Palate to Periosteum: A Multisystem Manifestation of Tuberculosis in an Unusual Distribution

Tuberculous (TB) arthritis accounts for approximately 1-3% of TB cases and typically involves large joints, whereas oral TB is extremely rare. The coexistence of an oral ulcerated mass and monoarticular erosive arthritis is unusual and may mimic malignancy, often leading to delayed diagnosis. We report a 50-year-old previously healthy Chinese male patient, who presented with a six-month history of right wrist pain, palatal pain, intermittent fever, anorexia, and significant weight loss, followed by difficulty in chewing and swallowing. Examination revealed cachexia, an ulcerated mass on the hard palate, and synovitis of the right wrist. Investigations showed anemia, elevated inflammatory markers, hypercalcemia, and renal impairment. Wrist radiographs demonstrated erosive changes, while chest radiography showed reticulonodular opacities. Acid-fast bacilli (AFB) were detected in nasogastric lavage and endotracheal aspirate specimens, with subsequent culture confirmation, while histopathological examination of the palatal lesion confirmed TB. Although direct tissue confirmation of the wrist lesion was not obtained, its clinical and radiological features were highly suggestive of musculoskeletal involvement in the context of disseminated disease. Despite initiation of anti-TB therapy, the patient rapidly deteriorated and succumbed to multiorgan failure.  This single case highlights an uncommon presentation of disseminated TB with oral, pulmonary and probable wrist involvement. It reinforces the need for a high index of clinical suspicion and timely tissue biopsy, where feasible, to facilitate early diagnosis and improve patient outcomes.