Diagnostic Challenges of Spinal Tuberculosis Simulation of Cancer in Patients Undergoing Hemodialysis: A Case Report and Literature Analysis

Diagnostic Challenges of Spinal Tuberculosis Simulation of Cancer in Patients Undergoing Hemodialysis: A Case Report and Literature Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Diagnostic Challenges of Spinal Tuberculosis Simulation of Cancer in Patients Undergoing Hemodialysis: A Case Report and Literature Analysis Yu-Xin Jin, Yun-Lei Deng, Zhu Liang, Ying Shu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7024358/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Spinal tuberculosis (TB) rarely occurs in hemodialysis (HD) patients, which makes diagnosis challenging. Therefore, we report a case of spinal TB with a psoas muscle abscess in an HD patient. The patient had been on the HD programme for two years and was complaining of intermittent fever and low back pain. Positron emission tomography/computed tomography (PET/CT) revealed increased metabolism of the hepatic hilum and pancreatic neck, multiple enlarged lymph nodes (LNs), and destruction of the L3 vertebra invading the psoas muscle bilaterally. To confirm the diagnosis of the disease, a biopsy of the psoas abscess via fine needle aspiration under computed tomography (CT) guidance was carried out, which revealed the formation of a caseating granuloma. Anti-TB drug therapy resolved the systemic symptoms. The final diagnosis was spinal TB. A diagnosis of extrapulmonary TB should be suspected when nonspecific uremic symptoms persist in HD patients. Moreover, the combination of multiple diagnostic methods is essential for accurately diagnosing TB. Spinal tuberculosis Case report Hemodialysis PET/CT Biopsy Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction End-stage renal disease (ESRD) is characterized by a glomerular filtration rate below < 15 ml/min/1.73 m 2 [1] and is typically treated by kidney replacement therapy, involving dialysis and transplantation [2]. During 2022, approximately 815,896 individuals worldwide developed ESRD, and around 59.5% of patients received maintenance hemodialysis (MHD) [3]. However, patients receiving MHD are at high risk of death. According to 2022 data from the United States Renal Data System, the mortality rate was 185.1 for MHD patients per 1,000 patient-years. Cardiovascular disease, including cerebrovascular events, accounted for 55.9% of mortalities with a known cause. However, for more than a quarter of HD patients who died in 2022, the cause of mortality was either missing or unknown. In recent years, increasing evidence has suggested that tuberculosis (TB) is an important source of mortality in dialysis patients[4]. TB is caused by the bacillus Mycobacterium tuberculosis ( M. tuberculosis ), which remains the leading cause of death from an infectious disease among adults worldwide[5]. According to the World Health Organization (WHO), the reported global number of people newly diagnosed with TB was 7.5 million in 2022 (WHO, 2023). The incidence rates of HD patients are notably high, reaching 5611 per 100,000 individuals[4], primarily due to suppressed cell-mediated immunity resulting from various factors, such as advanced age, hypoalbuminemia, malnutrition, uremia, and immunosuppressive therapy. Compared with the widespread concern surrounding pulmonary tuberculosis (PTB), extrapulmonary tuberculosis (EPTB) has received relatively little attention. EPTB refers to an infection caused by M. tuberculosis that affects almost any organ or body site outside the lungs, trachea, bronchi, or pleura[6]. EPTB is characterized by atypical clinical symptoms, difficult diagnosis, high disability, and a high mortality rate, which not only seriously threatens patients’ health but also places a heavy economic burden on patients, families, and society[7]. In China, spinal TB is one of the leading subtypes of EPTB[7]. It accounts for approximately half of all skeletal TB cases, with para-discal TB being the most common type. If left untreated, infection can lead to severe complications, including cold abscess formation, paraplegia, and spinal deformity[8]. The clinical presentation of spinal TB is often subtle. Patients may exhibit typical symptoms such as weight loss, evening fever, loss of appetite, and persistent back pain unresponsive to physiotherapy, or they may present without any noticeable symptoms. Additionally, the difficulty in obtaining samples and the low etiological positivity rate pose significant challenges to the effective diagnosis and management of spinal TB. In this context, we report a case of spinal TB in an HD patient who had experienced intermittent fever for an extended period of time. Case Report An 80-year-old female patient with a 9-month history of intermittent fever and a 1-month history of low back pain without any respiratory complaints was admitted to our hospital. She reported other symptoms, such as malaise, weight loss, and night sweats. Her medical history included hypertension, type 2 diabetes mellitus, a unilateral nephrectomy for renal clear cell carcinoma, and ESRD. The patient had been receiving HD three times a week for almost two years and was completely anuric. The patients had no history of human immune deficiency virus (HIV) or hepatitis and declared no exposure history to active TB in the past, although the bacillus Calmette–Guerin vaccination status was unclear. In addition, there was no history of any trauma, smoking or alcohol abuse. At the time of admission, her blood pressure, pulse rate, respiration rate, and body temperature (BT) were 138/43 mmHg, 76 beats/min, 20 breaths/min, and 37.9°C, respectively. Lumbar vertebrae were painful with palpation. The myodynamia of the lower limb decreased to grade 4, while the muscle tension was normal. Neurological examination revealed no focal motor deficits. Examination of the respiratory system was normal, the abdomen was soft, with no organomegaly or tenderness noted, and there was no palpable peripheral lymphadenopathy. The tunnelled cuffed venous catheters were normal. The results of laboratory analyses of the patient blood samples are shown in Table 1 . A peripheral blood test on admission revealed increased white blood cell and neutrophil proportions. C-reactive protein, procalcitonin, and the erythrocyte sedimentation rate were significantly elevated. In addition, serology for respiratory viruses (adenovirus, influenza A virus, influenza B virus, parainfluenza, and respiratory syncytial virus) and bacteriological assays (Chlamydia pneumonia and Legionella) were negative, whereas Mycoplasma pneumoniae was weakly positive. Peripheral blood and catheter blood cultures were both negative. However, both the interferon-gamma release assay and the purified protein derivative tuberculin skin test were positive. Anti-HIV antibodies, treponema pallidum antibodies, hepatitis B surface antigen, and hepatitis C virus antigen were all negative. The carbohydrate antigen 72 − 4 and cytokeratin fragment 21 − 1 levels were 11.70 U/mL and 2.37 ng/mL, respectively, whereas the other related female tumor markers were within the normal range (Table 1 ). Table 1: Laboratory analysis of the blood of patients in the study Characteristics Values Reference Range Blood routine tests White blood cell (× 10^9/L) 10.03 3.5-9.5 Neutrophils (× 10^9/L) 7.96 1.8-6.3 Monocytes (× 10^9/L) 0.75 0.1-0.9 Red blood cell (× 10^12/L) 3.61 3.8-5.1 Hemoglobin (g/L) 113 115-150 Blood platelet (× 10^9/L) 226 125-350 C-reactive protein (mg/L) 132.76 ﹤10 Erythrocyte sedimentation rate (mm/H) 120 0-40 Procalcitonin (ng/mL) 2.03 0-0.05 Routine coagulation tests PT (sec) 13.2 11.0-15.0 APTT (sec) 41.9 24.0-43.0 INR 1.0 0.8-1.2 Fibrinogen (g/L) 7.93 2.0-4.0 D-dimer (mg/L) 1.76 0.00-0.50 Liver function Albumin (g/L) 32.8 35.0-55.0 Tbil (umol/L) 2.8 ﹤28 Direct bilirubin (umol/L) 1.4 ﹤9 Indirect bilirubin (umol/L) 1.4 ﹤19 ALT (U/L) 8 ﹤40 AST (U/L) 12 ﹤40 Renal function Urea (mmol/L) 21.41 2.90-8.20 Creatinine (umol/l) 745 49-90 Electrolytes Potassium (mmol/L) 6.12 3.50-5.30 Sodium (mmol/L) 136.3 135.0-148.0 Chlorine (mmol/L) 101.4 96.0-108.0 Intact parathyroidhormone Cancer marker NSE (ng/ml) 14.00 ﹤16.30 CYFRA21-1 (ng/ml) 2.37 ﹤2.08 SCC-Ag (ng/ml) 1.50 ﹤1.50 CA 72-4 (ng/ml) 11.70 ﹤6.90 CA125 (U/ml) 34.90 ﹤35.00 CA15-3 (U/ml) 13.00 ﹤26.40 CA 19-9 (U/ml) 26.80 ﹤27.00 CEA (ng/ml) 4.13 ﹤4.70 AFP (ng/ml) ﹤0.91 ﹤7.00 Abbreviations: PT, prothrombin time; APTT, activated partial thromboplastin time; INR, International Normalized Ratio; Tbil, total bilirubin; ALT, alanine transaminase; AST, aspartate transaminase; NSE, Neuron-specific enolase; CYFRA21-1, Cytokeratin fragment; SCC-Ag, Squamous cell carcinoma antigen; CA, Carbohydrate antigen; CEA, Carcino-embryonic antigen; AFP, Alpha-fetoprotein. Chest computed tomography (CT) revealed chronic inflammatory changes, multiple nodules in both lungs and bilateral pleural effusion. Multiple enlarged lymph nodes (LNs) were observed in the mediastinal and right hilus of the lung. With suspicion of bacterial infection, we administered piperacillin/tazobactam (4.5 g, twice a day). She then chose to undergo regular traditional waist massage therapy every day. However, the patient’s fever (BT, 37.4°C), low back pain, and night sweats persisted. Because the origin of the fever and pain was not clear, an abdominal CT was performed, which revealed multiple masses with irregular walls in the hepatic hilum and pancreatic neck and adjacent lymphadenopathy (Fig. 1 ). Lumbosacral CT plain and contrast-enhanced images revealed destruction of the body and right appendage of the L3 vertebra and abscess formation invading the psoas muscle bilaterally (Fig. 2 ). The CT results suggested the following diagnosis: a tumor in the hepatic hilar-pancreatic neck region with multiple metastases, including LNs and bone. Owing to the patient's advanced age and multiple comorbid conditions, a multidisciplinary team meeting (MDTM) was subsequently held to discuss the management of the tumor. The meeting members included six chief physicians from the Departments of Oncology, Infectious Disease, Respiration, Orthopedic, Imaging and Rehabilitation Medicine (The Third People's Hospital of Chengdu). Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is an excellent method for diagnosing pancreatic lesions and has shown high accuracy for its use in pathologic diagnosis[9]. EUS-FNB with a core biopsy needle is a safe and highly accurate diagnostic option for assessing indeterminate hepatic solid masses[10]. However, the patient’s family members hope to minimize the degree of damage caused by invasive operations. 18 F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is used for the diagnosis and staging of many malignant diseases. Its overall sensitivity ranges between 85% and 97%[11]. Therefore, the meeting members hypothesized that 18 F-FDG PET/CT may be an optimal auxiliary examination. The PET/CT results were as follows: infectious lesions were suspected in the L3 vertebra invading the bilateral psoas major muscle; infectious lesions were also considered in the soft tissue of the hepatic hilum and the head and neck of the pancreas, as were multiple LNs in the right hilus pulmonis and abdominal cavity (Fig. 3 ). To confirm the diagnosis, a biopsy was performed on the swollen area of the psoas muscle. Considering the patient's advanced age and multiple underlying conditions, we undertook aspiration biopsy under CT guidance of the mass in the right psoas major. Histopathology of the mass (Fig. 4 ) revealed caseous necrosis and multinucleated giant cells, which was consistent with TB, whereas acid fast bacteria (AFB) showed no positive results. Owing to financial difficulties, the patient did not undergo polymerase chain reaction or Xpert Mycobacterium tuberculosis /Rifampicin testing, as did blood T-SPOT. TB testing. The patient's BT returned to normal after repeated treatment with moxifloxacin before admission. Therefore, the final diagnosis was spinal TB, with possible multifocal TB. We treated the patient as drug-susceptible TB. According to the consultation opinion of the Department of Infectious Diseases, the patient undergoing HD was given daily oral anti-TB drug therapy consisting of isoniazid (300 mg/d), rifampicin (450 mg/d), and ethambutol hydrochloride (750 mg/q48h)[12]. During the day of dialysis, treatment was given immediately after HD. The patient was discharged from the hospital after the resolution of systemic symptoms, which confirmed that the diagnosis was correct. The patient was subsequently referred to a specialized center to implement an anti-TB treatment plan. Three months after the initiation of anti-tuberculosis therapy, follow-up lumbosacral CT demonstrated improvement of the psoas abscess. Unfortunately, the patient died of heart failure one month later. Discussion Previous studies have identified CKD as a risk factor for the development of TB disease in countries with intermediate[13] and high[14] incidences of TB. The incidence of TB in patients with ESRD is 10–15 times greater than that in the general population[4], which could be attributed to the immunocompromised state of individuals with CKD. There is substantial evidence indicating functional abnormalities in various immune cells, including B and T cells, neutrophils, monocytes, and natural killer cells, in patients with advanced CKD[15]. As kidney function declines and waste products accumulate, immune deficiencies deteriorate accordingly[16]. Owing to impaired cell-mediated immunity, dialysis patients have an increased risk of infection, including M. tuberculosis , which may worsen or reactivate latent TB infection from distant exposure. In addition, advanced age, male sex, malnutrition, silicosis, and chronic obstructive pulmonary disease are independent risk factors for TB infection in patients with ESRD[17]. Patients with ESRD are also more frequently exposed to pathogens because of their regular medical visits[18]. Spinal TB is typically caused by the hematogenous spread of infection from a primary site, often in the lungs or another location. It is characterized by the involvement of intervertebral discs, is linked to the shared segmental arterial supply, and can lead to severe morbidity even years after appropriate therapy[8]. The pus formed in the vertebral focus moves forward anteriorly and develops paraspinal abscesses called “cold abscesses”, which do not present signs of local inflammation. Patients may present with common symptoms such as unexplained weight loss, evening fever, decreased appetite, and persistent back pain unresponsive to physiotherapy; these symptoms can be found but are associated with many disorders in other patients. However, some individuals may present with minimal or even no symptoms. Owing to its insidious onset and confusion with other disorders, Spinal TB leads to difficulties in diagnosis and delays in treatment, particularly in HD patients[19]. The diagnosis of spinal TB typically relies on clinical and radiographic cues, along with microbiological and histological markers [8]. Isolating M. tuberculosis from clinical samples is crucial not only for diagnostic confirmation but also for drug susceptibility testing. However, due to paucibacillary and anatomical nature of spinal TB, it is difficult to obtain adequate specimens for molecular testing, histology, culture, or microscopy. Granuloma is hallmark of TB, which is a structured aggregates of immune cells and develops in response to persistent antigenic stimulation [20]. Caseous necrosis in granulomas is a defining feature of TB, particularly in advanced cases. This process results from immune responses that aim to contain the pathogen but can also lead to tissue damage and cavity formation, facilitating disease spread. Our patient had been undergoing HD for several years and complained of intermittent fever, low back pain and general weakness at the time of admission. At the beginning of the research, we did not consider the possibility of TB infection because the clinical presentation and laboratory tests provided few valuable clues, and our patient had no history of this infection. We conducted empirical antimicrobial therapy for community-acquired pneumonia and previously performed traditional waist massage therapy. However, fever and pain continued, and an abdominal mass with distant metastases was suggested on the basis of the CT results. Whole-body PET/CT revealed destruction of the L3 vertebra and abscess formation, which bilaterally invaded the paravertebral psoas muscle. While PET/CT scans with F-18 FDG tracer reveal metabolic differences between normal and malignant cells[21], F-18 FDG exhibits nonspecific uptake in both tumor cells and inflammatory/infective lesions , such as those affected by TB or sarcoidosis[22]. In regions where TB is prevalent around the world, clinical suspicion is crucial for the early diagnosis of spinal TB. Therefore, we performed fine needle aspiration. When pulmonary or lymph node TB is confirmed, or when samples can be obtained from extraskeletal sites, collecting spinal or paraspinal specimens is not absolutely necessary [22]. The diagnosis of our patient was made by determining the formation of granulomas in an aspiration specimen obtained from the paravertebral abscess via fine needle aspiration under CT guidance. In addition, our patient's BT returned to normal after treatment with moxifloxacin but not other antibiotics. Fluoroquinolones have advantageous pharmacokinetics and activity against M. tuberculosis , so they have considerable promising for treating TB. The WHO recommends later-generation fluoroquinolones, including moxifloxacin, for second-line anti-TB agents [23]. Therefore, under the guidance of the Department of Infectious Diseases, we initiated anti-TB drug therapy. Systemic symptoms such as fever and low back pain markedly resolved after the initiation of anti-TB medications. Finally, our patient was diagnosed with spinal TB with multifocal TB. However, the definitive diagnosis of spinal TB and treatment initiation were delayed because of nonspecific symptoms. These results suggest the importance of combining multiple methods for the diagnosis of disease. Conclusions In conclusion, in our patient who underwent HD, radiologic examinations suggested cancer with LN involvement and spinal metastases. However, spinal TB was documented via CT-guided psoas muscle puncture biopsy. On the basis of the findings of this case, if nonspecific uremic symptoms persist in HD patients, the possibility of extrapulmonary TB should be considered, particularly when imaging results suggest that lesions have metastasized from systemic malignancies. In addition, the combination of multiple diagnostic methods was crucial for accurately diagnosing TB. Abbreviations AFB, acid fast bacteria; BT, body temperature; CT, computed tomography; ESRD, End-stage renal disease; EPTB, extrapulmonary tuberculosis; EUS-FNB, Endoscopic ultrasound-guided fine-needle biopsy; FDG, 18 F-fluorodeoxyglucose; HD, hemodialysis; HIV, human immune deficiency virus; LNs, lymph nodes; MHD, maintenance hemodialysis; M. tuberculosis, Mycobacterium tuberculosis ; MDTM, multidisciplinary team meeting; PTB, pulmonary tuberculosis; PET/CT, Positron emission tomography/computed tomography; TB, tuberculosis; WHO, World Health Organization. Declarations Ethics approval and consent to participate The study protocol was approved by the institutional medical ethics committee of the Third People's Hospital of Chengdu. The next of kin of the participant was provided written informed consent before data collection. The present study was performed in accordance with the Declaration of Helsinki. Clinical Trial Not applicable. Consent for publication Written informed consent was obtained from the patient’s next of kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author (Ying Shu, e-mail: [email protected] ) upon reasonable request. Competing interests The authors declare that they have no conflicts of interest. Funding Not applicable. Authors' contributions Conceptualization: YS. Data curation: YL D, ZL Formal analysis: YS. Methodology: YS, YX J. Validation: YL D, ZL, YX J. Writing: YX J. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Andrassy KM: Comments on 'KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease' . Kidney Int 2013, 84 (3):622-623. 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Niu T, He F, Yang J, Ma C, Xu J, Sun T, Zhang X, Chen S, Ru C: The epidemiological characteristics and infection risk factors for extrapulmonary tuberculosis in patients hospitalized with pulmonary tuberculosis infection in China from 2017 to 2021 . BMC Infect Dis 2023, 23 (1):488. Li T, Yan X, Du X, Huang F, Wang N, Ni N, Ren J, Zhao Y, Jia Z: Extrapulmonary tuberculosis in China: a national survey . Int J Infect Dis 2023, 128 :69-77. Leowattana W, Leowattana P, Leowattana T: Tuberculosis of the spine . World J Orthop 2023, 14 (5):275-293. Delsa H, Bellahammou K, Okasha HH, Ghalim F: Cheesy material on macroscopic on-site evaluation after endoscopic ultrasound-guided fine-needle biopsy: Don't miss the tuberculosis . World J Clin Cases 2023, 11 (10):2181-2188. Chon HK, Yang HC, Choi KH, Kim TH: Endoscopic Ultrasound-Guided Liver Biopsy Using a Core Needle for Hepatic Solid Mass . Clin Endosc 2019, 52 (4):340-346. Ghidini M, Vuozzo M, Galassi B, Mapelli P, Ceccarossi V, Caccamo L, Picchio M, Dondossola D: The Role of Positron Emission Tomography/Computed Tomography (PET/CT) for Staging and Disease Response Assessment in Localized and Locally Advanced Pancreatic Cancer . Cancers (Basel) 2021, 13 (16). British Thoracic Society Standards of Care C, Joint Tuberculosis C, Milburn H, Ashman N, Davies P, Doffman S, Drobniewski F, Khoo S, Ormerod P, Ostermann M et al : Guidelines for the prevention and management of Mycobacterium tuberculosis infection and disease in adult patients with chronic kidney disease . Thorax 2010, 65 (6):557-570. Cheng KC, Liao KF, Lin CL, Liu CS, Lai SW: Chronic kidney disease correlates with increased risk of pulmonary tuberculosis before initiating renal replacement therapy: A cohort study in Taiwan . Medicine (Baltimore) 2018, 97 (39):e12550. Carr BZ, Briganti EM, Musemburi J, Jenkin GA, Denholm JT: Effect of chronic kidney disease on all-cause mortality in tuberculosis disease: an Australian cohort study . BMC Infect Dis 2022, 22 (1):116. Zuo L, Wang M, Chinese Association of Blood Purification Management of Chinese Hospital A: Current burden and probable increasing incidence of ESRD in China . Clin Nephrol 2010, 74 Suppl 1 :S20-22. Carrero JJ, Stenvinkel P: Inflammation in end-stage renal disease--what have we learned in 10 years? Semin Dial 2010, 23 (5):498-509. Li SY, Chen TJ, Chung KW, Tsai LW, Yang WC, Chen JY, Chen TW: Mycobacterium tuberculosis infection of end-stage renal disease patients in Taiwan: a nationwide longitudinal study . Clin Microbiol Infect 2011, 17 (11):1646-1652. Chang CH, Fan PC, Kuo G, Lin YS, Tsai TY, Chang SW, Tian YC, Lee CC: Infection in Advanced Chronic Kidney Disease and Subsequent Adverse Outcomes after Dialysis Initiation: A Nationwide Cohort Study . Sci Rep 2020, 10 (1):2938. Kayabasi H, Sit D, Kadiroglu AK, Yilmaz Z, Bukte Y: An atypical localisation of tuberculosis infection in patients undergoing haemodialysis: a case report . J Ren Care 2010, 36 (1):49-53. Ramakrishnan L: Revisiting the role of the granuloma in tuberculosis . Nat Rev Immunol 2012, 12 (5):352-366. Gambhir SS, Czernin J, Schwimmer J, Silverman DH, Coleman RE, Phelps ME: A tabulated summary of the FDG PET literature . J Nucl Med 2001, 42 (5 Suppl):1S-93S. Zheng Z, Pan Y, Guo F, Wei H, Wu S, Pan T, Li J: Multimodality FDG PET/CT appearance of pulmonary tuberculoma mimicking lung cancer and pathologic correlation in a tuberculosis-endemic country . South Med J 2011, 104 (6):440-445. Naidoo A, Naidoo K, McIlleron H, Essack S, Padayatchi N: A Review of Moxifloxacin for the Treatment of Drug-Susceptible Tuberculosis . J Clin Pharmacol 2017, 57 (11):1369-1386. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7024358","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":499574276,"identity":"570b3f93-bd02-4e8d-b903-6d4edb822547","order_by":0,"name":"Yu-Xin Jin","email":"","orcid":"","institution":"The Third People’s Hospital of Chengdu, The Affiliated Hospital of Southwest Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Yu-Xin","middleName":"","lastName":"Jin","suffix":""},{"id":499574277,"identity":"199e5073-90e1-4e3a-96b6-27f85a42dbc2","order_by":1,"name":"Yun-Lei Deng","email":"","orcid":"","institution":"The Third People’s Hospital of Chengdu, The Affiliated Hospital of Southwest Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Yun-Lei","middleName":"","lastName":"Deng","suffix":""},{"id":499574278,"identity":"7a8c8458-981f-4179-ad21-63c48939d75b","order_by":2,"name":"Zhu Liang","email":"","orcid":"","institution":"The Third People’s Hospital of Chengdu, The Affiliated Hospital of Southwest Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Zhu","middleName":"","lastName":"Liang","suffix":""},{"id":499574279,"identity":"3e22a3da-5e71-43d8-8315-76c26572f2c8","order_by":3,"name":"Ying Shu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBACefb2AwYffvyXsz/eQKQWw54zCYUze5iNGc4cINaaGwkGn3nYmBMbbiQQqYOx50DiZh4eNmPGmY833mCosYkmqIWdvfGw4RwLHjlm6bRiC4ZjabkNRNiSZvCGR8KYTTrHTIKx4TBhLUC/mP/gYTNI7JE8Q7wWA0MetoTEGRI8RGoBBbLhzJ4DxgY8QL8kEOMXaFQekDNgP7zxxocaGyIchgQMJBJIUQ7RQqqOUTAKRsEoGBkAAGpNQb2RKnp2AAAAAElFTkSuQmCC","orcid":"","institution":"The Third People’s Hospital of Chengdu, The Affiliated Hospital of Southwest Jiao Tong University","correspondingAuthor":true,"prefix":"","firstName":"Ying","middleName":"","lastName":"Shu","suffix":""}],"badges":[],"createdAt":"2025-07-02 02:23:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7024358/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7024358/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88982910,"identity":"fa49a7fc-0091-48ed-993a-35b1ba88f3b7","added_by":"auto","created_at":"2025-08-13 11:56:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":180693,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal computed tomography (CT). Initial abdominal CT scan shows a mass with irregular walls which is located just hepatic hilum and pancreatic neck (arrows), with the formation of adjacent multiple lymphadenopathy. CT, computed tomography\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7024358/v1/1c5771f5c8f2b025e999c9d5.png"},{"id":88983550,"identity":"344cb570-5deb-4904-b76a-c8acdb0ad310","added_by":"auto","created_at":"2025-08-13 12:04:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":156778,"visible":true,"origin":"","legend":"\u003cp\u003e(A and B) Enhanced lumbosacral CT images showing bony destruction with paravertebral osseous debris, paravertebral soft tissue, and bilateral psoas abscess.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7024358/v1/e384a20e4cfe99f4352fb154.png"},{"id":88983553,"identity":"2b7347d0-3e87-45ed-b982-86d6795101e2","added_by":"auto","created_at":"2025-08-13 12:04:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":340119,"visible":true,"origin":"","legend":"\u003cp\u003e\u003csup\u003e18\u003c/sup\u003eF-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography at presentation revealed bony destruction and bilateral psoas abscess with increased 18F-FDG uptake (maximum standardized uptake value of 13.3), soft tissue with increased 18F-FDG uptake (2.5) in the hepatic hilum, head and neck of the pancreas, and enlarged lymph nodes with increased 18F-FDG uptake in the right hilus pulmonis (7.3) and abdominal cavity (3.9). FDG, fluorodeoxyglucose.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7024358/v1/180a30d6000251bc47887158.png"},{"id":88983551,"identity":"06a470a5-c36d-485b-bb49-b7c89b20004c","added_by":"auto","created_at":"2025-08-13 12:04:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":349960,"visible":true,"origin":"","legend":"\u003cp\u003eMicroscopic features of the psoas muscle samples. Hematoxylin and eosin stain shows granulomas and caseous necrosis.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7024358/v1/ad3be9f05f6e1d402b09c2d7.png"},{"id":104880934,"identity":"3bc675a3-cfc6-46db-86ae-23bc5e9aaf41","added_by":"auto","created_at":"2026-03-18 09:14:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2825745,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7024358/v1/d9c89f09-b917-4eaa-ab7a-7be7dd1ab7b1.pdf"},{"id":88982913,"identity":"ab29f9a4-276a-4ebc-b168-047c149ffc5c","added_by":"auto","created_at":"2025-08-13 11:56:30","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":737090,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7024358/v1/098a2d2546b4768bfa6ddc3d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnostic Challenges of Spinal Tuberculosis Simulation of Cancer in Patients Undergoing Hemodialysis: A Case Report and Literature Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEnd-stage renal disease (ESRD) is characterized by a glomerular filtration rate below \u0026lt;\u0026thinsp;15 ml/min/1.73 m\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[1] and is typically treated by kidney replacement therapy, involving dialysis and transplantation\u003c/span\u003e[2]. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDuring 2022, approximately 815,896 individuals worldwide developed ESRD, and around 59.5% of patients received maintenance hemodialysis (MHD)\u003c/span\u003e[3]. However, patients receiving MHD are at high risk of death. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAccording to 2022 data from the United States Renal Data System, the mortality rate was 185.1 for MHD patients per 1,000 patient-years. Cardiovascular disease, including cerebrovascular events, accounted for 55.9% of mortalities with a known cause. However, for more than a quarter of HD patients who died in 2022, the cause of mortality was either missing or unknown.\u003c/span\u003e In recent years, increasing evidence has suggested that tuberculosis (TB) is an important source of mortality in dialysis patients[4].\u003c/p\u003e\u003cp\u003eTB is caused by the bacillus \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e (\u003cem\u003eM. tuberculosis\u003c/em\u003e), which remains the leading cause of death from an infectious disease among adults worldwide[5]. According to the World Health Organization (WHO), the reported global number of people newly diagnosed with TB was 7.5\u0026nbsp;million in 2022 (WHO, 2023). The incidence rates of HD patients are notably high, reaching 5611 per 100,000 individuals[4], primarily due to suppressed cell-mediated immunity resulting from various factors, such as advanced age, hypoalbuminemia, malnutrition, uremia, and immunosuppressive therapy. Compared with the widespread concern surrounding pulmonary tuberculosis (PTB), extrapulmonary tuberculosis (EPTB) has received relatively little attention. EPTB refers to an infection caused by \u003cem\u003eM. tuberculosis\u003c/em\u003e that affects almost any organ or body site outside the lungs, trachea, bronchi, or pleura[6]. EPTB is characterized by atypical clinical symptoms, difficult diagnosis, high disability, and a high mortality rate, which not only seriously threatens patients\u0026rsquo; health but also places a heavy economic burden on patients, families, and society[7]. In China, spinal TB is one of the leading subtypes of EPTB[7]. It accounts for approximately half of all skeletal TB cases, with para-discal TB being the most common type. If left untreated, infection can lead to severe complications, including cold abscess formation, paraplegia, and spinal deformity[8]. The clinical presentation of spinal TB is often subtle. Patients may exhibit typical symptoms such as weight loss, evening fever, loss of appetite, and persistent back pain unresponsive to physiotherapy, or they may present without any noticeable symptoms. Additionally, the difficulty in obtaining samples and the low etiological positivity rate pose significant challenges to the effective diagnosis and management of spinal TB. In this context, we report a case of spinal TB in an HD patient who had experienced intermittent fever for an extended period of time.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eAn 80-year-old female patient with a 9-month history of intermittent fever and a 1-month history of low back pain without any respiratory complaints was admitted to our hospital. She reported other symptoms, such as malaise, weight loss, and night sweats. Her medical history included hypertension, type 2 diabetes mellitus, a unilateral nephrectomy for renal clear cell carcinoma, and ESRD. The patient had been receiving HD three times a week for almost two years and was completely anuric. The patients had no history of human immune deficiency virus (HIV) or hepatitis and declared no exposure history to active TB in the past, although the bacillus Calmette\u0026ndash;Guerin vaccination status was unclear. In addition, there was no history of any trauma, smoking or alcohol abuse. At the time of admission, her blood pressure, pulse rate, respiration rate, and body temperature (BT) were 138/43 mmHg, 76 beats/min, 20 breaths/min, and 37.9\u0026deg;C, respectively. Lumbar vertebrae were painful with palpation. The myodynamia of the lower limb decreased to grade 4, while the muscle tension was normal. Neurological examination revealed no focal motor deficits. Examination of the respiratory system was normal, the abdomen was soft, with no organomegaly or tenderness noted, and there was no palpable peripheral lymphadenopathy. The tunnelled cuffed venous catheters were normal. The results of laboratory analyses of the patient blood samples are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A peripheral blood test on admission revealed increased white blood cell and neutrophil proportions. C-reactive protein, procalcitonin, and the erythrocyte sedimentation rate were significantly elevated. In addition, serology for respiratory viruses (adenovirus, influenza A virus, influenza B virus, parainfluenza, and respiratory syncytial virus) and bacteriological assays (Chlamydia pneumonia and Legionella) were negative, whereas \u003cem\u003eMycoplasma pneumoniae\u003c/em\u003e was weakly positive. Peripheral blood and catheter blood cultures were both negative. However, both the interferon-gamma release assay and the purified protein derivative tuberculin skin test were positive. Anti-HIV antibodies, treponema pallidum antibodies, hepatitis B surface antigen, and hepatitis C virus antigen were all negative. The carbohydrate antigen 72\u0026thinsp;\u0026minus;\u0026thinsp;4 and cytokeratin fragment 21\u0026thinsp;\u0026minus;\u0026thinsp;1 levels were 11.70 U/mL and 2.37 ng/mL, respectively, whereas the other related female tumor markers were within the normal range (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 1: Laboratory analysis of the blood of patients in the study\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValues\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReference Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood routine tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eWhite blood cell (\u0026times;\u0026thinsp;10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e10.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e3.5-9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eNeutrophils (\u0026times;\u0026thinsp;10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e7.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e1.8-6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eMonocytes (\u0026times;\u0026thinsp;10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e0.1-0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eRed blood cell (\u0026times;\u0026thinsp;10^12/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e3.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e3.8-5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eHemoglobin (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e115-150\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eBlood platelet (\u0026times;\u0026thinsp;10^9/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e125-350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC-reactive protein (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e132.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eErythrocyte sedimentation rate (mm/H)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e0-40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProcalcitonin (ng/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e2.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e0-0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRoutine coagulation tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003ePT (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e11.0-15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eAPTT (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e41.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e24.0-43.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e0.8-1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eFibrinogen (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e7.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e2.0-4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eD-dimer (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e1.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e0.00-0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiver function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eAlbumin (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e32.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e35.0-55.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eTbil (umol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eDirect bilirubin (umol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eIndirect bilirubin (umol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eALT (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eAST (U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal function\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eUrea (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e21.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e2.90-8.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eCreatinine (umol/l)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e49-90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElectrolytes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003ePotassium (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e6.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e3.50-5.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eSodium (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e136.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e135.0-148.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eChlorine (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e101.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e96.0-108.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntact parathyroidhormone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer marker\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eNSE (ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e14.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤16.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eCYFRA21-1 (ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eSCC-Ag (ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eCA 72-4 (ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e11.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤6.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eCA125 (U/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e34.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤35.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eCA15-3 (U/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e13.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤26.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eCA 19-9 (U/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e26.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤27.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eCEA (ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e4.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤4.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49.6849%;\"\u003e\n \u003cp\u003eAFP (ng/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3782%;\"\u003e\n \u003cp\u003e﹤0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.937%;\"\u003e\n \u003cp\u003e﹤7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbbreviations: PT, prothrombin time; APTT, activated partial thromboplastin time; INR, International Normalized Ratio; Tbil, total bilirubin; ALT, alanine transaminase; AST, aspartate transaminase; NSE, Neuron-specific enolase; CYFRA21-1, Cytokeratin fragment; SCC-Ag, Squamous cell carcinoma antigen; CA, Carbohydrate antigen; CEA, Carcino-embryonic antigen; AFP, Alpha-fetoprotein.\u003c/p\u003e\u003cp\u003eChest computed tomography (CT) revealed chronic inflammatory changes, multiple nodules in both lungs and bilateral pleural effusion. Multiple enlarged lymph nodes (LNs) were observed in the mediastinal and right hilus of the lung. With suspicion of bacterial infection, we administered piperacillin/tazobactam (4.5 g, twice a day). She then chose to undergo regular traditional waist massage therapy every day. However, the patient\u0026rsquo;s fever (BT, 37.4\u0026deg;C), low back pain, and night sweats persisted. Because the origin of the fever and pain was not clear, an abdominal CT was performed, which revealed multiple masses with irregular walls in the hepatic hilum and pancreatic neck and adjacent lymphadenopathy (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Lumbosacral CT plain and contrast-enhanced images revealed destruction of the body and right appendage of the L3 vertebra and abscess formation invading the psoas muscle bilaterally (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The CT results suggested the following diagnosis: a tumor in the hepatic hilar-pancreatic neck region with multiple metastases, including LNs and bone. Owing to the patient's advanced age and multiple comorbid conditions, a multidisciplinary team meeting (MDTM) was subsequently held to discuss the management of the tumor. The meeting members included six chief physicians from the Departments of Oncology, Infectious Disease, Respiration, Orthopedic, Imaging and Rehabilitation Medicine (The Third People's Hospital of Chengdu). Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is an excellent method for diagnosing pancreatic lesions and has shown high accuracy for its use in pathologic diagnosis[9]. EUS-FNB with a core biopsy needle is a safe and highly accurate diagnostic option for assessing indeterminate hepatic solid masses[10]. However, the patient\u0026rsquo;s family members hope to minimize the degree of damage caused by invasive operations. \u003csup\u003e18\u003c/sup\u003eF-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is used for the diagnosis and staging of many malignant diseases. Its overall sensitivity ranges between 85% and 97%[11]. Therefore, the meeting members hypothesized that \u003csup\u003e18\u003c/sup\u003eF-FDG PET/CT may be an optimal auxiliary examination. The PET/CT results were as follows: infectious lesions were suspected in the L3 vertebra invading the bilateral psoas major muscle; infectious lesions were also considered in the soft tissue of the hepatic hilum and the head and neck of the pancreas, as were multiple LNs in the right hilus pulmonis and abdominal cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo confirm the diagnosis, a biopsy was performed on the swollen area of the psoas muscle. Considering the patient's advanced age and multiple underlying conditions, we undertook aspiration biopsy under CT guidance of the mass in the right psoas major. Histopathology of the mass (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e4\u003c/span\u003e) revealed caseous necrosis and multinucleated giant cells, which was consistent with TB, whereas acid fast bacteria (AFB) showed no positive results. Owing to financial difficulties, the patient did not undergo polymerase chain reaction or Xpert \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e/Rifampicin testing, as did blood T-SPOT. TB testing. The patient's BT returned to normal after repeated treatment with moxifloxacin before admission. Therefore, the final diagnosis was spinal TB, with possible multifocal TB. We treated the patient as drug-susceptible TB. According to the consultation opinion of the Department of Infectious Diseases, the patient undergoing HD was given daily oral anti-TB drug therapy consisting of isoniazid (300 mg/d), rifampicin (450 mg/d), and ethambutol hydrochloride (750 mg/q48h)[12]. During the day of dialysis, treatment was given immediately after HD. The patient was discharged from the hospital after the resolution of systemic symptoms, which confirmed that the diagnosis was correct. The patient was subsequently referred to a specialized center to implement an anti-TB treatment plan. Three months after the initiation of anti-tuberculosis therapy, follow-up lumbosacral CT demonstrated improvement of the psoas abscess. Unfortunately, the patient died of heart failure one month later.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrevious studies have identified CKD as a risk factor for the development of TB disease in countries with intermediate[13] and high[14] incidences of TB. The incidence of TB in patients with ESRD is 10\u0026ndash;15 times greater than that in the general population[4], which could be attributed to the immunocompromised state of individuals with CKD. There is substantial evidence indicating functional abnormalities in various immune cells, including B and T cells, neutrophils, monocytes, and natural killer cells, in patients with advanced CKD[15]. As kidney function declines and waste products accumulate, immune deficiencies deteriorate accordingly[16]. Owing to impaired cell-mediated immunity, dialysis patients have an increased risk of infection, including \u003cem\u003eM. tuberculosis\u003c/em\u003e, which may worsen or reactivate latent TB infection from distant exposure. In addition, advanced age, male sex, malnutrition, silicosis, and chronic obstructive pulmonary disease are independent risk factors for TB infection in patients with ESRD[17]. Patients with ESRD are also more frequently exposed to pathogens because of their regular medical visits[18].\u003c/p\u003e\u003cp\u003eSpinal TB is typically caused by the hematogenous spread of infection from a primary site, often in the lungs or another location. It is characterized by the involvement of intervertebral discs, is linked to the shared segmental arterial supply, and can lead to severe morbidity even years after appropriate therapy[8]. The pus formed in the vertebral focus moves forward anteriorly and develops paraspinal abscesses called \u0026ldquo;cold abscesses\u0026rdquo;, which do not present signs of local inflammation. Patients may present with common symptoms such as unexplained weight loss, evening fever, decreased appetite, and persistent back pain unresponsive to physiotherapy; these symptoms can be found but are associated with many disorders in other patients. However, some individuals may present with minimal or even no symptoms. Owing to its insidious onset and confusion with other disorders, Spinal TB leads to difficulties in diagnosis and delays in treatment, particularly in HD patients[19].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThe diagnosis of spinal TB typically relies on clinical and radiographic cues, along with microbiological and histological markers\u003c/span\u003e[8]. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIsolating\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eM. tuberculosis\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003efrom clinical samples is crucial not only for diagnostic confirmation but also for drug susceptibility testing. However, due to paucibacillary and anatomical nature of spinal TB, it is difficult to obtain adequate specimens for molecular testing, histology, culture, or microscopy. Granuloma is hallmark of TB, which is a structured aggregates of immune cells and develops in response to persistent antigenic stimulation\u003c/span\u003e[20]. Caseous necrosis in granulomas is a defining feature of TB, particularly in advanced cases. This process results from immune responses that aim to contain the pathogen but can also lead to tissue damage and cavity formation, facilitating disease spread.\u003c/p\u003e\u003cp\u003eOur patient had been undergoing HD for several years and complained of intermittent fever, low back pain and general weakness at the time of admission. At the beginning of the research, we did not consider the possibility of TB infection because the clinical presentation and laboratory tests provided few valuable clues, and our patient had no history of this infection. We conducted empirical antimicrobial therapy for community-acquired pneumonia and previously performed traditional waist massage therapy. However, fever and pain continued, and an abdominal mass with distant metastases was suggested on the basis of the CT results. Whole-body PET/CT revealed destruction of the L3 vertebra and abscess formation, which bilaterally invaded the paravertebral psoas muscle. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWhile PET/CT scans with F-18 FDG tracer reveal metabolic differences between normal and malignant cells[21], F-18 FDG exhibits nonspecific uptake in both tumor cells and inflammatory/infective lesions\u003c/span\u003e, such as those affected by TB or sarcoidosis[22]. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIn regions where TB is prevalent around the world, clinical suspicion is crucial for the early diagnosis of spinal TB.\u003c/span\u003e Therefore, we performed fine needle aspiration. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWhen pulmonary or lymph node TB is confirmed, or when samples can be obtained from extraskeletal sites, collecting spinal or paraspinal specimens is not absolutely necessary\u003c/span\u003e[22]. The diagnosis of our patient was made by determining the formation of granulomas in an aspiration specimen obtained from the paravertebral abscess via fine needle aspiration under CT guidance. In addition, our patient's BT returned to normal after treatment with moxifloxacin but not other antibiotics. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFluoroquinolones have advantageous pharmacokinetics and activity against\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eM. tuberculosis\u003c/span\u003e, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eso they have considerable promising for treating TB. The WHO recommends later-generation fluoroquinolones, including moxifloxacin, for second-line anti-TB agents\u003c/span\u003e[23]. Therefore, under the guidance of the Department of Infectious Diseases, we initiated anti-TB drug therapy. Systemic symptoms such as fever and low back pain markedly resolved after the initiation of anti-TB medications. Finally, our patient was diagnosed with spinal TB with multifocal TB. However, the definitive diagnosis of spinal TB and treatment initiation were delayed because of nonspecific symptoms. These results suggest the importance of combining multiple methods for the diagnosis of disease.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, in our patient who underwent HD, radiologic examinations suggested cancer with LN involvement and spinal metastases. However, spinal TB was documented via CT-guided psoas muscle puncture biopsy. On the basis of the findings of this case, if nonspecific uremic symptoms persist in HD patients, the possibility of extrapulmonary TB should be considered, particularly when imaging results suggest that lesions have metastasized from systemic malignancies. In addition, the combination of multiple diagnostic methods was crucial for accurately diagnosing TB.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAFB, acid fast bacteria; BT, body temperature; CT, computed tomography; ESRD, End-stage renal disease; EPTB, extrapulmonary tuberculosis; EUS-FNB, Endoscopic ultrasound-guided fine-needle biopsy; FDG, \u003csup\u003e18\u003c/sup\u003eF-fluorodeoxyglucose; HD, hemodialysis; HIV, human immune deficiency virus; \u0026nbsp;LNs, lymph nodes; \u0026nbsp;MHD, maintenance hemodialysis; \u003cem\u003eM. tuberculosis, Mycobacterium tuberculosis\u003c/em\u003e; MDTM, multidisciplinary team meeting; PTB, pulmonary tuberculosis; PET/CT, Positron emission tomography/computed tomography; TB, tuberculosis; WHO, World Health Organization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the institutional medical ethics committee of the Third People\u0026apos;s Hospital of Chengdu. The next of kin of the participant was provided written informed consent before data collection. The present study was performed in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026rsquo;s next of kin for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author\u0026nbsp;(Ying Shu, e-mail:\u0026nbsp;[email protected]) upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: YS.\u003c/p\u003e\n\u003cp\u003eData curation: YL D, ZL\u003c/p\u003e\n\u003cp\u003eFormal analysis: YS.\u003c/p\u003e\n\u003cp\u003eMethodology: YS, YX J.\u003c/p\u003e\n\u003cp\u003eValidation: YL D, ZL, YX J.\u003c/p\u003e\n\u003cp\u003eWriting: YX J.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAndrassy KM: \u003cstrong\u003eComments on \u0026apos;KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease\u0026apos;\u003c/strong\u003e. \u003cem\u003eKidney Int \u003c/em\u003e2013, \u003cstrong\u003e84\u003c/strong\u003e(3):622-623.\u003c/li\u003e\n\u003cli\u003eHole B, Hemmelgarn B, Brown E, Brown M, McCulloch MI, Zuniga C, Andreoli SP, Blake PG, Couchoud C, Cueto-Manzano AM\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eSupportive care for end-stage kidney disease: an integral part of kidney services across a range of income settings around the 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\u003cstrong\u003e104\u003c/strong\u003e(6):440-445.\u003c/li\u003e\n\u003cli\u003eNaidoo A, Naidoo K, McIlleron H, Essack S, Padayatchi N: \u003cstrong\u003eA Review of Moxifloxacin for the Treatment of Drug-Susceptible Tuberculosis\u003c/strong\u003e. \u003cem\u003eJ Clin Pharmacol \u003c/em\u003e2017, \u003cstrong\u003e57\u003c/strong\u003e(11):1369-1386.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spinal tuberculosis, Case report, Hemodialysis, PET/CT, Biopsy","lastPublishedDoi":"10.21203/rs.3.rs-7024358/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7024358/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSpinal tuberculosis (TB) rarely occurs in hemodialysis (HD) patients, which makes diagnosis challenging. Therefore, we report a case of spinal TB with a psoas muscle abscess in an HD patient. The patient had been on the HD programme for two years and was complaining of intermittent fever and low back pain. Positron emission tomography/computed tomography (PET/CT) revealed increased metabolism of the hepatic hilum and pancreatic neck, multiple enlarged lymph nodes (LNs), and destruction of the L3 vertebra invading the psoas muscle bilaterally. To confirm the diagnosis of the disease, a biopsy of the psoas abscess via fine needle aspiration under computed tomography (CT) guidance was carried out, which revealed the formation of a caseating granuloma. Anti-TB drug therapy resolved the systemic symptoms. The final diagnosis was spinal TB. A diagnosis of extrapulmonary TB should be suspected when nonspecific uremic symptoms persist in HD patients. Moreover, the combination of multiple diagnostic methods is essential for accurately diagnosing TB.\u003c/p\u003e","manuscriptTitle":"Diagnostic Challenges of Spinal Tuberculosis Simulation of Cancer in Patients Undergoing Hemodialysis: A Case Report and Literature Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 11:56:25","doi":"10.21203/rs.3.rs-7024358/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d0fc2eb-388b-4ce8-9632-f6475130e852","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-18T09:13:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-13 11:56:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7024358","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7024358","identity":"rs-7024358","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}