Cavitating Lung Nodule and Lytic Spinal Lesions in an Adolescent Male

A previously healthy 17-year-old boy from northern New Brunswick presented to his local physician with a six-week history of mid-thoracic back pain and a 4 kg weight loss. There was no history of trauma, fever or night sweats; the review of systems was otherwise normal. He had no recent travel outside of the province, no recent infectious contacts, took no medications and his immunizations were up to date. He was a nonsmoker and denied illicit drug use. A brief exposure to his grandfather with suspected tuberculosis 12 years earlier was noted. Physical examination revealed a tall, thin and well-looking adolescent male. His vital signs, including temperature, were normal. His head and neck examinations were unremarkable. Tactile fremitus was noted over his left upper lung fields, but on auscultation, air entry was good bilaterally with no adventitious sounds. His cardiac and abdominal examinations were normal. There was no tenderness on palpation of the spine or paraspinal muscles. His neurological examination was normal. Initial laboratory results included a normal complete blood cell count and an absolute neutrophil count. The erythrocyte sedimentation rate was elevated at 60 mm/h. Serology tests for antinuclear antibody, perinuclear anticytoplasmic antibody and circulating antineutrophil cytoplasmic antibody were negative. A nuclear bone scan demonstrated an increased uptake in the sacrum and mid-thoracic spine, further defined on computed tomography (CT) scan as a lytic right-sided S1/S2 sacral lesion involving adjacent soft tissue. A large lytic lesion of T9 was also seen, as well as a cavitating 3 cm diameter lung lesion in the left upper lobe of the lung, surrounded by minimal alveolar infiltrate. No hilar adenopathy was present. The patient was referred to the IWK Health Centre (Halifax, Nova Scotia) for further evaluation. Over the course of investigations, a mild nonproductive cough developed. Further studies noted normal serum quantitative immunoglobulin levels, a normal sweat chloride test and a negative tuberculin skin test. An oxidative burst assay of neutrophil function was normal. An open sacral biopsy was performed revealing neutrophilic and eosinophilic infiltrates, but no dysplasia or malignancy. Gram, Kinyoun and Calcofluor stains for bacteria, mycobacteria and fungi were negative. Routine bacterial and mycobacterial cultures were negative. Pathology noted the rim of a granuloma in one section. Two weeks later, a repeat CT scan documented rapid disease progression despite the indolent symptoms. The lytic T9 lesion had extended into T10 with increased soft tissue swelling and rim enhancement (Figure 1), and there were increased infiltrates around the pulmonary cavitation. Mycobacterial and fungal cultures of the biopsy material remained negative. Nucleic acid amplification tests for mycobacteria were negative from the biopsy. Figure 1) Coronal computed tomography image before the computed tomography-guided vertebral biopsy and the thoracoscopic lung biopsy. An intermediate window-level setting depicts both the spine and lung lesions. The lytic T9 lesion, the left paraspinal soft tissue ... In pursuit of a firm diagnosis, both a T9 CT-guided needle biopsy and thoracoscopic excisional lung biopsy of the cavitation were performed. Necrotizing granulomas were seen in the tissue from both sites. What is the diagnosis?

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