09 August 2024: Articles
Unmasking Pott Disease: A Diagnostic Challenge Mimicking Metastatic Lung Cancer – A Case Report
Unusual clinical course, Challenging differential diagnosis, Diagnostic / therapeutic accidents
Anna Romaszko-Wojtowicz 1BDEF*, Ewa Malinowska1ABEF, Anna Doboszyńska 1CDFDOI: 10.12659/AJCR.943578
Am J Case Rep 2024; 25:e943578
Abstract
BACKGROUND: Tuberculosis spondylitis, also known as Pott disease, is a rare form of the ancient infectious disease tuberculosis. It bears a complex clinical and radiological profile, often necessitating an extensive differential diagnostic approach for accurate identification. The disease was named in honor of the first diagnosed patient, highlighting its historical significance.
CASE REPORT: We report a case involving a 69-year-old male initially admitted to the Pulmonology Department under the suspicion of a left lung tumor, as indicated by a chest X-ray. A subsequent CT scan revealed a tumor-hilar mass, enlarged subcarineal lymph nodes, and a pathological mass at the C6/C7 vertebral level. Despite negative tuberculosis tests, the patient was misdiagnosed with disseminated lung cancer with spinal metastases. Following radiotherapy targeting the cervical and thoracic spine, the definitive diagnosis of spinal tuberculosis was confirmed via histopathological examination from an open biopsy of the C6 and C7 vertebrae.
CONCLUSIONS: Tuberculosis can present with an insidious and misleading clinical picture, often mimicking other diseases such as cancer. Early and accurate diagnostic processes are crucial for effective treatment. This case underscores the importance of considering tuberculosis in the differential diagnosis, especially when clinical presentations are ambiguous.
Keywords: Mycobacterium tuberculosis, lung neoplasms, Tuberculosis, Spinal
Introduction
Tuberculosis (TB) is a disease caused by acid-resistant bacilli from the group
Tuberculosis of the bones and joints now corresponds to 2.2% to 4.7% of all cases of TB in Europe and the United States [12]. Involvement of the bones and joints accounts for about 10% of extrapulmonary tuberculosis cases, and the most commonly affected site is the spine, accounting for 50% to 70% [13–15]. Tuberculosis spondylitis is one of the oldest diseases plaguing humans. It has been detected in Egyptian mummies dating back to 3400 BC [16]. The damage to the disc space and adjacent vertebral bodies as well as to other elements of the spine with progressing kyphosis has been named Pott disease [17]. The disease manifests as chronic backache, which typically locates in the lower thoracic and lumbar spine. The infection begins as inflammation of the intervertebral discs and then progresses along the ligaments of the vertebral column, invading adjacent vertebral bodies [18].
The aim of this paper is to present a case of a patient with an insidious picture of extrapulmonary tuberculosis implicating disseminated neoplastic disease.
Case Report
A 69-year-old male patient, with a history of hypothyroidism, prostatic hypertrophy, a former smoker (not smoking for 26 years), was admitted to the Pulmonology Department of the hospital on February 28, 2023, presenting with chest pain that had been worsening for about 3 weeks, pyrexia, dry cough, and loss of appetite (loss of body mass by about 10 kg in 3 months). He was a professional teacher who had fallen ill after having resided in Venezuela for an extended period. He had relocated to Poland 2 years earlier and denied any history of tuberculosis exposure. A chest X-ray taken in an outpatient clinic prior to the admission to hospital demonstrated the widening of a shadow of the left pulmonary hilum (Figure 1). A computed tomography (CT) scan of the chest, performed on March 1, 2023, revealed an infiltrate mass in the hilum of the left lung, adjacent to the left pulmonary artery (Figure 2). A pathological 20-mm wide lymph node was visualized in the subcarinal region, a lymph node, measuring 15-mm wide, was seen in the right hilum, and a lymph node with a diameter of 16 mm located below the left lower pulmonary veins (Figure 3). At the height of the C6-C7 vertebrae, there was a visible pathological mass, heterogenous and weakly separated, 33 to 38 mm in dimension, destroying the antero-right parts of the vertebral bodies, the right arch of C6, and invading the prespinal tissues on the right side. It was adjacent to the right side of the esophageal wall and spreading down the spine toward Th2, probably pervading from the front into the spinal canal (Figure 4). The lesion was assessed on magnetic resonance imaging, where the image indicated metastasized neoplastic disease. During bronchofiberoscopy, performed on March 2, 2023, specimens were taken from the submucosal infiltrate underneath the departure of segment 6 of the left lung, and their histopathological examination did not reveal any neoplastic tissue. A bronchial secretion test for specific infection, acid-fast bacilli, yielded a negative result. Histopathological examination of sections from the nodular infiltration on the lateral wall of the bronchi revealed tissue fragments partially covered with epithelium, consisting of fibrous connective tissue, T and B lymphocytes, plasma cells, and neutrophils. Additionally, the bronchial secretions predominantly contained cuticles of normotypic respiratory epithelium, squamous epithelium, macrophages, and lymphocytes. On March 9–14, 2023, the C4-Th2 area was irradiated (20 Gy in 5 fractions). Due to the newly diagnosed paresis of the right peroneal nerve, a CT scan of the entire spine was done, which revealed a hypodense infiltrate in the projection of the external obturator muscle and the quadratus femoris to the right side, and within the adductor magnus muscle, occupying an area of approximately 67×22 mm, with no evident pathological enhancements.
The follow-up chest CT scan on March 29, 2023, preceding the patient’s qualification for an endobronchial ultrasound (EBUS) test, revealed significant regression of the tumor nodal mass (Figure 5). On March 20, 2023, an EBUS and endoscopic ultrasound (EUS) needle aspiration test was conducted, in which samples of material from a group 7 lymph nodes and from the tumor mass in the proximity of C6-C7 were collected for cytological examination. Again, no neoplastic tissue was detected. Histopathological examination revealed bronchial epithelial cells, macrophages, and lymphoid cells. On April 6, 2023, the patient was qualified for an open biopsy of the C6 and C7 vertebrae, which was performed at the Orthopedic Ward of the MSWiA Hospital in Olsztyn. The histopathological examination revealed chronic granulomatous inflammation, with the presence of necrosis. No cultures were performed. On May 2, 2023, the final results were obtained from the culture of bronchial secretion grown on the Löwenstein-Jensen medium. The strain of
Discussion
We reported a case of a 69-year-old patient with Pott disease, whose signs and symptoms were initially considered to display an image of disseminated neoplastic disease with a probable origin in the lungs. Changes in the spine were thought to be metastases of the primary lung cancer. Due to the CT image, with the visible invagination of the pathological mass at the C6-C7 vertebrae, prior to the final diagnosis and for fear of tetraplegia, the patient was submitted to radiotherapy of this area.
In 2022, 4 cases of tuberculosis spondylitis were detected in Poland; meanwhile, approximately 20 000 new cases of lung cancer are diagnosed in our country each year [11,19]. The differential diagnosis of this type of lesion in the spine includes bacterial infections (eg, brucellosis), neoplastic diseases, myeloma, or dissemination of neoplastic disease [20–22]. An unquestionable problem in the present case was the co-occurrence of the tumor nodular mass on the chest CT scan, which in the early clinical picture implicated the diagnosis of disseminated cancer. However, this diagnosis was undermined by the regression of the lesion observed later in the follow-up chest CT and by the results of the 2 biopsies (during bronchofiberoscopy and during the EBUS test), which did not reveal any changes of the neoplastic character.
The invasion of the spine in a course of TB is usually a consequence of the spread of
Initial suspicion of Pott disease is often based on the clinical picture and results of imaging tests, but the final diagnosis relies on the isolation and identification of the pathogen. This applies to all pulmonary and extrapulmonary forms of tuberculosis [25,26].
Conventional microbiological methods, such as staining with the Ziehl-Neelsen method for acid-resistant bacilli and culture of
The time waiting for the results of a bacterial culture was of fundamental importance in the present case. The etiological confirmation of a diagnosis can be achieved either by determining the presence of acid-resistant bacilli in the pathological material or by confirming the presence of epithelial cells in a histopathological test on biopsy material [29]. Needle biopsy of a lesion is the criterion standard in the early histopathological diagnosis of spinal tuberculosis [30]. Histological examinations confirm the diagnosis of tuberculosis spondylitis in about 60% of patients. The cytological changes most often observed are epithelial cell granulomas (90%), granular necrotic background (86%), and lymphocytic infiltration (76%). In over 50% of patients, the biopsy material is found to contain disseminated multinucleated cells and Langhans giant cells [21,31,32]. In our patient, the biopsy revealed granulomatous inflammation with the presence of necrosis, which is typical of tuberculosis [33]. Despite the absence of specific diagnostic criteria, the patient’s clinical presentation with respiratory and osteoarticular symptoms, coupled with a history of extended residence in a high TB-burden area, such as Venezuela, should have triggered a robust suspicion of TB. The biopsy findings of granulomatous inflammation with necrosis further supported this suspicion, aligning with typical features of tuberculosis spondylitis. This case underscores the need for a proactive approach to diagnosis, where clinical judgment is used to initiate empiric TB treatment promptly in cases of high suspicion, even before microbiologic confirmation is obtained. Waiting for definitive test results can result in diagnostic inertia and potential harm to the patient’s health. Therefore, healthcare providers should leverage available clinical evidence and diagnostic tools, such as histopathological examinations and rapid molecular tests, to expedite treatment initiation and improve patient outcomes in suspected cases of tuberculosis.
Conclusions
The presented case highlights the key role of making a differential diagnosis correctly, employing all available methods. The lack of specific clinical criteria for the diagnostic process should not dissuade us from searching for tuberculosis, despite a suggestive clinical image. Even in countries with low tuberculosis incidence, patients presenting with lung or spinal lesions should be evaluated for tuberculosis. The utilization of readily accessible rapid molecular tests substantially reduces the duration of tuberculosis diagnosis. It is imperative to ensure that an appropriate diagnostic approach has been undertaken. Rapid molecular tests, which are increasingly accessible, can substantially shorten the time to diagnosis and should be integrated into diagnostic algorithms to expedite treatment initiation and improve patient outcomes, particularly in cases of suspected tuberculosis.
Figures
Figure 1.. A 65-year-old male patient’s screening chest X-Ray. The arrow indicates a nodularly enlarged hilum of the left lung. Figure 2.. Chest computed tomography scan from March 1, 2023 (lung window). The arrow indicates a infiltration-nodal mass of the left lung hilum. Figure 3.. Chest computed tomography scan from March 1, 2023 (contrast-enhanced). The arrow indicates an enlarged subcarinal lymph node. Figure 4.. Chest computed tomography scan from March 1, 2023 (contrast-enhanced). The arrow shows destroyed anterior-right parts of the vertebral bodies. Figure 5.. Follow-up computed tomography scan from March 29, 2023 (contrast-enhanced). The arrow indicates a reduced subcarinal lymph node, showing a decrease in size, compared with the previous scan.References:
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