Costosternal swelling and diffuse bone pain in tubercular osteomyelitis

For about a year a 28-year-old Nigerian had been suffering from diffuse bone pain, intermittent fever, weight loss and weakness. Physical examination was unremarkable except for a swelling at the sternal angle. The tuberculin test was clearly positive and tests for inflammatory disease were elevated, but the chest radiograph was normal. Bone scintigraphy demonstrated multiple sites of increased storage in the ribs and vertebral column. Magnetic resonance imaging revealed a large paravertebral abscess, which was needled under computed tomography monitoring. Polymerase chain reaction of the aspirate demonstrated Mycobacterium tuberculosis. While initial treatment with combined isoniazid, streptomycin, rifampicin and pyrazinamide, the first two drugs had to be discontinued, the microorganism not being sensitive to them, and were replaced by ethambutol and amikacin. The abscess was drained and the vertebral fracture surgically stabilised. There were no neurological abnormalities and the lesions largely healed. Even without pulmonary involvement tuberculosis must be included in the differential diagnosis of rheumatic diseases with joint and vertebral column involvement, such as the SAPHO syndrome and other inflammatory bone diseases.