Pott's Disease: A Case in Recognizing and Treating Extrapulmonary Tuberculosis
Parikh M, Bennett S, Williams J, Keimig WC, Chen A, and Brar I. Pott's disease-A case in recognizing and treating extrapulmonary tuberculosis. J Gen Intern Med 2018; 33(2):596-597.
J Gen Intern Med
Learning Objective #1: Recognize and treat extrapulmonary tuberculosis in the absence of pulmonary symptoms and negative skin testing in patients from endemic regions to facilitate early treatment and improve outcome.
CASE: Our patient is a 39 year old male who presented with a six month history of bilateral lower back pain, night sweats, and a 20-pound weight loss over 6 months. He had emigrated from Indonesia 3 years earlier, and had briefly returned home 2 years prior to his presentation. He had a family history significant for abdominal tuberculosis in his sister which reportedly had been successfully treated 16 years earlier. He reported being PPD negative on arrival to the USA. His physical examination, was significant only for an approximately 7 cm fluctuant non-erythematous mass on his back in the right lower lumbar region. As part of his initial evaluation, his quantiferon gold was positive. CT chest did not reveal any pulmonary disease. CT scan of the thoracolumbar spine was notable for bone lesions at multiple vertebral spaces, along with paraspinal and epidural fluid collections and an iliopsoas abscess. The paraspinal fluid collection was positive for acid fast bacilli (AFB) on smear, and cultures grew Mycobacterium Tuberculosis. Although on MRI there was evidence of cord compression, our patient had no deficits on exam. He was discharged with 4-drug therapy, and a back brace due to the extent of bone lesions.
IMPACT: Extrapulmonary tuberculosis (EPTB) accounted for 15% of newly diagnosed cases of tuberculosis worldwide in 2015. EPTB cases diagnosed in the United States are most prevalent in individuals from endemic regions. A high degree of suspicion should be maintained when evaluating individuals from endemic regions. Here we outline indications for surgical treatment and corticosteroid use in vertebral tuberculosis.
DISCUSSION: In patients with spinal tuberculosis, antituberculous treatment should be started as early as possible. Almost all antituberculous drugs penetrate well into vertebral lesions. Many experts prefer a duration of 12-24 months or until evidence of regression of disease occurs. Surgical management is indicated in patients that have a poor response to chemotherapy with evidence of ongoing vertebral deterioration. It is also indicated in cases exhibiting neurological deficits requiring spinal cord decompression and in cases with spine instability. Delay in establishing the diagnosis of spinal TB leads to neurologic deficits and spinal deformities. Corticosteroids for EPTB have shown mortality benefit in TB with pericarditis, and in TB meningitis, however there is no evidence for the use of corticosteroids in TB involving the vertebral column.