This is a 62-years old lady with fever. After an MRI that showed a focal L4 lesion, a PET/CT was done to look for other lesions in the body given the high chance of metastasis / myeloma / lymphoma.
The PET showed multiple lesions in the bones including the right femoral neck, with mediastinal nodes, lung nodules and a left pleural effusion. There was no primary neoplasm.
The working diagnosis was metastases versus infection.
I felt that the best site to biopsy to get adequate material for all tests would be the right femoral neck. Using an 18G coaxial biopsy gun and lightly tapping through the anterior cortex, I did the biopsy under intravenous sedation. The diagnosis was tuberculosis – it was PCR positive for M. Tuberculosis and not rifampicin resistant.
The case underscores the need to biopsy at all ages and how a PET/CT helps determine the appropriate biopsy site.