Student, Resident AND Fellow Research

Pott Disease: When TB Thinks Outside the Lungs

BY ISTIAQ MIAN, MD, AND DAN PEASE, MD, HENNEPIN COUNTY MEDICAL CENTER, INTERNAL MEDICINE RESIDENCY PROGRAM

27-year-old Kenyan woman arrived in the United States and immediately pre- Figure: MRI showing extensive paraspinal sented to the emergency department , severe spinal A cord compression and with an eight-month history of progressive associated . , intermittent fever and bilateral leg weakness. She had undergone MRI imaging in Kenya and been diagnosed with Pott disease shortly after symptom onset. Despite completing six months of anti- tubercular therapy in Kenya, her weakness progressed to . On presentation, she had 0/5 strength in her lower extremi- ties bilaterally. MRI imaging on the day of hospital admission revealed an extensive para- spinal abscess extending from T4 to T9, compressing the mediastinum, as well as multiple lytic lesions (Figure) from T3 to T9. Her thoracic spine was collapsed at T7 and T8, with and kyphosis of 45 degrees. An interven- tional radiologist drained the abscess, which yielded immediate improvement in her lower extremity strength; she was able to passively flex and extend her legs. Thereafter, neurosurgeons performed a T8 laminectomy and T1 to T12 spinal fusion. deformity). The clinical presentation from Although antimicrobial therapy is rec- With concern for resistant symptom onset to diagnosis includes back ommended for all patients, routine (TB), medical therapy was initiated (a pain and stiffness potentially progressing for spinal tuberculosis is not. Currently, six-drug regimen). Molecular testing of to neurologic compromise from spinal randomized controlled trials investigat- abscess fluid detected TB rRNA as sensi- cord compression. Active pulmonary dis- ing indications for surgery are lacking; tive to and rifampin. The patient ease is not present in most cases, so a lack however, most experts agree that surgi- underwent two weeks of intense inpatient of pulmonary symptoms is not helpful in cal intervention should be undertaken rehab and eventually regained the ability ruling out the diagnosis.1 in the presence of neurological deficits, to ambulate on her own. The approach to medical treatment for spinal instability, large paraspinal abscess Pott disease is similar to that for pulmo- or inadequate response to antimicrobial Discussion nary TB. Although duration of treatment therapy.2 MM This case demonstrates successful treat- is still uncertain, at least six months of ment of tuberculous , also first-line agents is recommended. A longer REFERENCES known as Pott disease. This is a rare mani- treatment period of nine to 12 months 1. McDonal M, Sexton DJ. Skeletal tuberculosis. In: festation, affecting only 2% of TB cases. should be considered if rifampin is con- UpToDate. Available at: www.uptodate.com/contents/ Extrapulmonary TB of the spine typically traindicated or if the patient has extensive skeletal-tuberculosis. Accessed March 16, 2015. 1 2. Jutte PC, van Loenhout-Rooyackers JH. Routine spreads to the thoracic and upper lumbar disease. surgery in addition to chemotherapy for treating area. Once two adjacent vertebrae are spinal tuberculosis. Cochrane Database Syst Rev. 2006;25(1):CD004532. affected, infection can enter the interver- tebral disc space, causing necrosis, ver- tebral collapse and kyphosis (the Gibbus

42 | MINNESOTA MEDICINE | APRIL 2015