Pott disease (tuberculous spondylitis)
A. Place the patient in airborne isolation and begin ethambutol, isoniazid, pyrazinamide, and rifampin
The keys to the correct diagnosis were MRI findings of a paraspinal mass with signal abnormality and extensive contrast enhancement in the lower thoracic vertebral bodies and relative sparing of the intervertebral disks (consistent with Pott disease), along with fever, cough, and consolidation on chest computed tomography in a patient who had traveled to a country with a high prevalence of tuberculosis.1 The combination of ethambutol, isoniazid, pyrazinamide, and rifampin (choice A) is first-line treatment for drug-susceptible tuberculosis.
Cefepime and vancomycin (choice C) would be appropriate empirical antibiotics for bacterial vertebral osteomyelitis, characterized by contrast enhancement of the vertebral bodies along with signal abnormalities within the intervertebral disks. Empirical therapy for Brucella spondylitis (choice D) could be considered if there was exposure to animals or unpasteurized animal products. Metastatic spinal tumors are included in the differential diagnosis of multiple spinal lesions on MRI, particularly in the absence of disk involvement; however, osteoblastic metastases from prostate cancer (choice B) do not enhance on MRI and are characterized by very-low-signal intensities in all sequences.