Late tubercular dissemination in tubercular spondylitis

History and admission diagnosis: A 65-year-old man, known to have had a gas tric ulcer and chronic rheumatoid arthritis as well as alcohol and nicotine abuse, was admitted because of suspected endocarditis. Physical examinatio n revealed marked pain on pressure over the throacic spine. Vesicular breat h sounds were reduced over the entire thorax and there was a systolic murmu r over Erb's point (above the right clavicle). There was a purulent bursiti s over the olecranon. Investigations: Abnormal laboratory tests were: elevated C-reactive protein , elevated leucocyte count (up to 33 thousand during the hospital stay). Sm ears from the bursitis and blood cultures revealed Staph. aureus. Computed tomography demonstrated a fracture of the 7th thoracic vertebra with a para vertebral abscess. Echocardiography showed anatherosclerotic aortic valve w ith floating particles. Diagnosis, treatment and course: Treatment of the suspected staphylococcal bacteraemia with purulent bursitis, spondylitis and aortic valvar endocardi tis was begun with broad-spectrum antibiotics, but the patient soon develop ed 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 diss emination from the tubercular spondylitis. Conclusion: Tuberculosis can be a life-threatening infection. Uncharacteris tic history and extrapulmonary manifestations can make it very difficult to arrive at the correct diagnosis.