{"ops":[{"insert":"A 35-year-old man presents with upper back pain for two weeks, which is constant and dull in nature, without radiation. Both weight-bearing and movement aggravate the pain. There is no weakness or numbness of the upper or lower limbs.\n\nFurther questioning reveals an intermittent nonproductive cough for one and a half years, associated with anorexia and fatigue, and a total weight loss of ~10 kg.\n \nThere is no history of trauma, exposure to tuberculosis, animal contact, or foreign travel within or immediately before that period. He has been healthy until now and is not on any medications. \n \nHis family history is only significant for a myocardial infarction in his father, at the age of 62 years. He has smoked for 15 years and continues to do so, consuming around two to three cigarettes per day. He only drinks socially and denies using recreational drugs.\n\nA complete blood count is significant for a Hb of 9.5 g\/dL (normal: 11-18), with a MCV of 85 fL (normal: 75-95). His ESR and CRP are 82 mm\/1h (normal: \u003C10) and 24 mg\/L (normal: \u003C6) respectively. Chest x-rays reveal a heterogeneous opacity in the left upper lobe.\n"},{"insert":"\n"},{"insert":{"image":"\/storage\/case-images\/pd\/PD-M-254_en.png"}},{"insert":"\n"}]}
2
Investigate
MRI spine
{"ops":[{"insert":"T1-weighted images show collapse of the T10-T12 vertebrae. The T10-T11 and T11-T12 disc spaces are destroyed. A kyphotic angulation of 15\u00b0 is seen over T10-T12 due to the vertebral collapse.\n \nMultiple rim-enhancing lesions can be seen in the left paravertebral and sub-ligamental spaces at the level of T10-T12, suggestive of abscesses. The spinal cord is unaffected.\n"}]}
CT-guided percutaneous spine biopsy
{"ops":[{"insert":"Microscopy of the biopsy samples reveals epithelioid cell granulomas against a granular necrotic background, with dense lymphocytic infiltration.\n \nZiehl-Neelsen staining reveals acid-fast bacilli. Polymerase chain reaction (PCR) confirms the presence of Mycobacterium tuberculosis.\n"}]}
