Tuberkulöse Spätstreuung bei Spondylitis tuberculosa

HISTORY AND ADMISSION DIAGNOSIS: A 65-year-old man, known to have had a gastric ulcer and chronic rheumatoid arthritis as well as alcohol and nicotine abuse, was admitted because of suspected endocarditis. Physical examination revealed marked pain on pressure over the throacic spine. Vesicular breath sounds were reduced over the entire thorax and there was a systolic murmur over Erb's point (above the right clavicle). There was a purulent bursitis over the olecranon. INVESTIGATIONS: Abnormal laboratory tests were: elevated C-reactive protein, elevated leucocyte count (up to 33 thousand during the hospital stay). Smears from the bursitis and blood cultures revealed Staph. aureus. Computed tomography demonstrated a fracture of the 7th thoracic vertebra with a paravertebral abscess. Echocardiography showed anatherosclerotic aortic valve with floating particles. DIAGNOSIS, TREATMENT AND COURSE: Treatment of the suspected staphylococcal bacteraemia with purulent bursitis, spondylitis and aortic valvar endocarditis was begun with broad-spectrum antibiotics, but the patient soon developed a severe acute respiratory distress syndrome and he died of multi-organ failure. Autopsy revealed as cause of death left heart failure with aortic valvar endocarditis and gelatinour pneumonia caused by late tubercular dissemination from the tubercular spondylitis. CONCLUSION: Tuberculosis can be a life-threatening infection. Uncharacteristic history and extrapulmonary manifestations can make it very difficult to arrive at the correct diagnosis.