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Multifocal Thoracic Tuberculosis

      A 44-year-old North African woman was admitted for a 4-month history of weight loss, dry cough, and back pain. Physical examination showed a temperature of 39°C and a 4-cm painless elastic mass in her right chest wall. Laboratory data showed lymphopenia (552/mm3), high erythrocyte sedimentation rate (123 mm/h), and high C-reactive protein (162 mg/dL) with negative HIV test result. Anteroposterior chest X-ray showed a widening of the posterior mediastinum with increased prevertebral soft tissue shadow, alveolar opacity in the left upper lobe, and lytic lesion involving the sixth right rib anteriorly (Figure 1).
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      Figure 1Chest X-ray showing alveolar opacity in the left upper lobe, a bilateral medisatinal enlargement, and bone destruction of the sixth right rib.
      Tuberculin test and sputum smears for acid fast staining were negative.
      The chest computed tomography scan revealed a chest wall collection in front of the sixth rib with bone destruction (Figure 2, A), large paravertebral fluid mass of soft tissue surrounding the vertebra, extending from T1 to T6 measuring 120 × 27 mm, destruction of vertebral bodies from T3 to T5 (Figure 2, B), and parenchymal condensation in the upper left lobe.
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      Figure 2A, Chest computed tomography scan revealed an abscess of the right chest wall and B, paravertabral fluid mass along the prevertebral fascia, with multiple destructive lesions extending from T1 to T6.
      Magnetic resonance imaging of the spine showed thoracic paraspinal abscess with severe spondylodiscitis, diffuse spine destruction, and prevertebral sacral spine collection with epidural abscess (Supplemental Figure, available online at http://www.mayoclinicproceedings.org). Bacteriological analysis of computed tomography–guided aspiration of the chest wall abscess confirmed the diagnosis of tuberculosis (TB). Anti-TB chemotherapy was started and led to clinical improvement within 2 months.
      Skeletal TB remains a frequent disease in developing countries, and represents 10% of extrapulmonary tuberculosis.
      • Jutte P.C.
      • van Loenhout-Rooyackers J.H.
      • Borgdorff M.W.
      • van Horn J.R.
      Increase of bone and joint tuberculosis in The Netherlands.
      Among patients with skeletal TB, spinal and rib involvement accounts for approximately 50% and 5% of the cases, respectively.
      • Jutte P.C.
      • van Loenhout-Rooyackers J.H.
      • Borgdorff M.W.
      • van Horn J.R.
      Increase of bone and joint tuberculosis in The Netherlands.
      • Tatelman M.
      • Drouillard E.J.
      Tuberculosis of the ribs.
      Typical chest X-ray in thoracic spinal tuberculosis shows a posterior mediastinal mass.
      • Ansari S.
      • Amanullah M.F.
      • Ahmad K.
      • Rauniyar R.K.
      Pott's spine: diagnostic imaging modalities and technology advancements.
      Rib TB can mimic a metastatic tumor with bone destruction. In such cases, lung nodules and condensate can provide an indication for the diagnosis of TB.
      Computed tomography visualizes the discovertebral lesions and paravertebral abscesses. Magnetic resonance imaging is the appropriate imaging examination in TB spondylitis due to its superior soft tissue resolution and multiplanar capability.

      Acknowledgments

      We acknowledge the assistance of Mehdi Charfi, MD, Rimeh Ayari, MD, and Med Ridha Charfi, PhD, in the preparation of this medical image.

      Supplemental Online Material

      Supplemental Online Material

      Supplemental material can be found online at http://www.mayoclinicproceedings.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.

      References

        • Jutte P.C.
        • van Loenhout-Rooyackers J.H.
        • Borgdorff M.W.
        • van Horn J.R.
        Increase of bone and joint tuberculosis in The Netherlands.
        J Bone Joint Surg Br. 2004; 86: 901-904
        • Tatelman M.
        • Drouillard E.J.
        Tuberculosis of the ribs.
        Am J Roentgenol Radium Ther Nucl Med. 1953; 70: 923-935
        • Ansari S.
        • Amanullah M.F.
        • Ahmad K.
        • Rauniyar R.K.
        Pott's spine: diagnostic imaging modalities and technology advancements.
        N Am J Med Sci. 2013; 5: 404-411