A 23-year-old male presented with lower back pain, fatigue, cough, and fever for three months. Physical examination revealed tenderness in the lower back and ribs as well as an enlarged lymph node. Imaging showed bony lesions in the ribs and spine consistent with a diagnosis of multifocal skeletal tuberculosis, also known as Potts disease. The patient was started on antitubercular medications while further tests were conducted to confirm the diagnosis.

1. Morning Report
Dr. Aasems Jacob

2. Patient Profile
23 year old AA male presented to outpatient
clinic with
• Back pain
• Fatigue
X 3months

3. History of Present Illness
• Lower back pain
– 5/10 intensity
– No radiation
– No lower extremity weakness
– No bowel/bladder incontinence
• Non productive cough with intermittent fever
• Decreased appetite

4. • Denies
– trauma
– loss of weight
– diarrhea
– hemoptysis
– rashes
– lymph node enlargement
– cold intolerance

5. Past medical and surgical history
• Negative HIV 2 years ago
• PPD positive 3 years ago- not followed up
• Father with diabetes and hypertension
• Uncle who died of tuberculosis when patient
was a child
Family Medical history

6. Personal and Social history
• 1-2 beers on weekends
• 1 cigar/day x quit 5 months ago
• No illicit drug use
• Multiple sexual partners in past 1 year
• Spent past 2 years in a homeless shelter in
New Orleans
• Unemployed

7. Review of systems
• Negative except for the symptoms mentioned
in HPI

8. Physical Examination
• Vitals
– 100.4ᴼF
– Pulse 88/’
– BP 119/80
– SpO2 98% in room air
• No pallor, icterus
• 2x2 cm Rt. supraclavicular node
• Tenderness over L2 vertebra
• No kypho-scoliosis

9. • Chest
– Bilateral lower rib tenderness
– Clear on auscultation
• Abdomen
– No hepatosplenomegaly
• Neurological
– Straight leg raising test negative
– Power 5/5 in all limbs ; Reflexes normal
– No sensory loss

10. Investigations
• CBC, U/A, BMP, LFT, S.Creat: Normal
• Serum electrophoresis: negative
• Chest X-ray: Negative
• Awaiting PPD, blood culture

11. • CT showed multiple lytic osseous lesions in
ribs and L2 spine with invasion into posterior
soft tissues
• MRI- Rt. Paravertebral mass at L2 destroying
pedicles and transverse process. Reactive
inflammatory changes in psoas muscle

12. Assessment and plan
• Presumptive diagnosis:
Multifocal skeletal TB
(Potts disease)

13. Assessment and plans
1. HIV, RPR
2. Bone scan
3. FNAC supraclavicular lymph node, CT biopsy
lumbar mass
4. Fentanyl IV 50µg bolus every 3 hrs
5. Empiric treatment with
• INH (5mg/kg)
• Rifampin (10mg/kg)
• Pyrazinamide (15-30mg/kg)
• Ethambutol (15-25mg/kg)

14. Summary
• 23 year old AAM
• lower back pain and fatigue x 3months
• history of non productive cough, fever and loss of
appetite for 3 months
• Chronic smoker quit 6 months back
• Unemployed and lives in homeless shelter
• R. supraclavicular lymph node, bilateral lower rib
tenderness and tenderness over L2.
• Paravertebral mass at L2 with inflammatory
changes in psoas muscle in MRI