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A young patient with back pain

Published:October 05, 2017DOI:https://doi.org/10.1016/j.ejim.2017.10.002
      A 25 year-old Nigerian woman, was admitted because of a 7 month lasting lumbar pain irradiated to the abdomen. She's been in Italy for 5 months. Her medical history was mute except for a malaria infection during childhood. No fever or systemic symptoms were referred, physical examination was unremarkable except for a right convex scoliosis. An abdominal ultrasound revealed a mass below the lower pole of the left kidney. An abdominal CT scan showed collapse of T12 over L1 with lytic lesions of the vertebral bodies (Fig. 1, arrow) and abscesses inside the left psoas muscle (Fig. 1, asterisks).

      1. What is the diagnosis?

      Pott's disease

      2. Discussion

      Pott's disease, or tuberculous spondylodiscitis, is a serious clinical condition described for the first time by the English surgeon Percival Pott in 1779[
      • Trecarichi E.M.
      • Di Meco E.
      • Mazzotta V.
      • Fantoni M.
      Tuberculous spondylodiscitis: epidemiology, clinical features, treatment, and outcome.
      ] and is characterized by an extrapulmonary localization of tuberculosis to the spine. Most patients show no fever or high inflammatory indexes. The most frequent complaints are back pain, lower limbs weakness and general malaise. Due to the lack of specific symptoms, diagnosis is often delayed, usually from 2 to 24 months[
      • Colmenero J.D.
      • Ruiz-Mesa J.D.
      • Sanjuan-Jimenez R.
      • Sobrino B.
      • Morata P.
      Establishing the diagnosis of tuberculous vertebral osteomyelitis.
      ]. As tuberculosis is an opportunistic infection, immunocompromised patients are particular susceptible to this disease and HIV represents the strongest risk factor[
      • Havlir D.V.
      • Getahun H.
      • Sanne I.
      • Nunn P.
      Opportunities and challenges for HIV care in overlapping HIV and TB epidemics.
      ]. Diagnosis relies on the demonstration of granulomatous lesions and can be achieved by means of a vertebral biopsy. However, it could be arduous to find vertebral lesions as healthy bone coexists alongside granulomatous lesions. In this respect, a muscle biopsy with the demonstration of alcohol-acid resistant bacteria in the abscess fluid can prove useful in establishing a definitive diagnosis. Our patient was tested for HIV but resulted negative. We also tested the fluid material from the psoas abscesses and we were able to demonstrate mycobacterial DNA in it. The patient started a four drugs therapy with rifampicin, isoniazid, ethambutol and pyrazinamide for 6 months. Moreover, the patient underwent surgery to stabilize the spine. Now she is in good clinical conditions and doesn't complain about back pain any more.

      References

        • Trecarichi E.M.
        • Di Meco E.
        • Mazzotta V.
        • Fantoni M.
        Tuberculous spondylodiscitis: epidemiology, clinical features, treatment, and outcome.
        Eur Rev Med Pharmacol Sci. 2012; 16: 58-72
        • Colmenero J.D.
        • Ruiz-Mesa J.D.
        • Sanjuan-Jimenez R.
        • Sobrino B.
        • Morata P.
        Establishing the diagnosis of tuberculous vertebral osteomyelitis.
        Eur Spine J. 2013; 22: 579-586
        • Havlir D.V.
        • Getahun H.
        • Sanne I.
        • Nunn P.
        Opportunities and challenges for HIV care in overlapping HIV and TB epidemics.
        JAMA. 2008; 300: 423-430