Dangerous errors in the diagnosis and treatment of bony tuberculosis

In rare diseases such as tuberculosis of bone, the diagnosis may be missed despite clear and overt clinical manifestations if the findings are misinterpreted and the causative organism escapes detection.

A 30-year-old man who had been successfully treated for acute lymphatic T-cell leukemia (T-ALL) 18 years earlier developed multiple osteolytic lesions with compression fractures in the cervical spine, accompanied by an elevated serum concentration of C-reactive protein (CRP). One of the foci was biopsied, and the histological findings were interpreted as showing recurrent T-ALL. Induction chemotherapy was performed; this was followed by progressive osteolysis, abscesses, and visual disturbances due to an intracerebral infectious granuloma. High-dose chemotherapy was then planned, but the patient refused to undergo it. Further biopsies of the cranium and iliac crest revealed sterile abscesses. The newly proposed diagnosis was chronic, recurrent multilocular osteomyelitis (CRMO), for which treatment was begun with prednisolone and indomethacin. A fall in the CRP concentration and transient symptomatic improvement resulted. Two months later, however, the patient developed an intra-abdominal abscess. After this was surgically drained, mycobacteria were demonstrated for the first time, finally enabling a correct diagnosis. The patient underwent tuberculostatic treatment with 4 different drugs for 2 years. His CRP became normal, and all of the abscesses and other symptoms resolved completely.

A T-ALL recurrence confined to bone would have been an extremely rare event, and this putative diagnosis should have been critically questioned. The high-dose chemotherapy that was proposed would have been life-threatening for a patient with florid tuberculosis. Inflammatory responses in bone can mimic the histological appearance of CRMO. The staining method can be problematic for the microbiological demonstration of tuberculosis. In this case, the causative organism was finally demonstrated with an auramine stain and fluorescence microscopy.