This is a 73 years old man who presented with fever. His radiographs showed a right pleural effusion and multiple rib lesions – this was confirmed on CT scan and then PET/CT.

The pattern of bone involvement is unusual with expansile and non-necrotic soft tissue. Since the PET/CT did not show another primary, my first diagnosis was myeloma.

The biopsy from the right 6th rib lesion was simple using an 18G coaxial biopsy gun.

The diagnosis was tuberculosis.

Time and again, in an endemic country, TB fools us. The rules remain the same. In this age group, we must assume these lesions to be metastases, myeloma or lymphoma unless proven otherwise, and it is only when we biopsy all these lesions, that we get to the correct answer, which in this case…surprise…was tuberculosis.