A Rare Presentation: Pott’s Disease

Posted on August 4, 2013

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I’d like to share with you a very interesting case of spinal tuberculosis, or Pott’s Disease.  It’s a condition we all learn about in medical school, and which many US physicians will never see due to its rarity.  According to the CDC, about 10,500 cases of TB were reported in the US in 2011, and Pott’s Disease, although still the most common manifestation of musculoskeletal TB (comprising 40-50% of cases), occurs in only 1-2% of total cases.  That means for the same year, there should only have been between 100-200 cases.

I was going to turn this into a medical challenge, but I decided instead to share the impressive imaging right off the bat.

A young foreign-born patient presented with sub-acute back pain and the following lateral chest x-ray:

Can you spot the abnormality?

Can you spot the abnormality?

There is a pathologic fracture of the T8 vertebra and resultant kyphotic deformity from the collapse of the anterior portion of the bone.

T7 and T9 vertebrae (outlined in green), with collapsed T8 (outlined in red).

T7 and T9 vertebrae (outlined in green), with collapsed T8 (outlined in red).

Computed tomography and MRI imaging was obtained given the patient’s recent return from a TB-endemic area and high clinical suspicion.

Sagittal CT imaging demonstrating abscess formation (green arrow) with collapsed vertebra (red arrow) and obvious involvement of a nearby vertebral body (yellow arrow).

Sagittal CT imaging demonstrating abscess formation (green arrow) with collapsed vertebra (red arrow) and obvious involvement of a nearby vertebral body (yellow arrow).

For comparison, a representative slice of uninvolved vertebra (note the normal enhancement of the ring of spinal fluid surrounding the spinal cord).

For comparison, a representative slice of uninvolved vertebra (note the normal enhancement of the ring of spinal fluid surrounding the spinal cord).

Abscess surrounding the involved vertebra (green line) with impingement of the spinal canal (red arrow).

Abscess surrounding the involved vertebra (green line) with impingement of the spinal canal (red arrow).

Obliteration of the vertebral body, with abscess (green line) and spinal cord impingement (red arrows)

Obliteration of the vertebral body, with abscess (green line) and spinal cord impingement (red arrows)

Abscess (green arrow) demonstrated in sagittal MRI imaging, with multi-level involvement of the spine (red arrows).

Abscess (green arrow) demonstrated in sagittal MRI imaging, with multi-level involvement of the spine (red arrows), and impingement of the cord (yellow arrow).

 

Obliteration of the vertebra

Abscess & kyphotic deformity of the spine (red arrow).  Again demonstrated is impingement on the cord (yellow arrow).

Amazingly, the patient had no neurologic deficits on presentation, and complained only of mild-moderate back pain exacerbated by movement.  In fact, they delayed coming to the hospital for 1-2 days because transportation was not readily available.

Emergent CT-guided biopsy was performed, and the infectious disease, cardiothoracic surgery, & neurosurgery services were consulted.  The patient underwent surgical debridement to relieve the cord impingement, and received an implant to stabilize the spine.  A post-surgical chest x-ray is shown below.

Upright chest x-ray demonstrating residual apical pneumothorax (blue arrow), chest tube (yellow arrow), staples (red arrow), and implanted hardware (green arrow).

Upright chest x-ray demonstrating residual apical pneumothorax (blue arrow), chest tube (yellow arrow), staples (red arrow), and implanted hardware (green arrow).

Bronchial washings and acid-fast bacillus staining of the sputum revealed no evidence of active pulmonary tuberculosis.  PCR analysis of the abscess contents confirmed the diagnosis. The patient tolerated the surgery well, and is undergoing rehabilitation while undergoing treatment with a multi-drug regimen.

 

 

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