spinal tuberculosis - associated symptoms are not so unique as to immediately indicate the proper diagnosis in most cases . distinguishing spinal tuberculosis ( pott 's disease ) from pyogenic spondylitis is often difficult , and lesions metastatic from systemic malignancy are the other major entity from which spinal tuberculosis must be distinguished . a 27-year - old male patient presented with a history of back pain after a minor trauma 1 month ago . computed tomography and magnetic resonance imaging of the thoracic spine showed multiple osteolytic bone lesions at the bodies of t9 , t10 and t11 vertebrae and the spinous processes of t12 and l1 . other noncontiguous osteolytic lesions were noted at s2 body and right sacro - iliac joint . to confirm the pathologic diagnosis , the patient underwent an open biopsy for the t12 and l1 spinous process lesions and a percutaneous transpedicular biopsy on t9 , t10 , t11 lesions . the patient received an appropriate enteral anti - tuberculosis therapy and recovered without any complications . follow - up mri taken after a year of medical treatment revealed marked resolution of the lesions . current research indicates the incidence of multi - level noncontiguous , remote vertebral tuberculosis is 1.1% to 16% . because tuberculous spondylitis could represent variant and atypical pattern , the disease should be considered in differential diagnosis along with other diseases such as metastatic neoplasm , pyogenic spondylitis , especially when the radiologic studies are revealing multiple spinal lesions . features of spinal tuberculosis ( pott 's disease ) , an extrapulmonary form of tuberculosis , include destruction of the intervertebral space and collapse of vertebral bodies , leading to progressive kyphosis . spinal tuberculosis used to be an uncommon disease in developed countries , and its associated symptoms are not so unique as to immediately indicate the proper diagnosis in most of cases2 ) . distinguishing spinal tuberculosis from pyogenic osteomyelitis , however , is often very difficult and , lesions metastatic from systemic malignancy are the other major entity from which spinal tuberculosis must be distinguished2 ) . usually , two or more contiguous vertebrae are involved in spinal tuberculosis due to hematogenous spread through one vertebral artery feeding two adjacent vertebrae3,4 ) . noncontiguous , multiple , remote involvement of tuberculous spondylitis is relatively rare , and most of the reported cases have lesions only in two levels3,4,5,6 ) . cur rent research indicates the incidence of multiple - level noncontiguous vertebral tuberculosis is 1.1% to 16%7 ) . we present a case of atypical spinal tuberculosis in a 27-year - old man with noncontiguous multiple spinal lesions . a 27-year - old male patient presented with a 1-month history of pain in his back after a minor trauma 1 month ago . there was no visible or palpable deformity but tenderness could be elicited over the spinous processes of the lower thoracic vertebrae . computed tomography ( ct ) and magnetic resonance imaging ( mri ) of the thoracic spine showed multiple osteolytic bone lesions . at the bodies of t9 , t10 and t11 vertebrae , osteolytic bone lesions were noted along with the similar lesions at the spinous processes of t12 and l1 . other noncontiguous osteolytic lesions were also noted at s2 body and right sacro - iliac joint on the further mri study . on enhanced studies , these lesions were well enhanced with heterogeneous pattern ( fig . 1 , 2 ) . chest x - ray and enhanced chest ct studies did not show any parenchymal lung lesion or lympho - adenopathy , and three times of sputum acid fast bacilli stain showed all negative results . complete blood count , routine biochemistries , urinalysis , liver function tests , thyroid function tests , lipid profiles , and creatine kinase level were all normal . anti - human immune deficiency virus ( hiv ) antibodies , hepatitis b surface ( hbs ) antigen , and hepatitis c virus ( hcv ) antigen were all negative . venereal disease research laboratory ( vdrl ) , syphilitic serology tests , and serum tumor markers were all within normal ranges . whole body bone scan showed multiple hot uptakes in the lower thoracic spines , sacrum and sacro - iliac joint on the right ( fig . 3 ) . to confirm the pathologic tissue diagnosis , the patient underwent an open biopsy for the t12 and l1 spinous process lesions through a midline small skin incision and a percutaneous transpedicular biopsy on t9 , t10 , t11 lesions under general anesthesia . the specimens were further checked by polymerase chain reaction ( pcr ) test for tuberculosis and reported as positive . the patient received an appropriate enteral anti - tuberculous therapy and recovered without any complications . follow - up mri taken after a year of anti - tuberculous therapy revealed marked resolution of the lesions ( fig . tuberculosis , a disease that once was on the decline and almost eradicated in the first world , has made a dramatic comeback . according to the world health organization , tuberculosis is the number one specific infectious cause of death worldwide8 ) . it is estimated that one - third of the world 's population is infected with tuberculosis , an estimated 2 billion people . south africa has the world 's highest reported incidence of tuberculosis at 718/100,000 reaching 1.2% of the population in certain areas8 ) . extrapulmonary tuberculosis consists of 15 - 20% of the patients if you include pleural and lymphatic disease , which is most common8 ) . skeletal tuberculosis is 10% of this , of which spinal tuberculosis accounts for approximately 50% . this gives an incidence of between 1 and 2% for osteoarticular tuberculosis and 0.5 - 1% for spinal tuberculosis9 ) . tuberculosis has a worthy reputation as one of the great mimickers in medicine with a multitude of clinical pictures and variations . this makes the characteristic features of the classic disease problematic , with most texts and articles describing a typical clinical and radiological picture followed by many atypical derivatives . although tuberculous spondylitis frequently involves multiple adjacent spinal vertebrae , noncontiguous , remote involvement is reported as rare in literature3,4,5,6,8 ) . a feature most typically distinguishing spinal tuberculosis from pyogenic osteomyelitis is the relative sparing of the intervertebral discs . mycobacteria lack the proteolytic enzymes found in bacteria that commonly cause pyogenic osteomyelitis , and this may be responsible for the relative sparing of the disc10 ) . the avascularity of the discs may prevent them from serving as an initial site of infection , and it has been suggested that disc destruction begins only when the two adjacent vertebral bodies are so involved that the disc loses its nutritional support . these abscesses may be located anterior , posterior , lateral , or circumferentially around the vertebral body . the wall of the abscess is characteristically thick and irregularly enhancing on both ct and mr images , and this feature is thought to be diagnostic of tuberculous spondylitis2 ) . multiple metastatic spinal lesions from systemic malignancy are the major entity from which multiple spinal tuberculosis must be distinguished . when the spinal tuberculosis involves multiple noncontiguous vertebrae , its imaging appearance can be easily mistaken for metastatic malignancy . factors that should indicate and distinguish spinal tuberculosis from neoplastic disease include the presence of paravertebral abscesses and subligamentous spread2 ) . in our case , tuberculosis involved mainly he vertebral bodies not the pedicles , that impressed spinal tuberculosis rather than other malignancy . in the presenting case of the authors , the osteolytic pattern of t9 , t10 , t11 vertebral bodies could be considered as relatively typical form of spinal tuberculosis . there was , however , no evidence of bony involvement or paravertebral abscess formation in the anterior or middle columns of t12 and l1 vertebrae , and spinous processes were only involved . especially at the level of t12 , spinous process was destroyed near totally but pedicles and vertebral body was intact in the imaging studies . thoracic and lumbar vertebrae , sacrum , and iliac bone were involved simultaneously with discontinuity . noncontiguous spinal tuberculosis is far more common ( 16.3% ) than that reported in literature8 ) . there was a trend towards a higher incidence of neurology in the noncontiguous group compared to the single focus8 ) . this trend may not necessarily reflect more severe disease , but instead may be a product of heightened probability due to the increased levels involved and/or the double - crush neural phenomenon . noncontiguous spinal tuberculosis is not an obvious manifestation of hiv , multi - drug resistant ( mdr ) tuberculosis or chronicity as in our patient . it is not a " fulminant " type of tuberculosis as suggested by emel , et al3 ) . evangelista , et al reported that bone scan can anticipate radiograph by 2 to 5 months and help guidance of the site of biopsy.11 although skeletal locations mostly involve the dorsolumbar spine , nuclear imaging allows assessment of the whole body . in our case , mri and whole body bone scan revealed remote noncontiguous lesions , though patient did not complained of any symptoms on sacrum or sacro - iliac area . atypical osseous tuberculosis lesions of the spine share several features in common as reported by naim - ur - rahman , et al11,12 ) . first , atypical vertebral lesions readily involve the neural arch , sparing the vertebral body and discs ( referred to as " posterior pott " ) . second , skip lesions are often present , as defined by the presence of two or more vertebral lesions separated by an uninvolved vertebra . finally , lesions may manifest as solid tumor - like masses with no evidence of abscess formation , discovered at the time of surgery and indistinguishable from a solid spinal extradural tumor . in the present case , imaging study revealed such a similar pattern of osseous lesions , and involvement of the neural arch of t12 and l1 was first observed on the mri . asymptomatic lesions of sacrum and the right sacro - iliac joint were identified as a scintigraphic pattern of multiple , disseminated foci of uptake together with normal uptake of other vertebrae . finally , scintigraphic heterogeneity of the right sacroiliac lesion could be interpreted as a tumor - like lesion . when symptomatic , tuberculous sacro - iliitis can present with nonspecific complaints of buttock pain , which may also evoke several pathologies , such as psoas abscess , appendicitis , sciatica or pyelonephritis , and some primary bone tumors like chordoma or chondrosarcoma12 ) . as our case with neurologically intact condition or with minimal systemic symptoms , most patients demonstrate good outcomes with standard care8 ) . metastatic neoplasm , tuberculous spondylitis , and pyogenic spondylitis must be considered in the differential diagnosis of multiple spinal lesions . because spinal tuberculosis could represent a variant and atypical pattern , it should be kept in mind that appropriate radiologic examinations , such as whole body bone scan or spine mri , are useful in osseous tuberculosis , especially when the lesions are multiple .
objectivespinal tuberculosis - associated symptoms are not so unique as to immediately indicate the proper diagnosis in most cases . distinguishing spinal tuberculosis ( pott 's disease ) from pyogenic spondylitis is often difficult , and lesions metastatic from systemic malignancy are the other major entity from which spinal tuberculosis must be distinguished.clinical presentationa 27-year - old male patient presented with a history of back pain after a minor trauma 1 month ago . computed tomography and magnetic resonance imaging of the thoracic spine showed multiple osteolytic bone lesions at the bodies of t9 , t10 and t11 vertebrae and the spinous processes of t12 and l1 . other noncontiguous osteolytic lesions were noted at s2 body and right sacro - iliac joint.interventionto confirm the pathologic diagnosis , the patient underwent an open biopsy for the t12 and l1 spinous process lesions and a percutaneous transpedicular biopsy on t9 , t10 , t11 lesions . 
 frozen biopsy was reported as compatible with chronic granulomatous caseating necrosis without malignant cells . 
 the final diagnosis was an atypical presentation of multiple spinal tuberculosis . 
 the patient received an appropriate enteral anti - tuberculosis therapy and recovered without any complications . 
 follow - up mri taken after a year of medical treatment revealed marked resolution of the lesions.conclusioncurrent research indicates the incidence of multi - level noncontiguous , remote vertebral tuberculosis is 1.1% to 16% . 
 because tuberculous spondylitis could represent variant and atypical pattern , the disease should be considered in differential diagnosis along with other diseases such as metastatic neoplasm , pyogenic spondylitis , especially when the radiologic studies are revealing multiple spinal lesions .