Successful Empirical Treatment of Suspected Spinal Tuberculosis: A Case Report

Spinal tuberculosis is an uncommon extrapulmonary manifestation of tuberculosis infection, known as a great masquerade that often mimics other pathologies, such as pyogenic and non-pyogenic infection, bone metastasis, haematological malignancy, and metabolic bone disease. It presents great challenges in establishing a diagnosis, deciding on treatment, and monitoring the response to treatment. A tissue-proven diagnosis is the cornerstone of a definitive diagnosis before initiating medical antitubercular therapy, leading to successful treatment. Here, we present a distinct and rare instance of spinal tuberculosis with an atypical presentation of upper thoracic myelopathy. It involved the cervicothoracic junction, exhibiting minimal axial symptoms but intensive destruction of the affected levels radiologically, along with an incomplete neurological deficit and the possibility of catastrophic neurological complications. The ultimate distinctiveness of this case lies in the diagnostic challenge it posed. Despite undergoing three separate tissue biopsies, tuberculosis infection could not be established, as all results returned negative for cellular, molecular, and histopathological markers, leading to a delay in initiating empirical medical therapy. Nonetheless, the patient responded well to empirical antitubercular therapy, resulting in favourable outcomes. To the best of our knowledge, a case of spinal tuberculosis with numerous negative tissue diagnoses has not been previously reported.