Osteoarticular TB is very rare and as such, physicians are less experienced in diagnosing osteoarticular TB. This is compounded by the fact that the diagnosis of osteoarticular TB is difficult to achieve. Therefore, awareness and high index of suspicion of the disease is essential and referral to expertise should be made if diagnosis is indeterminate despite extensive investigations. A 26-year-old man from Afghanistan, with background history of hepatitis B diagnosed 3 years previously, was

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... rred by asylum seeker health centre practitioner with abnormal chest X-ray. He had lived in Pakistan for 1 month prior to moving to Ireland. He had lived in Ireland for one year prior to presenting with persistent dry cough for 4 weeks. He had three cousins with TB whom were fully treated in Afghanistan. He denied usage of intravenous drugs. He was an occasional smoker. He was attending hepatology clinic regularly and was on Tenofovir. On assessment, his vitals and physical examination were unremarkable. However, it was noted that he had right foot ulceration ongoing for a year (Figure 1a) . Routine haematology showed lymphopaenia of 0.8 (1-2 Â 10 16 ml), hyponatraemia of 132 (135-144 mmol/l) and creatine reactive protein of 65 (<5 mmol/l). His chest X-ray (CXR) demonstrated left-sided airspace opacification in the apex. He was isolated and his sputum was taken for acid-fast bacilli and GeneXpert-MTB/RIF PCR based assay and was negative for both. Computed tomography (CT) of his chest showed left upper lobe opacities with necrotic mediastinal lymph nodes. Bronchoalveolar lavage (BAL) was negative for GeneXpert-MTB/RIF PCR based assay. While awaiting culture for his BAL, he had magnetic resonance imaging (MRI) of the foot which showed evidence of osteomyelitis of right calcaneus with overlying soft tissue swelling and fluid tract which extend to communicate with skin over plantar aspect of right foot Figure 1. (a) Right foot ulceration. (b) Evidence of osteomyelitis of right calcaneus with overlying soft tissue swelling and fluid tract which extend to communicate with skin over plantar aspect of right foot.