Multifocal skeletal tuberculosis with posterior-element spinal, sternal, and pelvic involvement presenting as a...

Multifocal skeletal tuberculosis is an uncommon manifestation of osteoarticular tuberculosis characterized by noncontiguous involvement of multiple skeletal sites. When associated with a mass-like pulmonary lesion, it may closely simulate disseminated malignancy. We report a 26-year-old immunocompetent male presenting with progressive neck stiffness, fever, cough, weight loss, and dysphagia. Imaging demonstrated a large right upper lobe mass with internal air bronchograms and associated centrilobular tree-in-bud nodules, along with multifocal destructive lesions involving the cervical, thoracic, and lumbar spine, sternum, sacroiliac joint, and pelvic bones. Extensive posterior-element involvement was present, with associated prevertebral, paraspinal, and epidural soft-tissue collections resulting in early spinal cord compression. Laboratory evaluation revealed elevated inflammatory markers, a strongly positive Mantoux test, and negative HIV serology. Bronchoalveolar lavage was negative for malignancy and acid-fast bacilli. Histopathological examination of a CT-guided biopsy demonstrated granulomatous inflammation with Langhans-type giant cells, while GeneXpert MTB detected Mycobacterium tuberculosis, confirming the diagnosis. The constellation of a pulmonary mass and multifocal destructive skeletal lesions initially raised strong suspicion for disseminated metastatic disease. This case highlights an uncommon radiologic phenotype of tuberculosis that closely mimics malignancy and underscores the importance of maintaining a high index of suspicion and obtaining early tissue diagnosis to facilitate appropriate management.