An atypical presentation of tuberculosis of the spine

Spinal Tuberculosis Mimicking Failed Back Surgery

Patient: Female, 59

Final Diagnosis: Spinal tuberculosis

Symptoms: Back pain • tiredness • night sweats

Medication: —

Clinical Procedure: Surgery and medical treatment

Specialty: Neurosurgery

Spinal tuberculosis: Our experience and a review of imaging methods

We share our experience of 2000 spinal tuberculosis (TB) cases, including both typical and atypical presentations. The aim of the study is to estimate the incidence and types of spinal TB referred to our department for diagnosis. 2000 patients were selected by convenience sampling from January 2006 to September 2010. Study design was descriptive and among 2000 mostly unknown cases without evidence of symptoms of systemic TB (1080 males and 920 females). MRI without and with IV contrast, CECT with MPR, and in some cases not fit for MRI, CT myelography, were performed. Out of 2000 cases of tuberculous spine, 1080 (54%) were male and 920 (46%) were female. Their age ranged from 8-60 years. About 90% of patients were below the age of 40 years. Peak age among the males and females was 20-29 years and 14-35 years, respectively. The most common site of involvement was dorsal spine (45%) followed by lumbo-sacral spine (33%), cervical spine (10%) and at multiple levels (12%). Biopsies were done in 240 (12%) cases. Spinal TB should always be suspected when radiographs demonstrate a destructive spinal process. Awareness and prompt management of TB spine will help in reducing the continuing morbidity of this disease.

Spinal Tuberculosis Presenting as Abdominal Pain: Rare Presentation of a Common Disease

A 25-year-old male presented with complaints of abdominal pain for the past two months. He was prescribed Buscopan and omeprazole by a general surgeon. It was only when patient started complaining of backache that he was referred to an orthopedic surgeon. On examination of spine, there was tenderness at the upper dorsal spine. A diagnosis of Pott's disease affecting the upper dorsal spine was made. Magnetic resonance imaging (MRI) confirmed the vertebral changes and showed subligamentous spread of paravertebral masses from D2 to D7. This case illustrates the unusual form in which spine tuberculosis can present. High index of suspicion is necessary for early diagnosis and prompt management. General surgeons should be aware of this atypical presentation of Pott's disease.

Single vertebra tuberculosis presenting with solitary localized osteolytic lesion in young adult lumbar spines

OBJECTIVE

To describe the clinical and imaging findings in young adults with single vertebra tuberculosis presenting with solitary osteolytic lesions.

METHODS

Six patients with proven tuberculosis of a single vertebra of the lumbar spine presenting with solitary osteolytic lesion were retrospectively evaluated. There were four male and two female patients with a mean age of 27.6 years (range, 22-38 years). The clinical and imaging features (plain radiographs, CT and MRI) were studied in all six patients.

RESULTS

Involvement occurred from L1 to L5 vertebral levels. The patients presented with local back pain and tenderness but without any obvious deformity of spine or cold abscess. In each case, imaging demonstrated a well-defined, solitary, lytic lesion of average diameter 1.6 cm with thin sclerotic margins within a vertebral body. There were no fragments within the lesions and no paravertebral soft tissue extension around the affected vertebral bodies. The tuberculous eitology was confirmed by CT-guided biopsy in two patients and by curettage of the lesion in four.

CONCLUSION

Tuberculosis affecting a single vertebral body presenting with a localized solitary osteolytic lesion is an unusual form of single vertebra tuberculosis. MRI combined with CT scan of the vertebral body can be very helpful for precisely defining the location of the lesion and extent of osseous destruction. Such small, solitary, osteolytic lesions are often confused with other single vertebra diseases that can have similar appearances on imaging.

Tuberculosis of the lower lumbar spine with an atypical radiological presentation - a case mimicking a malignancy -

A 65-year-old woman was treated for an atypical radiological presentation of spinal tuberculosis. Compared with previously reported cases, the following two different radiographic features were found. 1) Although there was multiple and skipped involvement of the vertebral body, the intervertebral disc was relatively preserved. 2) The presence of an epidural granuloma indicated an epidural extension of the lesion of the adjacent vertebral body. These findings strongly mimicked bone marrow infiltrative disease such as a malignancy. Tuberculosis was confirmed through an open biopsy and the patient was treated successfully with antitubercular chemotherapy. This case highlights the importance of being aware that spinal tuberculosis has many different radiographic features and can mimic a spinal malignancy.

Spinal tuberculosis: overlooked?

OBJECTIVE

The aim of the present study was to ascertain the degree of occurrence of tuberculous infection in patients presenting with low back pain (LBP).

METHODS

Forty consecutive patients seeking primary medical attention for the main symptom of LBP and presenting to the Rheumatology Outpatient Clinic of our institution from January 2004 to June 2005, were recruited in this cohort study. All patients were thoroughly interrogated (occupational, trauma, infection, diabetes mellitus and medication history), subjected to a rigorous clinical examination and a battery of investigations

RESULTS

Twelve of the 40 patients (33%) proved to have spinal TB as the cause of backache. Eight of these patients were above the age of 65. Five of the 12 patients with spinal TB also had concomitant osteoarthritic changes of the spine and two patients had concomitant disc prolapse. Eleven of the 12 patients with spinal TB had a completely normal chest X-ray and in 10 of these patients the plain X-ray of the lumbosacral region failed to show any significant lesion. In all 12 patients, sputum analysis failed to reveal acid-fast bacilli.

CONCLUSIONS

The findings of this study indicate that TB is a common cause of LBP that is liable to be overlooked in the differential diagnosis of LBP. Furthermore, evidence of concurrent active intrathoracic TB may be lacking and consequently a high level of suspicion is required. The need for prompt diagnosis and treatment of skeletal TB is of utmost importance to prevent serious bone and joint destruction and severe neurological sequelae. A reliable imaging modality for diagnosing spinal TB seems to be magnetic resonance imaging.

Sacral tuberculosis: a case report and review of the literature

BACKGROUND

We present a patient with a heterogeneously enhancing lesion within the body of the sacrum and the sacral canal. Sacral tuberculosis (TB) was suspected because of a history of familial exposure. Few cases isolated to the sacrum have been reported in the literature. The characteristic histopathologic and magnetic resonance imaging (MRI) findings are also presented.

CASE DESCRIPTION

A 31-year-old African-American male presented with an 8-month history of lower back pain radiating into his legs as well as numbness and weakness of the right foot. His history revealed PPD conversion following an exposure to active pulmonary TB 3 years prior for which he received 6 months of isoniazid prophylaxis. An MRI scan revealed a large heterogeneously enhancing lesion involving the sacrum with extension into the sacral canal. The patient underwent computed tomography (CT)- guided needle biopsy of the sacral lesion. Cytopathologic examination revealed caseating granulomas. Acid-fast bacilli cultures were positive for Mycobacterium tuberculosis. He was placed on a 6-month course of isoniazid, rifampin, pyrazinamide, and ethambutol. At 3-month follow-up, his examination and symptoms had improved.

CONCLUSIONS

Sacral TB is an extremely rare cause of lower back pain with radiation into the lower extremities. TB should always be considered in the differential diagnosis of isolated sacral masses, especially in light of today's increasing multidrug resistance and immunosuppressed population.

Atypical spinal tuberculosis

Typical spinal tuberculosis is readily diagnosed and treated. Certain atypical clinical and radiologic presentations of spinal tuberculosis are described. Failure to recognize these presentations may lead to delay in diagnosis and initiation of treatment. In some atypical forms of the disease, this may have disastrous consequences. The current authors present a new classification for atypical spinal tuberculosis and describe the various presentations. The role of advanced imaging studies such as computed tomography scanning and magnetic resonance imaging and imaging-guided aspiration cytology is discussed.