Radiology_May04 CASE REPORT 36 SA JOURNAL OF RADIOLOGY • May 2004 History A 15-year-old boy was referred from a peripheral clinic to Pretoria Academic Hospital with the history of a lump in his neck. He also had a 6- month history of malaise and weight loss. Clinical examination On clinical examination he was found to be feverish and appeared cachectic. He had a fluctuating mass in the right anterior triangle of his neck. He had tenderness over the tho- racic and lumbar spine and also ten- derness over his liver. Hepatomegaly was present. Laboratory examinations Some special examinations were done: C-reactive protein (CRP) 120 mg/l, urea and electrolytes (U + E) normal, serum albumin 25 g/l, ery- throcyte sedimentation rate (ESR) 100 mm/h, haemoglobin (Hb) 9.8 g/dl, white cell count (WCC) 10 x 109g/l and platelets 667 x 109g/l. No HIV test was performed. Imaging findings Chest radiograph Posteroanterior (PA) and lateral views of the chest were taken. Computed tomography Figs 3-9 are selected images rang- ing from the cervical area down to the upper abdomen depicting the extent of involvement. Diagnosis The histological diagnosis of tuber- culosis (TB) was made on lymphnode biopsy. Discussion In 1979 Sir Percival Pott from England provided the first full written account of the skeletal manifestations of tuberculous infection, and his name continues in use to describe the spondylitis associated with this infec- tion (Pott’s disease). Tuberculous spondylitis is defined as an infection caused by Mycobac- An unusual presenta- tion of tuberculous lymphadenopathy, paraspinal masses with spondylitis in a young boy Betsie van der Walt FCRad (D) SA Sonja Raven MB ChB Zarina Lockhat FFRad (D) SA Irma van de Werke FRCR Department of Radiology University of Pretoria Figs 1 and 2. PA and lateral view of chest showing posterior mediastinal and paraspinal widening extending from thoracic inlet into the thoraco-lumbar region. The lung fields are normal. Hepatomegaly is present. CASE REPORT 37 SA JOURNAL OF RADIOLOGY • May 2004 terium tuberculosis involving one or more components of the spine, name- ley the vertebra, intervertebral discs, paraspinal soft tissues and epidural space. Clinical and pathological features Symptoms and signs vary consid- erably and the medical history is not a reliable guide to the diagnosis. Except in children, there is typically a long latent period between the first episode of pulmonary infection and muscu- loskeletal manifestations. Approxi- mately 50% of patients with extrapul- monary TB have normal chest films or the stigmata of old inactive pul- monary disease. Patients with muscu- lo-skeletal involement may be afebrile and free of systemic complaints until the late stage of infection. The illness typically pursues an indolent course. In spinal infections the presenting symptom is often persistent spinal pain and local tenderness, with limita- tion of spinal mobility on clinical examination. Fever may be present at this stage. The erythrocyte sedimenta- tion rate (ESR) is elevated in more than 80% of cases and the tuberculin skin test is usually positive. Paralysis results from spinal cord compression caused by epidural tuberculous abscess formation, epidural tuberculous granulomatous tissue and/or bony fragments pro- Fig. 3. Axial view of the neck at the thyroid level showing left cervical lymphadenopathy with necrosis, as well as right subcutaneous hypoden- sities with rim enhancement due to tuberculous abscesses. Figs 4 and 5. Imaging done at the level of the thoracic inlet and superior mediastinum showing the massive paraspinal abscess displacing the oesophagus and trachea anteriorly. There is lymphadenopathy visible with necrosis and anterior vertebral body erosion. Figs 6 and 7. Images at the subcarinal and heart level showing continuation of the paraspinal abscess with necrotic mediastinal lymphadenopathy and associated pericardial effusion. Figs 8 and 9. Upper abdominal images demonstrating continuation of the paraspinal mass with a further abscess in the region of the spinous process. Para-aortic necrotic lymph nodes are also present. These abscesses continue into the psoas muscles. CASE REPORT 38 SA JOURNAL OF RADIOLOGY • May 2004 truding into the spinal canal. Endarteritis of the spinal arteries or intramedullary granulomas are also observed occasionally. The vertebral column is affected in 25-60% of cases of skeletal tuberculo- sis with the thoracic and lumbar spine mainly involved, especially the thora- co-lumbar junction, with the sacrum and cervical spine being less frequent- ly involved. Solitary vertebral lesions can occur, but it is usual to find more than one vertebral level affected. Skip lesions occur in up to 4% of cases. The anterior aspect of the vertebral body is affected more frequently than the posterior. The route of infection is usually haematogenous rather than contiguous or from direct implanta- tion. The infective mycobacterium initially lodges in the vascular mar- row. The arterial route generally is recognised as the more important method of transmission although Batson’s plexus has been implicated in certain cases as the route of infection. Direct involvement of the disc by bloodborne pathogens occurs only in the paediatric age group (< 20 years), because of the persistent fetal blood supply to the disc. Paravertebral soft- tissue abscesses reach a maximum size within 2 months of presentation and can take up to 15 months to resolve. CT of tubercu- lous spondylitis Axial CT cuts demonstrates bony destruction of the vertebral end plates with fragmentation. Bony fragments may migrate into surrounding struc- tures, e.g. the spinal canal, periverte- bral soft tissue and psoas muscles. If a pedicle is involved there may be asso- ciated destruction of the posterior aspect of the adjoining rib. CT demonstrates disc space nar- rowing, paravertebral soft-tissue masses, multi-level involvement and kyphosis. Associated soft-tissue mass- es are usually larger than the extent of bony destruction and are well demon- strated on axial scans. Calcifications within or surrounding these abscesses are pathognomic of TB. These paraspinal soft-tissue lesions usually extend in an anterolateral direction, although direct posterior extension has been observed. The thick nodular rim of an abscess on a pre-contrast scan represents the hypervascular, hypercellular, fibrotic wall of the inflammatory cavity. Following IV contrast strong rim enhancement is noted around low attenuation multiloculated fluid col- lections. These abscesses may extend into the superficial dorsal soft tissues, with loss of normal muscle/fat inter- faces. Abscesses may burrow for a dis- tance before perforating an internal organ or the skin. Tuberculous lum- bar pus produces a psoas abscess that may extend inferiorly into the pelvis and penetrate into the groin. In summary, CT depicts distur- bances of bony integrity and enables precise evaluation of paraspinal soft- tissue involement. This case is unusual in presenting with a cervical mass, whilst imaging showed massive tubercular abscess involvement from the cervical to the lumbar region. Acknowledgement We would like to thank Annelize Gates for her assistance in the prepa- ration of this article. Reference 1. Hassn S, Sharif, John L. et al. Imaging of tuber- culosis and cranio spinal tuberculosis. Radiol Clin North Am 1995; 33: 787-804.