Spinal Intramedullary Tuberculosis

Disseminated Tuberculosis Revealed by Conus Medullaris Tuberculoma

A 29-year-old man from Comoros presented with rapidly progressive paraplegia and sexual dysfunction. Magnetic resonance imaging (MRI) showed a contrast-enhanced conus medullaris lesion. Differential diagnoses included tumors, abscesses, and inflammatory diseases. Neurosurgery was delayed to complete examinations. Cerebral MRI showed three abscesses. Body computed tomography scan showed supracentimetric polyadenopathies, pulmonary nodules, prostatic lesion, and enhanced seminal vesicle, with hypermetabolism on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose scan. Histology of lymph node biopsy showed granulomatous infiltration without acid-fast bacilli, and positive polymerase chain reaction for Mycobacterium tuberculosis. Lymph node culture was positive after 2 months, urine culture after 3 weeks, but cerebrospinal fluid and sputum cultures were negative. A 1-year antituberculosis therapy was initiated, associated with corticosteroids because the patient developed tuberculosis-immune reconstitution syndrome, revealed by the recurrence of neurological symptoms. After 2 months the patient completely recovered and could run. MRI showed stability of the voluminous tuberculoma with decrease of medullary edema. Avoiding surgery in those cases may prevent iatrogenic neurological deterioration.

Intramedullary Spinal Tuberculoma: An Uncommon Presentation of a Common Disorder

Intramedullary tuberculoma (IMT) is rare and usually indistinguishable from spinal cord tumors. Thus, the diagnosis of an IMT is challenging. Our case deals with an unusual presentation of a 55-year-old Asian man who had presented with lower limb weakness which was found to be caused by the dissemination of tuberculosis (TB) resulting in an IMT, a rare complication of tuberculosis. The patient also had a concurrent incidental hepatitis B infection. The treatment of IMT is anti-tuberculous medication. This case highlights the significance of the prompt diagnosis of an IMT, urgent intervention particularly in developing areas of the world where tuberculosis is still endemic, an increased probability of patients having an IMT, and their diagnoses being missed.

Tubercular longitudinally extensive transverse myelitis (LETM): An enigma for primary care physicians

Albeit, all forms of tuberculosis (TB) are endemic in India, spinal intramedullary TB and tubercular longitudinally extensive transverse myelitis (LETM) is deemed extremely rare. With recent advances in the field of neurology, autoimmune astrocytopathy (neuromyelitis optica spectrum disorders, NMOSD), myelin-oligodendrocyte glycoprotein associated encephalomyelitis (MOG-EM), metabolic myelopathy, connective tissue diseases and viral infections have gained considerable focus in the list of differentials of LETM whereas tubercular association is often forgotten. This report presents a rare case of acute transverse myelopathy which unveiled previously undiagnosed pulmonary tuberculosis in an adult rural Indian male. The patient responded well to anti-tubercular therapy and corticosteroids. Exact pathogenesis of LETM in TB remains elusive. Association of TB with MOG-EM has been one of the recent hot-cakes. However, an ill-defined immune-inflammatory response to the infectious agent is the likely cause of tubercular LETM. Hence, the primary care physicians who are the first medical contacts of acute LETM cases and in most cases due to diagnostic dilemma there is an unavoidable delay in accurate diagnosis and initiation of therapy. Primary care doctors should nurture a high index of suspicion to diagnose this potentially lifetime-debilitating yet absolutely treatable clinical condition i.e. tubercular LETM.

Paraplegia from spinal intramedullary tuberculosis: A case report

BACKGROUND

Tuberculosis (TB) mostly attacks the lungs, and extrapulmonary TB involving the central nervous system is uncommon; among these cases, spinal intramedullary TB is even more rare. The clinical manifestations of spinal intramedullary TB are similar to those of intramedullary spinal cord tumors. Therefore, it is necessary to make a careful differential diagnosis of spinal intramedullary lesions to achieve the appropriate treatment and favorable prognosis. We report a rare case of a young male patient with paraplegia due to spinal intramedullary TB, which is uncommon and regrettable.

CASE SUMMARY

A 23-year-old male presented with fever accompanied by nausea and vomiting lasting for 2 mo and was then diagnosed with tubercular meningitis. After anti-TB treatment, his symptoms were significantly improved. However, 2 mo after the diagnosis of tubercular meningitis, the patient felt numbness below the costal arch level, which lasted for 1 wk, and he paid no attention to this symptom. What followed was paraplegia and urine/fecal incontinence. Magnetic resonance imaging of the thoracic spine showed a ring-enhanced intramedullary cord lesion at T8-T9. Lesion exploration showed enlargement of the spinal cord at T8-T9, and the lesion could be observed by incision. The lesion was adhered to the peripheral tissue and was grayish-white and tough with a poor blood supply and a diameter of approximately 0.8 cm. The lesion was resected completely. The results of pathological examination by both hematoxylin-eosin staining and acid-fast bacilli staining confirmed TB, accompanied by acute and chronic suppurative inflammation and granulation tissue formation. The patient was instructed to continue anti-TB treatment after the operation, but he did not follow the medical advice. Follow-up continued for ten years, the patient had persistent paraplegia, the numbness disappeared and urine/fecal sensation recovered.

CONCLUSION

Although TB is a kind of benign disease, some cases progress rapidly. Moreover, spinal intramedullary TB may seriously endanger quality of life and still needs timely diagnosis and proper treatment.

[Intramedullary Pott's abscess: a case study]

Central Nervous System (CNS) Tuberculosis (TB) is rare. It manifests in many forms, but the association between intramedullary abscess and multifocal Pott's disease is exceptional. We report the case of a 23-year old female patient diagnosed with multifocal Pott's disease at L2-L3 and L4-L5 based on computed tomography (CT) scan of the spine. She received antituberculous treatment. Two months after the beginning of treatment spinal cord compression occurred. Medullary magnetic resonance imaging (MRI) was performed, which showed intramedullary abscess at T4. She underwent surgery with drainage of intramedullary abscess and spinal stabilization. Outcome was favorable, during the 12-month follow-up. The association between intramedullary abscess and multifocal Pott's disease is exceptional. Treatment is based on anti-tuberculous drugs, surgery for spinal decompression and/or spine stabilization if possible.

Spinal Tuberculosis: Clinicoradiological Findings in 274 Patients

Background

Mycobacterium tuberculosis is a major cause of myelopathy and radiculopathy in settings with a high prevalence of tuberculosis/human immunodeficiency virus (HIV) coinfection. However, a paucity of publications exists on the spectrum of neurological and magnetic resonance (MR) imaging findings of spinal tuberculosis in these populations.

Methods

We conducted a retrospective study of adults with spinal tuberculosis at a referral center in South Africa for patients with spinal disease without bony involvement seen at plain film radiography. We report the clinical, laboratory and spinal MR imaging findings, compare HIV-infected and HIV-uninfected patients, and correlate clinical and cerebrospinal fluid findings with those of MR imaging.

Results

Of 274 patients, 209 (76%) were HIV infected and 49 (18%) were HIV uninfected. Radiculomyelitis occurred in 77% (n = 210), and spondylitis in 39% (n = 106). Subdural abscess (n = 42) and intramedullary tuberculoma (n = 33) were common. In 24% of HIV-infected and 14% of HIV-uninfected patients, spinal disease manifested as a paradoxical tuberculosis reaction, frequently following tuberculous meningitis. The triad of neurological deficit, fever, and back pain was similar in patients with spondylitis (24%), epi/subdural abscess without bony disease (14%), meningoradiculitis (17%), and isolated myelitis (17%) .

Conclusions

Radiculomyelitis is a common manifestation of spinal tuberculosis in settings with high tuberculosis/HIV prevalence, often presenting as a paradoxical reaction. We describe a high frequency of rarely reported spinal tuberculosis manifestations, suggesting that these are more common than implied by the literature.

Concomitant mycotic abdominal aortic aneurysm and lumbartuberculous spondylitis with cauda equina syndrome: a rare condition - a case report and literature review

INTRODUCTION

Concomitant mycotic abdominal aortic aneurysm and lumbar tuberculous spondylitis with psoas abscess and cauda equina syndrome is extremely rare. This condition can cause serious life-threatening problems if not diagnosed and treated properly.

CASE PRESENTATION

We report an unusual case of a 79-year-old Thai male, who was diagnosed with concomitant mycotic abdominal aortic aneurysm and lumbar tuberculous spondylitis at the L2-L3 level with left psoas abscess and cauda equina syndrome. The surgical plan was radical surgical debridement via transpsoas approach and the defect was filled with iliac crest strut graft and posterior decompressive laminectomy and fusion with a pedicle screws and rods system. During the operation, an abdominal aortic aneurysm was iatrogenically ruptured and then was emergently treated with endovascular stent graft implantation. Subsequently, hemostasis was achieved and the patient remained hemodynamically stable. A few days later, he underwent posterior decompressive laminectomy L2-L3, fusion and instrumentation with a pedicle screws and rods system at T11-L5. After surgery, the patient recovered well and his motor power improved gradually. He was continually treated with anti-tuberculous chemotherapy for 12 months.

DISCUSSION

Concomitant mycotic aortic aneurysm and lumbar tuberculous spondylitis with psoas abscess and cauda equina syndrome is an extremely rare condition that requires prompt diagnosis and management. Its consequences can lead to serious complications such as permanent neurological damage, paralysis or even death, if left untreated. The aims of the treatment are to eradicate infection, to prevent further neurological compromise, to stabilize the spine and to protect the aortic aneurysm from rupture.