Non-contiguous spinal tuberculosis.

DESCRIPTION A 26-year-old-man of Indian descent was referred to our rheumatology unit with 6 months of lower-back pain. He had lived in the UK for 5 years, travelling intermittently to holiday in India. His general practitioner detected a C-reactive protein of 55 mg/l and erythrocyte sedimentation rate of 95 mm/h and referred with a possible ‘spondyloarthritis’. The patient gave a history of back pain with stiffness throughout the day. He admitted to fever, sweats and significant weight loss but denied having a cough. On examination, he had slight limitation of lumbarspine-flexion with no focal spinal-tenderness or clinicalsacroilitis. Straight-leg-raise was 80° bilaterally. Resisted hip-flexion caused exacerbation of lower-back pain. Power and knee-jerks were normal but ankle-jerks were reduced. Chest-radiograph (figure 1) was normal and lumbarspine x-ray (figure 2) revealed a fifth lumbar-spine parsdefect only. Renal, liver and bone profile was normal. Three early-morning-urine samples, blood cultures and HIV-serology were negative. Fevers, sweats, weight loss and reduced ankle-jerks are considered atypical for a spondylo-arthritis. Malignancy or indolent spinal infection form important differential diagnoses. An urgent MRI-spine (figure 3) revealed multiple spinal-lesions and a para-spinal-abscess eroding the sacrum. Subsequent CT demonstrated a left sixth-riblesion, the biopsy and histology of which revealed non-caseous-granulomas and negative acid-fast-bacilli stain. Culture of this specimen yielded Mycobacterium tuberculosis after 4 weeks. About 23% of patients with spinal-tuberculosis (TB) may have normal spinal-plain-radiographs. Our case highlights the need for early spinal MRI in patients with suspected spinal TB, even when plain radiographs appear normal. TB-spondylitis frequently involves multipleadjacent spinal-vertebrae; non-contiguous vertebral involvement, as seen here, is relatively uncommon. Confusion with metastatic malignancy is possible; hence a tissue diagnosis is still essential.