This twenty-five-year young soldier arrived today with a perplexing story of a motorcycle wreck and low back injury two years ago. He fully recovered. Then, one year ago he began again to have low back pain and developed gradual angulation in his lumbar spine. He has not had cough, fever, nor any significant weight loss. As is typical in Angola, he received consultations at a number of health posts, and was prescribed a variety of analgesics and antibiotics without improvement. On exam, he has no back tenderness, can touch his toes, has a normal chest exam, and normal CRP laboratory results.
The above image shows the angulation in his lumbar spine, and corresponding findings on lumbar X-ray. What do you see? What is the most probable diagnosis?
The history of motorcycle injury and back pain is not likely related, given that he completely recovered. And, his recurrent back pain and progressive spine angulation one year later was slow in onset. Another important clue from the history is that a family member in his home is being treated for tuberculosis. Most likely, this man is suffering from tuberculosis of the lumbar spine, causing to collapse of the L 2-3 vertebral space, highlighted in the red circle above.
Extra pulmonary tuberculosis most often infects cervical lymph nodes, weight-bearing bones, and kidneys – all of which sport the presence of high oxygen tension necessary for TB growth. One outlier in this case is the normal CRP Laboratory finding. CRP is usually elevated in cases of tuberculosis.
How would you manage this patient? TB culture from extrapulmonary sites is rarely positive, and in Angola we have no TB culture facilities. His diagnosis is at best presumptive. Treatment will be immediately initiated with four anti-tuberculous medications. And what of the orthopedic injury? No corrective surgical procedure is available in our low resource setting. But the reassuring news is that his deformity is not likely to progress, and in this we are quite satisfied.