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Background
This case was an atypical presentation of tuberculous (TB) spondylitis in which diagnosis was delayed due to many factors. A Schmorl node 1 is a herniation of the nucleus pulposus through cartilaginous and bony endplate into the body of an adjacent vertebra. Schmorl nodes are mostly benign and asymptomatic, but some result in severe pain to the patient. In our case, this lesion was identified as a precursor lesion to spinal TB, which has previously not been reported in literature. Despite medical advancements, delayed diagnosis continues to be a feature in spinal TB and our case explores such contributing factors. Spinal TB should be considered in the differential diagnosis of chronic back pain with or without constitutional symptoms, especially in young, otherwise healthy immigrants from countries with a high prevalence of TB.
Case presentation
A 26-year-old female with no significant comorbidities presented to her primary care physician (PCP) with low back pain for 4 weeks characterised as moderate, aching in nature, with associated radiation down to bilateral lower limbs, worse with exertion and relieved with rest. She denied fever, chills, weight loss, fatigue, bowel or bladder involvement and had no history of trauma. She had returned from a 3-week trip to India 1week prior to presentation and had been residing there since birth until immigrating to the USA 1.5 years ago. Examination revealed limb length discrepancy and mild left sacroiliac tenderness; no focal spinal tenderness or deformity was appreciated. Over 4-5 months, despite physical therapy (PT) and non-steroidal anti-inflammatory drugs, she reported worsening back pain with increased urinary frequency and constipation. Urinalysis and culture were negative for infection. MRI showed a 10mm deep Schmorl node at L4, with surrounding marrow oedema, which was deemed incidental ( figure 1 ). Physical medicine and rehabilitation was consulted and she was diagnosed with pelvic floor dysfunction. She underwent pelvic PT that resolved the bowel and bladder symptoms.
The back pain gradually worsened about 9 months into her illness. Additionally, she reported pain in the small joints of hands with morning stiffness of >30min. Examination showed limited motion in the lumbar spine. Small joints and tendons of the hands and feet were tender without erythema or swelling. Autoimmune tests were unrevealing except for an erythrocyte sedimentation rate (ESR)...