CRA12 LOOKING BEYOND THE LUNGS: A MISSED BULGE, A MISSED DIAGNOSIS

Anandprakash Sivapirakasam, Sunita Devi Hukam Gopal Chand
Hospital Sultan Abdul Halim, Kedah, Malaysia

Introduction
In pulmonary tuberculosis (PTB), subtle radiographic signs may provide the first and only clue to extrapulmonary involvement. Missed spinal tuberculosis (TB) can result in inadequate treatment duration and long-term complications. This case highlights how astute chest X-ray interpretation led to early diagnosis of TB spine in the absence of classical symptoms.

Objectives
To illustrate the diagnostic significance of detecting a thoracic bulge, and the essential role of comprehensive chest X-ray interpretation in uncovering clinically silent TB spine.

Methodology
An 18-year-old Malay male, active smoker, presented with a 3-month history of intermittent cough and 4 kg weight loss. He had no fever, back pain, or neurological symptoms. Initial chest radiograph revealed a cavitating lesion in the right mid-zone, accompanied by a right thoracic bulge—an often-overlooked contour abnormality. This subtle sign raised suspicion of extrapulmonary involvement

Results
Subsequent contrast-enhanced CT and MRI of the thorax revealed a multiloculated right paravertebral collection extending from T7 to T11, consistent with TB spine, despite no vertebral destruction. Anti-TB therapy was initiated, with a temporary interruption due to drug-induced hepatotoxicity. The patient completed 9 months of treatment uneventfully, with full clinical recovery and radiological stability.

Conclusions
This case exemplifies the critical importance of meticulous chest X-ray interpretation in uncovering silent but clinically significant extrapulmonary TB. In endemic regions, such vigilance can transform outcomes by ensuring appropriate treatment duration and averting preventable morbidity