Multifocal Skeletal Tuberculosis involving the Calvarium and Posterior Spinal Elements in an Immunocompetent Patient

Abstract

Tubercular osteomyelitis, a form of extrapulmonary tuberculosis (TB), represents less than 2% of all TB cases and about 10% of all cases of extrapulmonary TB. Isolated involvement of the posterior elements of the spine and calvarial TB are rare manifestations of extrapulmonary TB, especially in immunocompetent patients. We, hereby, present a case of a 12-year-old female patient with the mentioned multifocal skeletal involvement presenting with spastic paraparesis. Magnetic resonance imaging (MRI) of the cervicodorsal spine was suggestive of lesion involving the posterior elements of the spine from C7 to D3 vertebra with marrow edema and without involvement of the vertebral bodies and intervertebral discs. The MRI of the brain was suggestive of a lenticular-shaped extra-axial lesion in the right frontal region arising from inner table of calvaria. The patient was first operated for the lesion in the cervicodorsal spine due to acute-onset paraparesis followed by complete excision of frontal lobe lesion, which was done after 2 weeks of removing the spinal lesion. Histopathological examinations of both the lesions were suggestive of TB. Majority of patients with multifocal skeletal TB have nonspecific generalized somatic symptoms and signs at presentation and inconclusive radiological findings. All these factors can lead to a delay in diagnosis in such cases. Hence, a high index of suspicion for TB is necessary for patients presenting with multiple somatic symptoms and multiple destructive skeletal lesions, particularly in areas where TB is endemic.