Tuberculous spondylitis

Case contributed by Laura Duerden
Diagnosis almost certain

Presentation

Several month history of intermittent fever, night sweats and upper thoracic back pain.

Patient Data

Age: 50 years
Gender: Male
x-ray

There is widening of the upper mediastinum, which is continuous with the structures at root of the neck. There is also widening of the paratracheal soft tissues. There are a few patchy lung infiltrates in both upper zones. The superior endplate of the T12 vertebral body is not well seen, and there is a curvilinear soft tissue opacity to the right of the T11 vertebral body.

mri

In the upper thoracic spine, there are bilateral paravertebral masses around the level of T2/3, which are intermediate/high signal on T2 indicating fluid. On the post-contrast images, there is peripheral enhancement indicating organized collections. There is an epidural component to the collections within the anterior spinal canal which is compressing the spinal cord. The T2 and T3 vertebral bodies are abnormal high signal on STIR. The T2/3 disc space is reduced in height.  

In the lower thoracic spine, the T12 vertebral body and inferior endplate of T11 are abnormal high signal on STIR. The T11/12 disc space is preserved. There are bilateral peripherally enhancing paravertebral collections around this level.

In the lower lumbar spine, the superior end plate of S1 has abnormal high signal on STIR and there is an enhancing collection involving the right body of the sacrum.

The patient was referred urgently to neurosurgery and underwent decompression of the upper thoracic spinal cord. Analysis of the fluid drained from the collection showed inflammatory cells, and subsequently grew Mycobacterium tuberculosis on culture.

Case Discussion

Paravertebral collections are an unusual cause of mediastinal widening which should be considered in patients with a history of travel to TB prevalent areas.  

Extrapulmonary TB spreads via the hematogenous route, which means that the anterior and central vertebral bodies are infected first.  

The immune response to TB is often slow, allowing large abscesses to form with relatively minor symptoms (these are also known as cold abscesses).  This also allows involvement of multiple spinal levels because bacilli spread via the paraspinal venous plexus.  These are features that help to distinguish TB from other causes of discitis.

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.