Introduction

Tuberculosis is a health problem in the world. It has many different clinical presentations and it is not infrequently presenting with surprising clinical and radiologic findings (₁, ₂, ₃). Here we reported a case with tuberculosis presented by a mediastinal mass invading vertebra and spinal cord.

Case Report

A 68 year-old-man was admitted to the hospital with back pain, cough and dyspnea since 2 months. He described severe pain non-responsive to conventional analgesics. There was no history of trauma, operation or cigarette smoking.

Physical exam: He was alert but he is anxious due to pain. The thyroid was palpable. There was no evidence of abnormal cardiac or respiratory findings. Also there was not organomegaly and/or lymphadenopathy. But there was weakness of both lower extremities.

Laboratory: Glucose was 102 mg/ml, AST / ALT was 24/25 IU, BUN/Cr was 17/0.7 mg7ml, Hb was 13.3 gr/dl, Hct was 37%, WBC 4.3 x 10 9 /l, platelet count was 370 x 10 9 /l, ALP was 648 IU, T Prot/Alb was 8.6/3.8 g/dl, LDH was 446 IU, Ca / P was 9.6 / 4.4, TSH was 0.854. ESR was 41 mm/h

Thyroid USG and scintigraphy showed multinodular goitre. Echocardiogram was reported as normal.

Chest X-Ray: Upper mediastinal mass (Figure 1).

Figure 1

Figure 1: Upper mediastinal mass

Thorax CT: Soft tissue mass destructing vertebral bodies, spreading to the neural foramen and spinal cord was detedted and this mass was located at posterior mediastinum (Figures 2).

Figure 2

Figure 2: Vertebra and posterior mediastinum is destructed by the mass

Thoracic MRI: There was a large mass invading vertebral corpuses and pedicles, compressing the medulla spinalis at the level of descending aorta and also showing epidural invasion (Figure 3).

Figure 3

Figure 3: large invasion of the vertebra

Clinical Outcome

Lung cancer metastasis to the vertebrae, mesenchymal tumor or plasmacytoma were thought clinically. FNA was performed 2 times from this large mass for diagnostic purpose. However, these samples were reported as necrotic material. After unsuccessfull FNAs, open biopsy was planned and performed. Caseified granulomatous reaction compatible with tuberculosis was found in the biopsy sample. Antituberculosis therapy including isoniazid, rifampicin, ethambutol was given post operatively on the first day. The paraparesis improved gradually and a surgical operation was not performed.

Discussion

Tuberculosis is a worldwide infection, its incidence is high in developing countries and is increasing in developed countries due to diseases causing immunosuppression (₁, ₂). Tuberculosis is a multisystem disease and all the organ or tissues of the body may be involved by tuberculosis. The most important clinical symptoms are fever, night sweats and weight loss and most frequent site is the lung. However, extrapulmonary disease is not uncommon and clinical presentation may be very heterogenous and challenging. Different clinical presentations mimicking tumor have been reported so far (₂, ₃). The most common challenging cases are ovarian tuberculosis and these cases look like to ovarian cancer (₄, ₅). Other clinical locations are pancreatic, pulmonary, cerebral, cerebellar, spinal tuberculosis and these cases present like a tumor (₆, ₇, ₈, ₉, ₁₀). Some tuberculosis cases with abdominal presentation show high levels of tumor markers such as CA-125(₄, ₅).

We reported a mediastinal mass invading vertebrae and spinal canal with clinical presentation of spinal cord compression. An etilogically malignant tumor was thought clinically. Radiographic findings also suggested a malignant tumor. Two FNA samples showed necrosis and clinically/pathologically this necrosis was attributed to the tumor necrosis. However biopsy showed caseified granulomatous infection compatible with tuberculosis.

In conclusion tuberculosis must be thought in differential diagnosis of the tumoral masses, even in cases with severe bone invasion and spinal cord compression.

Correspondence to

Hakan Poyrazoglu, MD, Çukurova University, Faculty of Medicine, Cardiovascular Surgery Department, 01330 Adana, Turkey E mail: hpoyrazoglu@yahoo.com