P3B106: Not All Back Pain Is Musculoskeletal..

Introduction: Disseminated Tuberculosis, should be considered in any patient presenting with back pain, particularly in recent immigrants. Immigrants have unique challenges to receiving adequate healthcare, and it is important for a clinician to formulate a broad differential when seeing these patients. Here, we present a case of disseminated tuberculosis in a patient undergoing workup up for chronic back pain.

Case Description: An 18-year-old male presented to the emergency department (ED) with complaint of lower back pain. The patient reported a 3-month history of back pain with associated 6 kilogram weight loss, night sweats and generalized weakness. The patient immigrated from Mexico on the day of his ED visit. He reported that while in Mexico, he had anemia that required a blood transfusion and a hand infection that required drainage and antibiotics. 2 days prior to arrival, he had also developed a headache, generalized body aches and upper back pain. His aunt noted the patient also appeared pale.
The patient denied fever, chills, nausea, vomiting, changes in bowel movements, cough or shortness of breath.

On exam, the patient was cachectic, pale, tachycardic and ill-appearing. Lungs were clear to auscultation bilaterally. Abdomen was distended with tenderness to palpation of the left quadrants. There were two large areas of fluctuance, erythema and tenderness at the left flank and overlying the right scapula (Figure 1). Labs showed leukocytosis with neutrophilic predominance and severe anemia, for which he received a blood transfusion. A computed tomography scan (CT) of the chest/abdomen/pelvis was obtained that revealed extensive lytic metastatic disease of the spine and multiple soft tissue masses concerning for malignancy versus infection. The patient was admitted for further workup and management. During admission, the infectious disease team was consulted and a large work-up was initiated. Imaging and lab workup confirmed the patient had disseminated tuberculosis. He was initiated on antibiotic treatment. Further imaging showed multiple abdominal, paraspinal and muscle abscesses (Figure 2), necessitating drain placement. The patient was continued on therapy for tuberculosis and discharged home.

Discussion: Disseminated tuberculosis is an extrapulmonary manifestation of tuberculosis. It results when mycobacterium spreads from the lungs to other parts of the body such as bones, muscles, meninges, and lymph nodes. The disease is most commonly seen in the immunosuppressed. Those born in areas with limited healthcare or high disease incidence are also at increased risk. Symptoms and exam findings depend on what organ is affected and can be nonspecific. Disseminated tuberculosis is confirmed once the patient tests positive for tuberculosis and if mycobacterium is found in the blood or bone marrow, or if it is seen within two noncontiguous organs.

Conclusion: This case demonstrates the importance of having a broad differential when presented with back pain, particularly in a patient with recent immigration history.