Espondilodiscitis tuberculosa con tumoración lumbar. Tuberculous spondylodiskitis with lumbar tumor. María Cristina López-Sáncheza, Gabriela Calvo Arrojoa. Download PDF. 1 / 2 Pages. Previous article. Go back to website. Next article. Download Citation on ResearchGate | On Feb 1, , Diego Piombino and others published Espondilodiscitis tuberculosa }.
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It is the most common granulomatous disease of the spine, which is characterized by being chronic and slowly progressive, to its confirmation Mycobacterium tuberculosis isolation or identification of granulomas in a sample obtained from the injured vertebrae is needed 23.
Imaging studies are important for diseases detection, mainly the computed axial tomography CT and magnetic resonance imaging MRI which since have made it possible to detect the disease at a predestructive phase and at rare sites of presentation 12. Treatment involves the use of antituberculosis drugs for at least 6 months, and surgery was reserved for cases with progressive deformity or neurological deficit in which medical treatment is not effective, which represents one-third of patients 134.
In the search made in PubMed database there were scarce cases with the same characteristics 56. In this report we represent two cases of tuberculous spondylodiscitis. He started symptoms 2 months before the admission at the clinics with pleuritic pain in the posterior thorax, which was intensified with deep breathing, partially decreasing with the administration of NSAIDs acetaminifen and diclofenacadding paresthesia and dysesthesia in the left lower limb.
Subsequently he presented morning fever quantified up to In the physical examination, decreased muscle strength and tendon reflexes of lower limbs, and sensory level in T6 dermatome were found. Chest X-ray result within normal parameters. CT of chest was performed, in which an image hypodense paravertebral between T2—T5 was observed, as well as a destruction of the vertebral bodies of T5 and T6 Figure 1.
Was requested thoracic spine MRI, finding mediastinal tumor involving vertebral bodies T4—T5, with spinal cord compression, in T2 an isointense, paravertebral and bilateral image was observed at T2—T5 level, suggestive of abscess, as well as fracture and collapse of the vertebral body of T5 Figure 1.
Biopsy was performed reporting chronic granulomatous inflammatory lesions with multinucleated giant cells with caseous necrosis without cellular atypia. Ziehl-Neelsen stain was made finding scarce acid-fast bacilli compatible with Mycobacterium tuberculosis.
It was valued by the spinal surgery department that suggested conservative management with permanent Jewett corset till control infection.
Management with Dotbal rifampin, isoniazid, pyrazinamide, ethambutoltwo tablets every 12 hours began, completing intensive and supportive phase. The treatment was successful, currently he presents results of the polymerase chain reaction PCR for Mycobacterium tuberculosis negative and sensory and motor recovery of the limbs, normal tendon reflexes, he performs physical effort without complications, without the presence of chest pain and also he has remained afebrile.
Magnetic resonance imaging MRI and tomography in which the vertebral body of T5 and the presence of paravertebral abscess can be observed. A MRI coronal T2 of backbone, bilateral paravertebral isointense image is observed between T2—T5; B MRI sagittal T2 of backbone, isointense image between T2—T5 is observed with fracture and collapse of the vertebral body of T5; C axial tomography of the chest with bone window in which a destruction of the vertebral body of the T6 and hypodense paravertebral image is observed; D axial tomography of the chest with bone window in which destruction of the vertebral body of T5 is observed, with involvement of the spinal canal and hypodense paravertebral image.
One male patient of 21 years old with a history of alcohol since 15 years old to the present, once a week. He began his current condition 3 months before admission with right hip pain of moderate intensity, with limitation of external rotation, which decreased the administration of analgesics.
Showed loss of 15 kg of weight in 6 weeks, then subsequently holocraneal headache not pulsatile, intermittent, which partially decreased due the use of NSAIDs diclofenacadded to the condition, tonic-clonic movements in the left side of the body, due this he was taken to hospitalization. At admission, the patient was conscious, oriented, referring the presence of holocraneal headache, no data targeting. TAC skull was done, reporting right parasagittal lesion with significant perilesional edema and reinforcement ring, subfalcial hernia and displacement of the midline Figure 2.
Espondilodiscitis tuberculosa con tumoración lumbar
He began antibiotic treatment and due not present clinical improvement was evaluated by neurosurgery, who decided abscess drainage. Studies of the sample were conducted, reported negative cultures, Gram stain negative, negative ink, Ziehl-Neelsen stain was made finding scarce acid-fast bacilli compatible with Mycobacterium tuberculosis. Chest radiography was performed, with results within normal parameters. Abscess drainage was performed with Ziehl-Neelsen stain, where acid-fast bacilli were compatibles with Mycobacterium tuberculosis were observed, confirming the diagnosis with culture.
Ziehl-Neelsen stain was requested in urine, resulting positive.
Management with Dotbal was initiated rifampin, isoniazid, pyrazinamide, ethambutol for 12 months due extrapulmonary affectation, which ended without sequelae or complications involvement. Based control PCR for Mycobacterium tuberculosis, gave a negative result. After the successful treatment, the patient has no hip pain or mobility limitation, no headache or hypertensive data skull.
Tomography of the skull in which the presence of rounded image with ring enhancement and presence of perilesional edema is observed.
A Skull tomography esspondilodiscitis axial section, in which hypodense image is observed with jagged edges at right parietal lobe level; B skull tomography with contrast in coronal section, in which the presence of a hypodense image emphasizing in ring at right parietal lobe, with subfalcial hernia and compression of right lateral ventricle is observed; C skull tomography with contrast in sagittal section, esponrilodiscitis the presence of a hypodense image emphasizing in ring at right parietal lobe, surrounded by a hypodense image, suggestive edema is observed; D skull tomography with contrast in axial section, where the presence of a hypodense image emphasizing in ring at right parietal lobe level, with midline shift to the left is observed.
Magnetic resonance imaging MRI of lumbosacral column where a collection is observed at S1—S3 level and in right lumbosacral joint. A MRI sagittal T1 with gadolinium lumbosacral spine, hypointense image is observed at the level of S1—S3, suggestive of collection; B MRI sagittal T2 with gadolinium lumbosacral spine, hyperintense image is observed at the level of S1—S3, suggestive of collection which grows to the intra-spinal space; C MRI axial section T2 with gadolinium, where hyperintense image is observed at the level of right sacroiliac joint, suggestive of collection; D MRI coronal T2 with gadolinium lumbosacral spine, where hyperintense image is observed at the level of right sacroiliac joint.
Since the advent of HIV, have emerged opportunistic diseases, including tuberculosis, nevertheless extrapulmonary manifestations, such as tuberculous spondylodiscitis, have increased their frequency 7 – 9.
The clinical presentation is associated with systemic disease, as with local injury. Neurological symptoms are second in frequency, as a weakness, paresthesias and paraplegia. Patients often have a chronic course with weight loss in half the cases, the presence of fever, malaise, and night sweats is also common in a third of patients 12 It is common the presence of comorbidities in these patients, especially those who have a decreased immune response cell type.
Increased risk has been observed in patients with diabetes mellitus, HIV infection, tubercilosa or liver failure, obstructive pulmonary disease, chronic corticosteroid use, alcohol consumption and use of immunosuppressive transplanted 2 In the case of our two patients, one of them had a history of chronic alcoholism. Similarly, tuverculosa may have tuberculosis infection in other locations, mainly in the lungs, followed by nodal level, but may also have renal and hepatic affectation 211 Our patients had no pulmonary tuberculosis, however one of them presented brain abscess secondary to Mycobacterium tuberculosis, which is rare and this combination has tunerculosa been reported in the literature.
Locally they can present paraspinal abscess, epidural or paraspinal psoas 2 The diagnosis is usually delayed from 2 months to 2 years, this due to the insidiousness of symptoms as the difficulty of recognizing the spinal injury.
Imaging studies are of great importance for the diagnosis, such as plain radiographs in which can be observe the processes of the vertebrae and the loss of its anatomy, the first radiographic sign espondilodicsitis osteoporosis of the body affected, followed by osteolysis which can progress to spondylodiscitis 1113 ; the axial CT scan allows us to observe the exact extent of bone lesion, lesions within the vertebral body and the presence of invasion of the spinal canal, can be used for diagnosis and monitoring of disease 11 – In the MRI can be observed osteolytic lesions, disc space narrowing, loss of vertebral body height, erosions in the endplates, the presence of intra and extravertebral abscesses and compression of the dural sac, preferably being the imaging study in this pathology 11 It is essential to confirm the presence of the agent, for this can be used intradermal reaction Mantoux PPDZiehl-Neelsen stain, PCR genome of the mycobacterium and quantification of interferon gamma released 11 Treatment involves the administration of antifimic drugs for a period of 12 months, being necessary only surgical treatment in a third of patients 134.
The classic findings are infection of the intervertebral disc, destruction of two or more continuous vertebras 5in our first patient, destruction of the fifth and sixth thoracic vertebral body was found, another classic finding is the presence of a paraspinal mass tubervulosa collection 5 as shown in Figure 1.
It is known that atypical presentations are characterized by the absence of lesions to the intervertebral disc 5so we could say that our cases are atypical presentation. This could be tubercullsa the disc is avascular, so that infection is observed belatedly. The MRI is the esspondilodiscitis of choice for the accurate diagnosis of lesions caused by Mycobacterium tuberculosis at the spine level, as was reported in the others similar articles 56likewise can be used in monitoring.
It has high sensitivity in detecting changes at the level of the espondilodiecitis cord and the initial inflammatory changes in the vertebral bodies. Because of this, our patients underwent this study to determine the lesions in the spine level, finding characteristic features as the paravertebral collection, the destruction of the vertebral bodies, however not intervertebral disc injury was found.
The authors have no conflicts of interest to declare. National Center for Biotechnology InformationU. Quant Imaging Med Surg. Author information Article notes Copyright and License information Disclaimer. Hospital Regional de Alta Especialidad Dr. Received Sep 29; Accepted Nov 8.
Copyright Quantitative Imaging in Medicine and Surgery. Open in a separate window. Case 2 One male patient of tuberculsa years old with a history of alcohol since 15 years old to the present, once a week.
Footnotes Conflicts of Interest: Tuberculous spondylodiskitis with lumbar tumor. Reumatol Clin ; 8: Tuberculous spondylodiskitis Pott’s disease: Experience in a general hospital.
Enferm Infecc Microbiol Clin ; Update on the surgical management of Pott’s disease. Orthop Traumatol Surg Res ; Management of Tuberculous Infection of the Spine. Asian Spine J ; Tuberculosis of the spine: CT and MR imaging features. Atypical, multilevel and noncontiguous tuberculous spondylitis that affected the vertebrae of thoracic, lumbar and sacrum: Int J Clin Exp Med ; 8: Automatic screening for tuberculosis in chest radiographs: Quant Imaging Med Surg ; 3: CT findings in splenic tuberculosis.