French teaching hospital. Joint Bone Spine. 2006;73:424–7.
Singh A, Chatterjee P, Pai MC, Chacko RT. Tuberculous osteomyelitis of the scapula masquerading as metastasis. J Radio Case Rep. 2009;3:27–31.
Ozdemir M, Ozdemir HG. Evaluation of patients admitted with musculoskeletal tuberculosis: sixteen years’ experience from a single center in Turkey. BMC Musculoskelet Disord. 2021;22:1–6.
Agashe VM, Johari AN, Shah M, Anjum R, Romano C, Drago L, et al. Diagnosis of osteoarticular tuberculosis: perceptions, protocols, practices, and priorities in the endemic and non-endemic areas of the world—a waiot view. Microorganisms. 2020;8:1–19.
Ur-Rahman N, El-Bakry A, Jamjoom A, Jamjoom ZAA, Kolawole TM. Atypical forms, of spinal tuberculosis: case report and review of the literature. Surg Neurol. 1999;51:602–7.
Al-Khudairi N, Meir A. Isolated tuberculosis of the posterior spinal elements: case report and discussion of management. JRSM Short Rep. 2014;5:1–6.
Lazrak F, Abourazzak FE, Elouzzani FE, Benzagmout M, Harzy T. A rare location of sacral tuberculosis: a report of three cases. Eur J Rheumatol. 2014;49:78–80.
Miller AG, Spicer PJ. Extrapulmonary tuberculosis: a case report involving the spine and soft tissues. Radio Case Rep. 2021;16:2236–9. https://doi.org/10.1016/j.radcr.2021.05.049.
Wierzba-Bobrowicz T, Michalak E, Michalik R, Stȩpień T. Cervical spinal tuberculosis. Folia Neuropathol. 2010;48:300–4.
Johnstone RH, Ardern DW, Bartle DR. Multifocal skeletal tuberculosis masquerading as metastatic disease. ANZ J Surg. 2011;81:731–3.
Lebowitz D, Wolter L, Zenklusen C, Chouiter A, Malinverni R. TB determined: tuberculous osteomyelitis. Am J Med. 2014;127:198–201. https://doi.org/10.1016/j.amjmed.2013.12.001.
Zhang Y, Zhao C, Liu H, Hou H, Zhang H. Multiple metastasis-like bone lesions in scintigraphic imaging. J Biomed Biotechnol. 2012;2012(Figure 4):1–9.
Shankar J, Jayakumar P, Vasudev M, Ravishankar S, Sinha N. The usefulness of CT perfusion in differentiation between neoplastic and tuberculous disease of the spine. J Neuroimaging. 2009;19:132–8.
Luk KDK. Tuberculosis of the spine in the new millennium. Eur Spine J. 1999;8:338–45.
Hong L, Wu JG, Ding JG, Wang XY, Zheng MH, Fu RQ, et al. Multifocal skeletal tuberculosis: experience in diagnosis and treatment. Med Mal Infect. 2010;40:6–11.
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Yuen, W.L.P., Loo, W.L. Multifocal tuberculous osteomyelitis mimicking widespread bony metastases: review of literature and case report. Spinal Cord Ser Cases 8, 23 (2022). https://doi.org/10.1038/s41394-022-00496-9