CRAB Manifestations in a Middle-Aged Female: A Diagnostic Dilemma

A 56 year old lady, presented to our institute with six months history of low grade fever, generalized weakness, decreased food intake and fluctuating sensorium. Initial investigations revealed hypercalcemia, renal dysfunction and anemia. Initial working diagnosis of likely underlying hematological malignancy such as lymphoma or multiple myeloma (MM) was kept after hyperparathyroidism was ruled out. Her skeletal survey revealed lytic lesions in the skull, bone marrow aspirate showed 12% plasma cells and beta-two microglobulin level was markedly elevated. However, the criterion for MM was not fully satisfied. In view of persistent altered sensorium, MRI brain was done which suggested the diagnosis of disseminated tuberculosis and was further confirmed through MR spectroscopy, bone marrow biopsy (showing granulomas) and whole body PET. She was started on anti-tubercular therapy along with steroids with marked response within a week. We describe the details of this interesting case through a systematic approach to the various features.