Chronic upper back and rib pain in a healthy man: re-examining the cause

INTRODUCTION Back and rib pain is a common presentation in primary care practice. Although most cases are secondary to non-specific musculoskeletal pain, it is essential for clinicians to identify patients presenting with life-threatening pathologies. AIM This case report serves as a reminder to clinicians to reconsider their initial diagnosis when a patient's pain fails to improve, while considering life-threatening pathologies. CASE HISTORY We describe a 44-year-old man from India who presents to his general practitioner with a 2-week history of rib and upper back pain. He was initially diagnosed with non-specific musculoskeletal pain. However, after representing twice 2 months later due to persistent pain and due to the uncertainty about his condition, he was investigated with different imaging modalities. It was discovered on bone scan that he had osteolytic lesions in the right 11th rib and T2 vertebrae. As the cause of his osteolytic lesions were unclear, he was referred to different specialists. Skeletal tuberculosis was suspected when one of his specialists discovered his recent visit to India, a tuberculosis-endemic country. This reminded the specialist of the possible risks of the patient's background and its association with his symptoms. Bone biopsy of his lytic lesions revealed Mycobacterium tuberculosis, consistent with skeletal tuberculosis. DISCUSSION Revisiting the diagnosis of back and rib pain while considering other obscure and urgent pathologies is essential if a patient fails to improve clinically. Clinicians should focus on aspects of their clinical assessment to explore these pathologies, enabling earlier recognition of the disease.