Ancient Active Disease :Ancient Active Disease Dr. Pradeep J Mentor: Dr. Kumar S


Chief Complaints :Chief Complaints Pain on and off whole spinal area – 2 year severe past 1 month Deformation noticed 1 year back Cough with expectoration – 2 month Loss of appetite – 1 month Weight loss 7kg in 1 month Breathlessness – 1 wk


H/o Presenting Illness :H/o Presenting Illness Started with fever 2 months back developed cough with expectoration in a week time After a month pain aggravated over the thoraco-lumbar region for which medication taken over the counter After 3 wks developed breathlessness approached hospital


H/o Past Illness :H/o Past Illness Diagnosed case of PLHA since May 2009 Not on CTZ prophylaxis Pulmonary TB on CAT I since 14/07/2009 No H/o Diabetes, Hypertension, jaundice


Personal History :Personal History Unmarried Fruit vendor Does not maintain personal hygiene Smoker, Alcoholic Ex IV drug abuser Had pre-marital sexual contact 5 yrs back


Summary :Summary 35 y.o fruit vendor ,known PLHA since May 2009 with base line CD4 134 cells, not on CTZ prophylaxis. presented with complaints of Breathlessness, cough with expectoration ,severe backache with deformed spine, and weight loss. On examination kyphotic deformity of spine in thoraco-lumbar region. On CAT I ATT past 1 month for PTB.


Primary Diagnosis? :Primary Diagnosis?


General Examination :General Examination Conscious, stable, afebrile, No Pallor, Cyanosis, Icterus or Pedal Edema wasting,generalised icthyosis. Oral thrush + Clubbing noted Lt axillary Lymphadenopathy Kyphotic deformity of spine Tattoo on the Rt deltoid area


Systemic Examination :Systemic Examination CVS : Apex beat normal in position S1 S2 audible, No added sounds RS : Trachea mid line NVBS No raised JVP P/A : Soft, No organomegaly CNS : NAD


Vital signs :Vital signs BP : 100/70 mm Hg Pulse : 86/min Temperature : Normal Height : 153 cm Weight : 31 kg BMI : 13.2


Local Examinations :Local Examinations Lt axillary region : Enlarged matted lymph nodes of size 3 x 2 cm Spine : Kyphotic deformity with small healing ulcer 1.5 x 1 cm over the D 10 D 12 area, on tender ,no warmth


Laboratory Investigations :Laboratory Investigations HB 9.2 gm/dl WBC 2 x 10 cu mm Lym 21% Mon 8.1% Gran 70.4 % RBC 3.18 x 10 cu mm PLT 100 x 10 cu mm RBS 84 mg/dl Sr. Urea 12 Sr.Creatinine 0.7 CD4 134 cells


Laboratory Investigations :Laboratory Investigations Sputum AFB neg Matoux neg Bil Total 1.0 mg/dl SGOT 4.9 u/l SGPT 44 u/l SAP 441 u/l Protien 7.8 gm/dl Albumin 2.4 gm/dl Globulin 5.4 gm/dl


Differential Diagnosis :Differential Diagnosis Tuberculosis Pyogenic Spondylitis Spinal Cord abscess Septic Arthritis Metastasis Multiple Myeloma Other Mycobacterium Fungal spondylo -arthropathies


Discussion :Discussion What other investigations that could be included?. How many months we have to treat this patient with anti tuberculosis drugs? Does this patient need surgical intervention? What will be the treatment outcome in HIV positive with TB spondylitis?


Final Diagnosis :Final Diagnosis PLHA with Disseminated TB WHO stage 4


Left: Mummy 003 Museo Arqueologico de la casa del Marques de San Jorge, Bogoto, ColombiaRight : Computerrised tomography showing lesions in the Vertebral bodies T10/T11Courtesy : Tuberculosis 2007 :Left: Mummy 003 Museo Arqueologico de la casa del Marques de San Jorge, Bogoto, ColombiaRight : Computerrised tomography showing lesions in the Vertebral bodies T10/T11Courtesy : Tuberculosis 2007


Pott’s disease :Pott’s disease This entity was first described by Percivall Pott. He noted this as a painful kyphotic deformity of the spine associated with paraplegia. Tuberculosis of the spine is one of the oldest diseases afflicting humans. Evidences of spinal tuberculosis have been found in Egyptian mummies dating back to 3400 BC


Slide 25:One fifth of TB population is in India. Three percent are suffering from skeletal TB, 50% of these suffer from spinal lesion and almost 50% are from pediatric group. An estimated 2 million or more patients have active spinal tuberculosis. Every day 1000 die of tuberculosis in India.


Regional Distribution :Regional Distribution


Pathophysiology :Pathophysiology Pott disease is usually secondary to an extraspinal source of infection. The basic lesion involved in Pott disease is a combination of osteomyelitis and arthritis that usually involves more than one vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is area usually affected. Tuberculosis may spread from that area to adjacent intervertebral disks.


Pathophysiology :Pathophysiology In adults, disk disease is secondary to the spread of infection from the vertebral body. In children, because the disk is vascularized, it can be a primary site*. Progressive bone destruction leads to vertebral collapse and kyphosis. The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord compression and neurologic deficits. *Davidson PT et al,  Tuberculosis and Nontuberculous Mycobacterial Infections. In: Schlossberg D, ed. Musculoskeletal Tuberculosis. 4th ed. Saint Louis, MO: W B Saunders; 1999:204-20.


Pathophysiology :Pathophysiology The kyphotic deformity is caused by collapse in the anterior spine. Lesions in the thoracic spine are more likely to lead to kyphosis than those in the lumbar spine. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin.


Frequency :Frequency The frequency of extrapulmonary tuberculosis has remained stable. Bone and soft-tissue tuberculosis accounts for approximately 10% of extrapulmonary tuberculosis cases and between 1% and 2% of total cases.


Frequency :Frequency Tuberculous spondylitis is the most common manifestation of musculoskeletal tuberculosis, accounting for approximately 40-50% of cases.*** Approximately 1-2% of total tuberculosis cases are attributable to Pott disease. ***Leibert E, Haralambou G. Tuberculosis. In: Rom WN and Garay S, eds. Spinal tuberculosis. Lippincott, Williams and Wilkins; 2004:565-77.


GHTM :GHTM In GHTM so far in this month 4 cases of Pott`s spine identified** **THIS


Mortality/Morbidity :Mortality/Morbidity Pott disease is the most dangerous form of musculoskeletal tuberculosis because it can cause bone destruction, deformity, and paraplegia. Pott disease most commonly involves the thoracic and lumbosacral spine.* ** *** ** *Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am. Dec 1985;67(9):1405-13.. **Pertuiset E, Beaudreuil J, Liote F, et al. Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980-1994. Medicine (Baltimore). Sep 1999;78(5):309-20. ***Turgut M. Spinal tuberculosis (Pott's disease): its clinical presentation, surgical management, and outcome. A survey study on 694 patients. Neurosurg Rev. Mar 2001;24(1):8-13.  ****Le Page L, Feydy A, Rillardon L, et al. Spinal tuberculosis: a longitudinal study with clinical, laboratory, and imaging outcomes. Semin Arthritis Rheum. Oct 2006;36(2):124-9


Mortality/Morbidity :Mortality/Morbidity Lower thoracic vertebrae is the most common area of involvement (40-50%), followed closely by the lumbar spine (35-45%). Approximately 10% of Pott disease cases involve the cervical spine.


Clinical History :Clinical History The presentation of Pott disease depends on the following: Stage of disease Affected site Presence of complications such as neurologic deficits, abscesses, or sinus tracts The reported average duration of symptoms at diagnosis is 4 months but can be considerably longer, even in most recent series.This is due to the nonspecific presentation of chronic back pain


Clinical History :Clinical History Back pain is the earliest and most common symptom. Patients with Pott disease usually experience back pain for weeks before seeking treatment. The pain caused by Pott disease can be spinal or radicular.


Slide 37:Potential constitutional symptoms of Pott disease include fever and weight loss. Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, and/or cauda equina syndrome.


Slide 38:Cervical spine tuberculosis is a less common presentation but is potentially more serious because severe neurologic complications are more likely. This condition is characterized by pain and stiffness. Patients with lower cervical spine disease can present with dysphagia or stridor. Symptoms can also include torticollis, hoarseness, and neurologic deficits.


Slide 39:The clinical presentation of spinal tuberculosis in patients infected with the human immunodeficiency virus (HIV) is similar to that of patients who are HIV negative; however, spinal tuberculosis seems to be more common in persons infected with HIV.*** ***Jellis JE. Human immunodeficiency virus and osteoarticular tuberculosis. Clin Orthop Relat Res. May 2002;27-31


Physical :Physical The examination should include the following: Careful assessment of spinal alignment Inspection of skin, with attention to detection of sinuses Abdominal evaluation for subcutaneous flank mass Neurologic examination


Slide 41:Almost all patients with Pott disease have some degree of spine deformity (kyphosis). Large cold abscesses of paraspinal tissues or psoas muscle may protrude under the inguinal ligament and may erode into the perineum or gluteal area. Neurologic deficits may occur early in the course of Pott disease. Signs of such deficits depend on the level of spinal cord or nerve root compression.


Slide 42:Pott disease that involves the upper cervical spine can cause rapidly progressive symptoms. Retropharyngeal abscesses occur in almost all cases. Neurologic manifestations occur early and range from a single nerve palsy to hemi paresis or quadriplegia. Many persons with Pott disease (62-90% of patients in reported series***) have no evidence of extra spinal tuberculosis, further complicating a timely diagnosis. ***Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am. Dec 1985;67(9):1405-13


Laboratory Studies :Laboratory Studies Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-95% of patients with Pott disease who are not infected with HIV. The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h).


Slide 44:Microbiology studies are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. These study findings are positive in only about 50% of the cases.


Imaging Studies :Imaging Studies Radiographic changes associated with Pott disease present relatively late. Radiographic changes characteristic of spinal tuberculosis on plain radiography:*** Lytic destruction of anterior portion of vertebral body Increased anterior wedging Collapse of vertebral body Reactive sclerosis on a progressive lytic process Enlarged psoas shadow with or without calcification ***Ridley N, Shaikh MI, Remedios D, et al. Radiology of skeletal tuberculosis. Orthopedics. Nov 1998;21(11):1213-20


Slide 46:Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or destroyed. Vertebral bodies show variable degrees of destruction. Fusiform paravertebral shadows suggest abscess formation. Bone lesions may occur at more than one level.


CT scanning :CT scanning CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference. Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal areas. CT scanning reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses. In contrast to pyogenic disease, calcification is common in tuberculous lesions.


MRI :MRI MRI is the criterion standard for evaluating Disk-space infection and osteomyelitis Extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression.*** ***Moorthy S, Prabhu NK. Spectrum of MR imaging findings in spinal tuberculosis. AJR Am J Roentgenol. Oct 2002;179(4):979-83


Slide 49:MRI findings useful to differentiate tuberculous spondylitis from pyogenic spondylitis In TB spondylitis thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal In pyogenic spondylitis thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal


Surgical indications :Surgical indications No sign of Neurological recovery after trial of 3-4 weeks therapy Neurological complication during treatment Neuro deficit becoming worse Recurrence of neuro complication Prevertebral cervical abscesses,neurological signs& difficulty in deglutition& respiration Advanced cases- Sphincter involvement, flaccid paralysis, Severe flexor spasms


Other indications :Other indications Recurrent paraplegia Painful paraplegia– d/t root compression,etc Posterior spinal disease--involving the post elements of vertb Spinal tumor syndrome resulting in cord compression Rapid onset paraplegia due to thrombosis,trauma etc Severe paraplegia Secondary to cervical disease and cauda equina paralysis


ACKNOWLEDGEMENTS :ACKNOWLEDGEMENTS The Superintendent , GHTM Medical Director, I TECH RMO, GHTM All Mentors, GHTM Chief fellow I TECH Faculty Fellows


Slide 53:Thank YOU !