Disseminated Tuberculosis Presenting as Transverse Myelitis with Bone Marrow Involvement: A Rare Case of Pyrexia of Unknown Origin

Abstract

In India, both pulmonary and Extrapulmonary Tuberculosis (TB) are prevalent. Central Nervous System TB (CNS-TB) is rare, with spinal intramedullary TB (SIMT) presenting as Longitudinally Extensive Transverse Myelitis (LETM) being even rarer. Diagnosing LETM often involves considering alternative aetiologies, frequently overlooking TB, particularly in patients without primary pulmonary TB. A 31-year-old male presented with high-grade fever, weight loss, and right hypochondriac pain. Initial investigations revealed pancytopenia and hepatosplenomegaly. Bone marrow biopsy showed granulomas and Acid-Fast Bacilli (AFB), but there was no evidence of Mycobacterium tuberculosis on the Cartridge-based Nucleic Acid Amplification Test (CBNAAT), leading to a presumptive diagnosis of disseminated TB. The patient was started on Antitubercular Therapy (ATT) but was non compliant with his medication, resulting in worsening symptoms, including paraparesis and urinary bladder involvement. Further investigations revealed LETM and ring-enhancing lesions in the brain. Despite negative CSF CBNAAT tests, empirical ATT with corticosteroids was resumed, and Mycobacterium tuberculosis was later confirmed via Lowenstein-Jensen (LJ) culture of the bone marrow. This case underscores the diagnostic challenges of disseminated TB with LETM, highlighting the importance of a high clinical suspicion and thorough evaluation, especially in endemic regions.

Keywords

• antitubercular therapy
• longitudinally extending transverse myelitis
• lowenstein-jensen culture
• ring enhancing lesion
• spinal intramedullary tuberculosis