Hypercalcemia in a Patient With Spinal Tuberculosis and Aspergillus Co-Infection: A Case-Report

Tuberculosis (TB), one of the leading infectious causes of mortality worldwide, may disseminate hematogenously and result in extrapulmonary manifestations. Spinal tuberculosis (ST) is an uncommon but serious form of extrapulmonary TB. In addition, TB may predispose patient to opportunistic infections, including Aspergillus species.

A 62-year-old man presented with chronic back pain and sudden paraplegia. High-resolution computed tomography (HRCT) of the chest demonstrated findings suggestive of miliary TB, which was supported by a strongly positive purified protein derivative (PPD) test and a positive sputum smears for acid-fast bacilli. Anti-TB therapy was subsequently initiated. Aspiration of an epidural abscess revealed a positive polymerase chain reaction (PCR) result for Mycobacterium tuberculosis, while histopathological examination demonstrated septate hyaline hyphae suggestive of Aspergillus species. During hospitalization, the patient developed recurrent fever, agitation, and progression of pulmonary lesions. In conjunction with a positive serum galactomannan assay, these findings raised suspicion for concomitant aspergillosis infection, prompting initiation antifungal therapy with amphotericin B and voriconazole. A major clinical challenge was severe hypercalcemia, which progressed despite intravenous hydration and calcitonin therapy, reaching a peak serum calcium level of 18.01 mg/dl. Subsequent treatment with pamidronate resulted in gradual normalization of serum calcium levels.

This case highlights the diagnostic and therapeutic challenges associated with spinal tuberculosis, probable Aspergillus co-infection, and severe treatment-resistant hypercalcemia. Clinicians should consider opportunistic fungal infections and metabolic complications when evaluating patients with disseminated TB.