Imaging update in spinal tuberculosis

Neutrophil-lymphocyte ratio: a correlation study of its effect on magnetic resonance imaging enhancement patterns in spinal parenchymal tuberculosis

OBJECTIVE

To explore the impact of the neutrophil-lymphocyte ratio (NLR) on magnetic resonance imaging (MRI) enhancement patterns in patients with spinal parenchymal tuberculosis.

METHODS

In this study, a retrospective analysis was conducted on 42 patients diagnosed for the first time with spinal parenchymal tuberculosis at Kunming Third People's Hospital between 2019 and 2024. They were divided into a homogeneous enhancement group and a ring enhancement group based on MRI characteristics and an analysis of their clinical presentations, imaging features and laboratory test results.

RESULTS

A total of 42 patients were included in the study, with 30 in the ring enhancement group and 12 in the homogeneous enhancement group. The ring enhancement group exhibited a significantly higher proportion of fever, night sweats and limb sensory/motor dysfunction compared with the homogeneous enhancement group (p < 0.05). For laboratory tests, the ring enhancement group showed remarkably elevated peripheral blood neutrophil counts and NLR, along with markedly reduced lymphocyte counts and proportions (p < 0.05). Additionally, the incidence of perilesional oedema was substantially higher in the ring enhancement group than in the homogeneous enhancement group (p < 0.05).

CONCLUSION

The NLR may serve as a potential indicator for assessing MRI enhancement patterns in spinal parenchymal tuberculosis, which is beneficial for identifying patients at different pathological stages of the disease. This study provides novel perspectives for clinical diagnosis and treatment while emphasising the need for further research on the application value of the NLR in tuberculosis.

Tubercular spondylitis with prevertebral and epidural abscess masquerading as a mediastinal mass

A 10-year old girl presenting with an insidious-onset low-grade fever for one month was found to have mediastinal widening with bilateral perihilar opacities. MRI scanning further revealed dorsal spondylitis with collapse of T2-4 vertebral bodies with prevertebral and epidural tubercular collections of 3 × 6.5 × 8 cm. This case emphasises the importance of considering TB among differential diagnoses of a mediastinal mass, especially among children from endemic countries.

Spinal Echinococcosis in a Japanese Woman Living in Tokyo: Diagnostic Challenges in Non-endemic Areas and Public Health Implications

Echinococcosis, caused by Echinococcus spp., often affects the lungs and liver, and spinal involvement is rare. Echinococcus multilocularis is prevalent in Japan, particularly in Hokkaido. We herein report a rare case of spinal echinococcosis in a 31-year-old woman who was diagnosed in Tokyo. Spinal echinococcosis is uncommon and often leads to misdiagnoses. The patient likely contracted the disease via contaminated fresh produce transported from an endemic region. This study emphasizes the diagnostic challenges of spinal echinococcosis in non-endemic regions and highlights the public health concerns related to the spread of infections in non-endemic areas.

Widespread 18 F-FDG Uptake in Osseous Tuberculosis Without Pulmonary Tuberculosis

ABSTRACT

A 30-year-old man with a 5-month history of lumbar pain was hospitalized due to worsening pain and restricted mobility. CT and MRI scans indicated multiple vertebral destructions, prompting further assessment with 18 F-FDG PET/CT. PET/CT imaging showed widespread and avid 18 F-FDG uptake in the bones, mainly in the vertebrae. No other suspicious lesions were detected. Pathology subsequently confirmed the presence of Mycobacterium tuberculosis . This case illustrates 18 F-FDG PET/CT imaging of osseous tuberculosis, characterized by widespread 18 F-FDG accumulation without pulmonary tuberculosis.

Deep learning radiomics model based on contrast-enhanced MRI for distinguishing between tuberculous spondylitis and pyogenic spondylitis

PURPOSE

This study aimed to develop and validate a deep learning radiomics nomogram (DLRN) to differentiate between tuberculous spondylitis (TS) and pyogenic spondylitis (PS) using contrast-enhanced MRI (CE-MRI).

METHODS

A retrospective approach was employed, enrolling patients diagnosed with TS or PS based on pathological examination at two centers. Clinical features were evaluated to establish a clinical model. Radiomics and deep learning (DL) features were extracted from contrast-enhanced T1-weighted images and subsequently fused. Following feature selection, radiomics, DL, combined DL-radiomics (DLR), and a deep learning radiomics nomogram (DLRN) were developed to differentiate TS from PS. Performance was assessed using metrics including the area under the curve (AUC), calibration curves, and decision curve analysis (DCA).

RESULTS

A total of 147 patients met the study criteria. Center 1 comprised the training cohort with 102 patients (52 TS and 50 PS), while Center 2 served as the external test cohort with 45 patients (17 TS and 28 PS). The DLRN model exhibited the highest diagnostic accuracy, achieving an AUC of 0.994 (95% CI: 0.983-1.000) in the training cohort and 0.859 (95% CI: 0.744-0.975) in the external test cohort. Calibration curves indicated good agreement for DLRN, and decision curve analysis (DCA) demonstrated it provided the greatest clinical benefit.

CONCLUSION

The CE-MRI-based DLRN showed robust diagnostic capability for distinguishing between TS and PS in clinical practice.

Magnetic resonance imaging in diagnosing spinal cord tuberculoma: A case series and literature review

Spinal cord tuberculoma is a clinically significant form of extra-pulmonary tuberculosis, despite its rarity. It leads to considerable neurological deficits and morbidity. Accurate diagnosis and early intervention depend on radiologic imaging, typically MRI, which reveals T2 hypointensity with rim enhancement, forming a ``target sign'' characteristic of caseous stage tuberculoma. In this article, we present 3 cases of spinal cord tuberculoma without adjacent vertebral involvement; 2 cases affect the lower thoracic region, while one involves the cervical cord. All patients exhibited some degree of body weakness, which improved following the initiation of anti-tuberculosis treatment. Also, we discuss the role of MRI in diagnosing spinal cord tuberculoma, highlighting its characteristic findings, and review recent literature on the topic.

Pediatric paraparesis: Radiological challenges in multidrug-resistant tuberculous spondylitis based on experience in Indonesia

Multidrug-resistant tuberculous spondylitis is a global health issue, especially in developing nations, and non-specific symptoms lead to delay in identification, treatment, and potential disability in children. Radiology plays a crucial role in diagnosing tuberculous spondylitis, which in turn might lead to effective treatment, prevention of disability and improved patient outcomes. Our case involved a 20-month-old malnourished child presented with paraparesis, revealing a history of contact with parental multidrug-resistant tuberculosis. Multimodality radiological examinations, including conventional radiography, CT, and MRI revealed extensive disease of the spine with disc involvement, large paravertebral abscess, and kyphotic deformity which produced neurological deficits, necessitating both anti-tuberculosis regimen and surgical intervention. Radiological examinations have a pivotal role in diagnosing, evaluating and guiding timely management of multidrug-resistant tuberculous spondylitis. Prompt diagnosis of the condition is crucial in order to prevent potentially severe complications, which contribute significantly to morbidity. Our case demonstrated the importance of radiology in diagnosing extensive spine involvement of the disease causing neurological deficits. Furthermore, radiology also helps in managing tuberculous spondylitis to prevent future disability in a child patient of a developing country. This case highlights the crucial significance of radiological imaging in the diagnosis and management of pediatric tuberculous spondylitis in impoverished nations. The patient's complex medical history highlights the socioeconomic factors contributing to tuberculosis burden. Early and comprehensive radiological assessment, together with collaboration between radiologists and clinicians, is vital for timely intervention and improved outcomes in pediatric tuberculous spondylitis cases to prevent the impact of this debilitating disease on children.

Analysis of the value of potential biomarker S100-A8 protein in the diagnosis and pathogenesis of spinal tuberculosis

Objectives

The objective of this study is to evaluate the value of S100-A8 protein as a diagnostic marker for spinal tuberculosis and to explore its role in the potential pathogenesis of spinal tuberculosis (STB).

Methods

The peripheral blood of 100 spinal tuberculosis patients admitted to the General Hospital of Ningxia Medical University from September 2018 to June 2021 were collected as the observation group, and the peripheral blood of 30 healthy medical examiners were collected as the control group. Three samples from the observation group and three samples from the control group were selected for proteomics detection and screening of differential proteins. Kyoto Encyclopedia of Genes (KEGG) was used to enrich and analyze related signaling pathways to confirm the target protein. The serum expression levels of the target proteins were determined and compared between the two groups using enzyme-linked immunosorbent assay (ELISA). Statistical methods were used to evaluate the value of target protein as a diagnostic marker for STB. A macrophage model of Mycobacterium tuberculosis infection was constructed and S100-A8 small interfering RNA was used to investigate the molecular mechanism of the target protein.

Results

S100-A8 protein has the value of diagnosing spinal tuberculosis (AUC = 0.931, p < 0.001), and the expression level in the peripheral blood of the observation group (59.04 ± 19.37 ng/mL) was significantly higher than that of the control group (43.16 ± 10.07 ng/mL) (p < 0.05). S100-A8 protein expression showed a significant positive correlation with both CRP and ESR values (p < 0.01). Its AUCs for combined bacteriological detection, T-SPOT results, diagnostic imaging, antacid staining results, and pathological results were 0.705 (p < 0.05), 0.754 (p < 0.01), 0.716 (p < 0.01), 0.656 (p < 0.05), and 0.681 (p < 0.01), respectively. Lack of S100-A8 leads to a significant decrease in the expression levels of TLR4 and IL-17A in infected macrophages.

Conclusion

S100-A8 protein is differentially expressed in the peripheral blood of patients with spinal tuberculosis and healthy individuals and may be a novel candidate biomarker for the diagnosis of spinal tuberculosis. The feedback loop on the S100-A8-TLR4-IL-17A axis may play an important role in the inflammatory mechanism of spinal tuberculosis.

Spine tuberculosis with an intercurrent active pulmonary location in a high incidence country: A rare case report

Spinal tuberculosis usually presents as destroyed contiguous vertebral bodies associated with intervertebral discs and paravertebral or psoas abscesses. Atypical forms are uncommonly reported. Vertebral involvement without disk destruction is a rare form that improves satisfactorily after appropriate medical management. We report the case of a 36-year-old male who had spine tuberculosis without disk involvement, associated with intercurrent active pulmonary location with good clinical improvement after treatment and follow-up imaging showing spectacular regression of bone lesions. By reporting this case, we also review the literature on this rare form of tuberculosis.

IL-10 and TGF-β1 may weaken the efficacy of preoperative anti-tuberculosis therapy in older patients with spinal tuberculosis

Spinal tuberculosis is a common extrapulmonary type that is often secondary to pulmonary or systemic infections. Mycobacterium tuberculosis infection often leads to the balance of immune control and bacterial persistence. In this study, 64 patients were enrolled and the clinicopathological and immunological characteristics of different age groups were analyzed. Anatomically, spinal tuberculosis in each group mostly occurred in the thoracic and lumbar vertebrae. Imaging before preoperative anti-tuberculosis therapy showed that the proportion of abscesses in the older group was significantly lower than that in the younger and middle-aged groups. However, pathological examination of surgical specimens showed that the proportion of abscesses in the older group was significantly higher than that in the other groups, and there was no difference in the granulomatous inflammation, caseous necrosis, inflammatory necrosis, acute inflammation, exudation, granulation tissue formation, and fibrous tissue hyperplasia. B cell number was significantly lower in the middle-aged and older groups compared to the younger group, while the number of T cells, CD4+ T cells, CD8+ T cells, macrophages, lymphocytes, plasma cells, and NK cells did not differ. Meaningfully, we found that the proportion of IL-10 high expression and TGF-β1 positive in the older group was significantly higher than that in the younger group. TNF-α, CD66b, IFN-γ, and IL-6 expressions were not different among the three groups. In conclusion, there are some differences in imaging, pathological, and immune features of spinal tuberculosis in different age groups. The high expression of IL-10 and TGF-β1 in older patients may weaken their anti-tuberculosis immunity and treatment effectiveness.

A high proportion of caseous necrosis, abscess, and granulation tissue formation in spinal tuberculosis

The special blood circulation, anatomy, and tissue structure of the spine may lead to significant differences in pathological features and drug resistance between spinal tuberculosis and pulmonary tuberculosis. Here, we collected 168 spinal tuberculosis cases and 207 pulmonary tuberculosis cases, and compared their clinical and pathological features as well as drug resistance. From the anatomical location, the highest incidence was of lumbar tuberculosis, followed by thoracic tuberculosis. PET-CT scans showed increased FDG uptake in the diseased vertebrae, discernible peripheral soft tissue shadow, visible internal capsular shadow, and an abnormal increase in FDG uptake. MRI showed infectious lesions in the diseased vertebral body, formation of paravertebral and bilateral psoas muscle abscess, and edema of surrounding soft tissues. As with control tuberculosis, the typical pathological features of spinal tuberculosis were chronic granulomatous inflammation with caseous necrosis. The incidence of granulomas was not statistically different between the groups. However, the proportions of caseous necrosis, acute inflammation, abscess, exudation, and granulation tissue formation in the spinal tuberculosis group were all significantly increased relative to the control tuberculosis group. Compared to the control tuberculosis group, the incidences of resistance to rifampicin (RFP) + isoniazid (INH) + streptomycin (STR) and INH + ethambutol (EMB) were lower in the spinal tuberculosis group, while the incidences of resistance to RFP + INH + EMB and RFP + EMB were higher. Moreover, we also found some differences in drug-resistance gene mutations. In conclusion, there are noticeable differences between spinal Mycobacterium tuberculosis and pulmonary tuberculosis in pathological characteristics, drug resistance, and drug resistance gene mutations.

Intraspinal and Intracranial Neurotuberculosis, Clinical and Imaging Characteristics and Outcomes in Hospitalized Patients: A Cohort Study (2000-2022)

Neurotuberculosis (neuroTB) is a devastating disease, and is difficult to diagnose. The aim of this study was to analyze the clinical and imaging characteristics, and outcomes of a retrospective cohort (2000-2022) of hospitalized patients diagnosed with intraspinal and intracranial neuroTB. This work was designed through clinical, laboratory and imaging findings. Variables included: demographic data, history of tuberculosis, neurological complications, comorbidities and outcomes. Morbi-mortality risk factors were identified by univariate analysis. The cohort included: 103 patients with intraspinal and 82 with intracranial neuroTB. During the study period, in-hospital mortality of 3% for intraspinal and 29.6% for intracranial neuroTB was estimated. Motor deficit was found in all patients with intraspinal neuroTB. Risk factors for the unfavorable outcome of patients with intraspinal neuroTB were: age ≥ 40 years, diabetes mellitus (DM), diagnostic delay, kyphosis and spondylodiscitis ≥ 3 levels of involvement. Among the patients with intracranial neuroTB, 79/82 (96.3%) had meningitis and 22 patients had HIV infection (10 of them died). Risk factors for mortality from intracranial neuroTB were: HIV infection, hydrocephalus, stroke, lymphopenia and disseminated and gastrointestinal TB. Patients with intraspinal neuroTB had a significant number of destroyed vertebrae that determined their neurological deficit status. The mortality burden in intracranial neuroTB was conditioned by HIV infection and renal transplantation patients.

Diagnosis and Treatment of Skipped Multifocal Spinal Tuberculosis Lesions

Spinal tuberculosis, also known as Pott's disease or tuberculous spondylitis, is usually secondary to primary infection in the lungs or other systems, and in most instances, is thought to be transmitted via blood. Typical manifestations of infection include narrowing of the intervertebral disc by erosion and bone destruction of adjacent vertebrae. Atypical spinal tuberculosis is a specific type of spinal tuberculosis. It mainly consists of single vertebral lesions, single posterior structure lesions, multiple vertebral lesions, and intra-spinal lesions. Skipped multifocal spinal tuberculosis is one of these types and is characterized by two or more vertebral lesions without the involvement of the adjoining intervertebral discs, regardless of their location. To date, only a few cases have been reported. Upon clinical admission, it can be treated conservatively or surgically, depending on the patient's symptoms. In addition, gene or biological therapies are being investigated. However, because of the exceptional imaging findings and insidious symptoms, it is often misdiagnosed as a neoplastic lesion, osteoporotic fracture, or other infectious spondylitis, increasing the risk of neurological deficit and kyphotic deformity, and delaying the optimal treatment window. In this study, we review the diagnosis and treatment strategies for skipped multifocal spinal tuberculosis lesions and enumerate the common differential diagnoses, to provide reference and guidance for clinical treatment and diagnosis direction.

Pathogenesis, Diagnostic Challenges, and Risk Factors of Pott's Disease

Tuberculosis (TB) prevalence is increasing in developed nations and continuing to cause significant mortality in low- and middle-income countries. As a result of the uptick in cases, there also exists an increased prevalence of extrapulmonary TB. TB is caused by Mycobacterium tuberculosis (M. tb). When M. tb disseminates to the vertebral column, it is called Pott's disease or spinal TB. The frequency, symptoms, and severity of the disease range by the location of the spine and the region of the affected vertebrae. While the current literature shows that timely diagnosis is crucial to reduce the morbidity and mortality from Pott's disease, there is a lack of specific clinical diagnostic criteria for Pott's disease, and the symptoms may be very non-specific. Studies have shown that novel molecular diagnostic methods are effective and timely choices. Research has implicated the risk factors for the susceptibility and severity of Pott's disease, such as HIV and immunosuppression, poverty, and malnutrition. Based on the current literature available, our group aims to summarize the pathogenesis, clinical features, diagnostic challenges, as well as the known risk factors for Pott's disease within this literature review.