Multi-level tuberculosis of the spine identified by 18 F-FDG-PET/CT and concomitant urogenital tuberculosis: a case report from the spinal TB X cohort

• Published in: Infection 2024-06, Vol.52 (6), p.2507-2519
• Main Authors: Scherer, Julian, Mukasa, Sandra L., Wolmarans, Karen, Guler, Reto, Kotze, Tessa, Song, Taeksun, Dunn, Robert, Laubscher, Maritz, Pape, Hans-Christoph, Held, Michael, Thienemann, Friedrich
• Format: Article
• Language: English
• Subjects: Adult; Antitubercular Agents - therapeutic use; Avidity; Back pain; Biopsy; Case Report; Computed tomography; Diagnosis; Family Medicine; Fluorodeoxyglucose F18; Gene expression; General Practice; Health services; Humans; Infectious Diseases; Inflammation; Informed consent; Internal Medicine; Lesions; Lungs; Magnetic resonance imaging; Male; Medical imaging; Medical instruments; Medicine; Medicine & Public Health; Microbiology; Musculoskeletal system; Mycobacterium tuberculosis - isolation & purification; Patients; Phenotypes; Positron emission; Positron emission tomography; Positron Emission Tomography Computed Tomography - methods; Spine; Sputum; Subclinical infection; Tomography; Tuberculosis; Tuberculosis, Spinal - diagnosis; Tuberculosis, Spinal - diagnostic imaging; Tuberculosis, Urogenital - diagnosis; Tuberculosis, Urogenital - diagnostic imaging; Tuberculosis, Urogenital - drug therapy; Urine
• ISSN: 0300-8126; 1439-0973; 1439-0973
• DOI: 10.1007/s15010-024-02327-5

Background Tuberculosis (TB) is caused by Mycobacterium tuberculosis ( Mtb ) and typically infects the lungs. However, extrapulmonary forms of TB can be found in approximately 20% of cases. It is suggested, that up to 10% of extrapulmonary TB affects the musculoskeletal system, in which spinal elements (spinal tuberculosis, STB) are involved in approximately 50% of the cases. STB is a debilitating disease with nonspecific symptoms and diagnosis is often delayed for months to years. In our Spinal TB X Cohort, we aim to describe the clinical phenotype of STB using whole-body 18 F-fluorodeoxyglucose positron emission tomography computed tomography (PET/CT) and to identify a specific gene expression profile for the different stages of dissemination on PET/CT. Here we report on the first patient recruited into our cohort who underwent PET/CT before treatment initiation, at 6-months and at 12-months - time of TB treatment completion. Case presentation A 27-year-old immunocompetent male presented with severe thoracolumbar back pain for 9 months with severe antalgic gait and night sweats. Magnetic resonance imaging (MRI) of the whole spine revealed multilevel spinal disease (T5/6, T11/12, L3/4) in keeping with STB. After informed consent and recruitment into the Spinal TB X Cohort, the patient underwent PET/CT as per protocol, which revealed isolated multilevel STB (T4-7, T11/12, L3/4) with no concomitant lung or urogenital lesion. However, sputum and urine were Xpert MTB/RIF Ultra positive and Mtb was cultured from the urine sample. CT-guided biopsy of the T11/12 lesion confirmed drug-sensitive Mtb on Xpert MTB/RIF Ultra and the patient was started on TB treatment according to local guidelines for 12 months. The 6-month follow-up PET/CT revealed new and existing spinal lesions with increased FDG-uptake despite significant improvement of clinical features and laboratory markers. After 9 months of treatment, the patient developed an acute urethral stricture, most likely due to urogenital TB, and a suprapubic catheter was inserted. The 12-month PET/CT showed significantly decreased PET/CT values of all lesions, however, significant persistent spinal inflammation was present at the end of TB treatment. Clinically, the patient was considered cured by the TB control program and currently awaits urethroplasty. Conclusions In our case, PET/CT emerged as a valuable imaging modality for the initial assessment, surpassing MRI by revealing more comprehensive extensive diseas