A case report of a young woman with spinal tuberculosis: Pharmacological managements and rehabilitation approach (CARE- compliant) : Medicine: Case Reports and Study Protocols

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Clinical Case Report

A case report of a young woman with spinal tuberculosis: Pharmacological managements and rehabilitation approach (CARE- compliant)

Al-Mahmood, Md. Rashid MBBS, MD*

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Medicine: Case Reports and Study Protocols 3(9):p e0261, September 2022. | DOI: 10.1097/MD9.0000000000000261
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Abstract

1. Introduction

Pott disease or Spinal TB is a very dangerous type of skeletal TB. It can be associated with neurologic deficit due to compression of adjacent neural structures and significant spinal deformity. It is a rare disease. The spinal column is involved in <1% of all cases of tuberculosis (TB). Therefore, early diagnosis, management and complication prevention should be done meticulously.[1]

Pott disease usually presents with chronic back pain which usually involves the lower thoracic and lumbar spine. The infection starts as a discitis and then spreads along the spinal ligaments to involve the adjacent anterior vertebral bodies, causing angulation of the vertebrae may result in kyphosis. Paravertebral and psoas abscess formation is common. CT or MRI is valuable in determining the extent of disease and the amount of cord compression.[2]

Usually there is male predominance. In USA, in a statistic, they found ratio of the spine tb patients are M: F ratio of 4:1.[3]

1. 1. Case history

Our patient, 21 years old, Muslim, married, housewife, normotensive, nondiabetic, nonsmoker, right-handed, hailing from Dhaka, Bangladesh, presented with complaints of upper back pain for 7-months, occasional fever for 5-months, anorexia for 4-months. This chronic “dull aching” upper back pain is mild to moderate in nature, aggravated on both rest and movements; specially with bending forward, twisting and relieved partially with analgesics. Pain was associated with morning stiffness, lasting for 30–40 minutes and night pain, causing sleep hindrance. Fever was occasional, low grade, associated with evening rise of temperature and night sweat. Patient also complained about anorexia. On query, she gave history of weight loss, but was not documented. Her bowel bladder habit was normal. She had occasional lightheadedness, palpitation and easy fatiguability.

There was no history of cough, chest pain, chest tightness, blood mixed sputum, breathlessness, abnormal sensation to limbs, limb weakness, walking difficulty, low back pain, other bone or joint pain, red eye, burning micturition, abdominal pain, any abnormal mass growth,skin lesion, recent trauma, malar rash, photosensitivity, oral ulcer, contact with known TB patient, blood loss, heat or cold intolerance, recent traveling to any specific fever endemic zone and promiscuity.

For these she visited to several physicians, took drug management leading to partial response. She was admitted to a tertiary hospital for better management.

She was blessed with 1 baby girl of 2.5 years & having normal menstrual history.

She was immunized as per schedule, with Bacillus Calmette-Guerin (BCG) vaccine mark presence over left arm. She had no relevant past medical, hospitalization or transfusion history.

She was living in a joint family, with husbands and in laws; all were enjoying good health and so did her parents & siblings.

She was free from tobacco or alcohol habits. She had no known drug reaction.

1. 2. Clinical findings

On general physical examination, she was anemic, pulse 88/min, BP 120/80, BMI (body mass index) 27, temperature 98°F.

Musculoskeletal system examination revealed mild thoracic kyphosis, grade 2 tender T4-T5 area, palpable gibbus on previously mentioned area, pain VAS (visual analogue scale) -6/10, active forward bending and rotation were painful but not restricted, cervical spine movement was normal in all direction. No other joint or musculoskeletal problem were found.

Nervous system examination revealed Intact higher psychic function; normal bulk, tone, power of both lower limbs, intact all reflexes, bilaterally flexor planter response; intact all modalities of sensation (pain, touch, temperature, vibration, position) on both side of body.

Respiratory system, cardiovascular system, gastrointestinal system examination revealed no abnormality.

1. 3. Investigation

Patient came with some previous lab findings of July 9, 2020. We repeated some, and added some more investigations on basis of previous findings. Table 1 expressed higher ESR, CRP with Hemoglobin E trait. Figure 1 was her Xray chest.

Table 1 - Investigation findings.
09-07-2020 4-10-2020
Hemoglobin (g/dl) 9.7 10
ESR (at 1 hour) 57 120
Rbc count (million/mm3) 5.27 5.3
Wbc count (/mm3) 6900 8500
Mcv (fl) 59 56
Mch (pg) 18 18.6
Peripheral blood film- Microcytic hypochromic anemia
Serum iron (micro gm/l) 20
Ferritin 41.8
TIBC (micro gm/l) 418
SGPT (u/l) 27
CRP (mg/l) 22
S.Creatinine (mg/dl) 1.09
RBS (mmol/l) 5.6
USG of whole abdomen normal
TSH 2.12
Hb electrophoresis Hb E trait
CRP = C reactive protein, ESR = erythrocyte sedimentation rate, MCH = mean corpuscular hemoglobin, MCV = mean corpuscular volume, RBC = red blood cell, RBS = random blood sugar, TIBC = total iron binding capacity, TSH = thyroid stimulating hormone, USG = ultrasonogram, WBC = white blood cell.

F1
Figure 1.:
Xray chest P/A view. There was suspicious narrowing of D4–5 area. No abnormality was noted in lung field.

MRI of dorsal spine with screening of whole spine with contrast report summary was–“Kyphosis noted at D4-D5 level, suggestive of Pott disease involving D4-D5 vertebrae; with pre, para vertebral (left > right) and anterior epidural abcess. Significant spinal canal stenosis, Cord and corresponding traversing root compression was present. On post contrast lesion showed heterogenous and marginal enhancement” (Figs. 2, 3).

F2
Figure 2.:
MRI screening of whole spine, T2 weighted sagittal view. Body and corresponding disc height reduced at D4-D5 region, hyperintense signal change was noted, there was suggestive of cord compression, marked angulation and increased thoracic kyphosis was visualized.
F3
Figure 3.:
MRI of Dorsal spine, T1 weighted sagittal view. Blue arrowing showing site of lesion.

Tuberculin test (MT) -20 mm (positive)

CT-guided FNAC from Vertebral body D4-D5 found Granulomatous inflammation, (no malignant cell seen) (Fig. 4).

F4
Figure 4.:
Ct guided FNAC from the lesion. Needle was visualized to take sample from site of lesion.

1. 4. Clinical diagnosis

Tubercular spondylodiscitis (Pott disease) at D4-D5 with Haemoglobin E trait.

1. 5. Management—

1. 5. 1. Goal setting.

  • ✓ Multidisciplinary team formation
  • ✓ Educate the patient & caregiver about nature, course, prognosis of disease
  • ✓ To treat primary disease
  • ✓ Prevention of secondary complications
  • ✓ Follow up planning

1. 5. 2. Drug management.

AntiTB category-1 regiment was given initially, she received Isoniazid (5 mg/kg/day), Rifampicin (10 mg/kg/day), Ethambutol (15 mg/kg/day), and Pyrazinamide (20 mg/kg/day) for at least 2 months (initial phase). This was followed by a 2-drug antiTB treatment (Rifampicin and Isoniazid) for 4 months (continuation phase). As symptoms and alteration of biochemical parameters were persistent so additional 6-month 2 two-drug antiTB treatment was continued (total 12 months).

Also pyridoxin, iron supplement, calcium, cholecalciferol, and NSAID were given. No drug-related adverse outcome was found.

1. 5. 3. Rehabilitation strategies.

Pott disease is one of the causes of nontraumatic spinal cord injury. This chronic disease needs long-term management as it may cause several complications. On other hand, our patient was a young woman of reproductive age. Considering all these situations, a rehabilitation program was customized as per potentials and problems of our patient.

1.5.3.1. Orthosis. Custom-made Taylor brace was prescribed (to restrict spine movements) (Fig. 5).

Advised to use during sitting and standing positions.

F5
Figure 5.:
Customized orthosis (Taylor brace). Parts of the brace were specified on left and middle image. It was consisted of 2 posterior uprights attached inferiorly to a pelvic band and superiorly to interscapular band. There was a corset for abdominal compression. Modification was done with an extra chest band with strap. On most right sided image, patient was wearing the brace.
1.5.3.2. ADL corrections. We suggested our patient to correct &/or modify some posture, position, and strategies necessary to protect spine. These were mentioned for both initial recovery period (while taking the antiTB drugs) and after recovery period (Table 2).
1.5.3.3. Exercise. (To prevent secondary musculoskeletal complications)
  • ▸ AROM (active range of motion) of all 4 limbs
  • ▸ Ball squeezing exercise
  • ▸ Isometric quadriceps and isometric back strengthening exercise
  • ▸ Shoulder shrugging
Table 2 - Adl (activities of daily living) correction strategies.
Initial period of recovery
•Complete bed rest during initial phase of antiTB drugs
•Change posture 2 hourly
•Avoid excess bending and twisting activities
•While turning–turn whole body
•Avoid carry heavy weight, backpacks
•Avoid strenuous spinal exercise
•Eating—with proper back support and utensil should be such height that need minimum bending to bring food to mouth
•Bathing—with shower (avoid pouring water from bucket)
•Use high commode
•Proper back protection techniques to getting up and down from bed
After initial recovery (after completing drug treatment)
•Avoid prolong standing, prolong sitting
•Avoid slouch position while sitting
•Proper chair with back support
•Follow proper weight lifting technique
•Don’t lift anything with sitting and bending laterally
•Avoid carry heavy weight, backpacks

All exercises were advised for 10 repetition 2–3 times daily or as tolerated.

1.5.3.4. Modalities. Deep heating modalities, massage or traction was not advised to use around affected area.

Warm moist compression &/or Transcutaneous electrical neuromuscular stimulation (TENS) were options for physical and electrotherapy. Patient used them occasionally.

1.5.3.5. Occupational therapy. Disease was hopefully recoverable, so only temporary modifications were suggested. These modifications were done keeping both short- and long-term plans.
  • o Home modification—well illuminated with adequate availability of sunlight entry (as patient was on complete bed rest for some period)
  • o Avoid obstacles on walking pathway that may risk in falling
  • o Bed modification- Non sagging mattress
  • o Toilet modification- avoid slippery floor, use of nonslippery mattress.
  • o Bathing chair.
  • o High commode with hand shower at sitting level.
  • o Kitchen utensils–within easily reach level
  • o Eating—with proper back support and utensil should be such height that need minimum bending to bring food to mouth.
  • o Long handle equipment for stocking, combing hair, cloth picking.
  • o Ergonomically fit reading table for study purpose.

1. 7. Advice

1. 7. 1. General.

  • ▪ High protein diet
  • ▪ Complete bed rest at least 2 months
  • ▪ Check pressure points to see any early skin color change.
  • ▪ While turning in bed, turn as log rolling (to prevent thoracic rotation movement)
  • ▪ Continue exercise as per advice to prevent muscle wasting & excess weight gain.

1. 7. 2. Obstetric advice.

Pregnancy lead increased thoracic kyphosis, so after complete stable spine pregnancy is preferable. So suggestion was given to delay pregnancy, preferably throughout the management period with addition of 2 years of follow up.

Oral contraceptive pills (OCP) was discouraged to use (rifampicin may induce ocp failure).Barrier or any other method were the options of contraception.

1. 7. 3. Hematological advice for associated HB E trait.

  • o Persistent low hemoglobin may present
  • o Other family member should be screened for Hemoglobin E trait.
  • o Before next pregnancy consult with hematologist also.

1. 7. 4. Covid preventive advice.

Tuberculosis is an immunosuppressive condition, so extra precautions are necessary. And as the patient was suffering in the COVID 19 era, we advised-

  • ▪ To use face mask specially when other persons were in room.
  • ▪ Maintain hand hygiene, avoid touching T zone of face.
  • ▪ Don’t allow much outsiders at room.
  • ▪ Avoid close contact.
  • ▪ Family members should also take all precautions and hygiene before serving.

1. 7. 5. Advice for psychological well being.

Although she was apparently normal in appearance, imaging and lab findings revealed conditions, which need prolonged rest, inactivity and drug intake; with some potential threat of drastic events.

These nearly opposite situations might lead psychological conflict, which may need expert opinion in future. Patient was educated regarding this issue. Also we advised breathing exercise and relaxation techniques obtained from opinions of psychiatrist.

2. Follow up

We had a follow up plan based on a guideline of India[4]

After 1 month and then every 4–6 weekly: Complete blood count with ESR,C reactive protein, liver and renal functions study

Xray chest and X-ray dorsal spine- every 3 monthly.

MRI dorsal spine- in 6th, 9th, at end of 12 month of initial MRI

After drug discontinuation we had plan to follow up clinically, 6 monthly for 2 year

With initial follow up, from hematological, biochemical and radiological reports, we found persistence of raised ESR, CRP. Clinically there was only mild improvement of pain (VAS was 4/10) with persistence of other symptoms. These features were present even after 6 months. With opinions from multiple disciplines including neurosurgery, infectious disease and internal medicine, her drugs were continued for a total period of 12 months. After 12 month there were normal blood parameters and clinically patient was much improved, evident by subsidence of fever, backache (VAS 1/10), anorexia and other constitutional features.

Due to economical restraint and COVID hinderance MRI was done after 10 months of first MRI with evidence of changes of improvement (Fig. 6).

F6
Figure 6.:
Follow up MRI screening of whole spine T2 weighted sagittal view (after 10 months). There was radiological improvement of cord compression and kyphosis.

2. 1. Hopes for our patient

Although the disease had some potentiality to develop miserable complications, till we found hopes for good prognosis for our patient and shared with her to ameliorate disease related anxiety. Some of them were- younger age, good general physical condition, diagnosis and treatment started before neural complications, no marked spine deformity or angulation, and presence of caregivers in family ensuring proper ADL measure and corrections.

3. Discussion

Among extra pulmonary tb, spine tb is a condition which may lead a person with paraparesis or paraplegia and their consequences. Usually, it is more predominant among male. Also, older age, immunosuppressed person have probability to suffer more. Majority time it affect the lower thoracic and upper lumbar region.[5,6] In contrast, our patent was a young healthy female,without any known co morbidity. Nevertheless she received BCG vaccine, had no history of direct contact with known TB patient. More over during the COVID era all were confined at home, so minimum chances to be exposed in front of random TB patients.

Patients with a milder form of the disease with minimal symptoms and without any neurological deficits recover well with conventional medical treatment. The patients with more severe disease of spinal TB in the form of severe disability, gross neurological deficits, spinal deformities, and autonomic involvement needs surgical debridement and fusion procedures in addition to conventional antiTB treatment.[7] Although from imaging cord compression were visualized, but she was clinically stable. So only conservative management were given.

Despite its high frequency of long-term morbidity, there are no straightforward guidelines for the diagnosis and treatment of spinal tuberculosis.[5] The duration (6, 9, 12, or 18 months) and frequency (daily vs alternate-day regimen) of administration of drugs have been controversial.[8] WHO recommends 6 months of multidrug antitubercular therapy, including 2 months of 4- or 5-drug treatment (isoniazid, rifampicin, pyrazinamide, ethambutol, and/ or streptomycin) constituting the initiation“ phase, followed by 4 months of “continuation” phase therapy with a 2-drug regimen including isoniazid and rifampicin.[9] The American Thoracic Spine Society recommends a regimen involving 9 months of treatment with the same drugs (“continuation” phase extending for a period of 7 months). The Canadian Thoracic Society recommends treatment for 9 to 12 months duration.[1]

From some classical text book, we also found difference regarding anti TB drugs duration for spine TB. According to some researcher, 6 months of therapy is appropriate for all patients with new-onset pulmonary TB and most cases of extrapulmonary TB. Also, 12 months of therapy is recommended for meningeal TB, including “involvement” of the spinal cord in cases of spinal TB.[2] Some author suggested a range of 6–12 months of drug treatment.[10] For bone and spine TB, longer initiation phase (5–6) month with continuation phase for 9 month were opined in some renowned orthopedic text books.[11]

Regarding rehabilitation, we had some specific plans for our patient. Complete bed rest is advised in most of case in spine TB with variable duration.[12,13] Those who are diagnosed and treated early are kept in bed only until pain and systemic symptoms subside, and thereafter are allowed restricted activity until the joint changes resolve (usually 6 months to a year).[11] So we addressed the future probable consequence of prolong bed rest and gave plans to avoid such conditions.

Protection of spine and cord was one of the major issues. So our patient was treated with orthosis. A customized Taylor brace was prepared. The thoracic spine can be divided into upper (T1–4), middle (T5–8), and lower (T9–11) segments. Taylor brace is a flexion-extension and partial rotation control orthosis. This brace limits the trunk extension, primarily in the mid-to-lower thoracic and upper lumbar areas with a compensatory increase in motion at the upper thoracic, lower lumbar, and lumbosacral junction.[14] As our patient had D4 and D5 area involved, that is junction of upper and mid thoracic area, so an extra chest band with strap was added to limit flexion-extension in upper thoracic area also.

ADL modifications, living environmental changes and home modification strategies were also suggested. To prevent unwanted musculoskeletal changes judicial therapeutic exercises were prescribed.

Obstetric part was another challenging issue in our patient. Our advice was to delay pregnancy with a view to avoiding unwanted spine conditions. As during pregnancy there are physiological change of spine curves occur, so a healthy spine is always preferable.

Limitation of the case study was, due to economical constraint and pandemic, the follow up was not done adequately as per plan. Although tele communication was present, still it was not substitute of direct examination and investigations. Exercise monitoring, electrotherapy or other rehabilitation strategies were also hampered to some extent.

4. Conclusions

Spine TB can lead to long term co morbidities and cause hindrance in personal, familial and social life. Undoubtedly it is more challenging for women specially during child bearing age. A proper anti TB drug guideline for such extrapulmonary TB is necessary. Well-designed rehabilitation strategies are also necessary to combat the potential adverse consequences. We had an endeavor to collaborate these management options.

Author contributions

Conceptualization,data curation, investigation ,writing original draft, writing review and editing done by Md. Rashid Al Mahmood.

Acknowledgments

We are grateful to professors and residents of Physical medicine and rehabilitation, Bangabandhu Sheikh Mujib Medical University, specially Professor Syed Mozaffer Ahmed, Professor Taslim Uddin, Associate Professer Dr Badrunnesa, residents Dr Ahasanul Haque, Dr K.M Sayeeduzzaman and Dr ATM Reaz Uddin.

We are also thankful to the staff of other departments (Neurosurgery, Radiology, Internal medicine) and allied professionals (physiotherapists, rehab nurse, occupational therapist, psychologist).

References

[1]. Rasouli MR, Mirkoohi M, Vaccaro AR, et al. Spinal tuberculosis: diagnosis and management. Asian Spine J. 2012;6:294–308.
[2]. Reid P, Innes J. Respiratory medicine. In: Ralston SH, Penman ID, Strachan MW, Hobson RP, eds. Davidson’s Principles and Practice of Medicine. 23rd ed. Elsevier Ltd2018:546–628.
[3]. Rezai AR, Lee M, Cooper PR, et al. Modern management of spinal tuberculosis. Neurosurgery. 1995;36:87–97.
[4]. Index TB Guidelines. Department of Medicine, All India Institute of Medical Sciences, New Delhi WHO Collaborating Centre (WHO-CC) for Training and Research in Tuberculosis Centre of Excellence for Extra-Pulmonary Tuberculosis, Ministry of Health and Family Welfare, G. of I; 2016:1–130.
[5]. Garg RK, Somvanshi DS. Spinal tuberculosis: a review. J Spinal Cord Med. 2011;34:440–54.
[6]. Yusuf N, Ali MA, Ahmad Q, et al. Pregnancy in Pott’s disease: a case report and review. Bangladesh J Obstet Gynecol. 2010;25:37–40.
[7]. Bodapati P, Vemula RV, Mohammad A, et al. Outcome and management of spinal tuberculosis according to severity at a tertiary referral center. Asian J Neurosurg. 2017;12:441441.
[8]. Jawahar MS. Current trends in chemotherapy of tuberculosis. Indian J Med Res. 2004;120:398–417.
[9]. Treatment of Tuberculosis: guidelines. 4th ed. Geneva: World Health Organisation2010. WHO/HTM/TB/2009. 420.
[10]. Bryce TN. Spinal cord injury. In: Cifu DX, Kaelin DL, Kowaleske K, et al. eds. Braddom’s Physical Medicine and Rehabilitation. 5th ed. Philadelphia, PA: Elsevier Inc.2016:1095–1135.
[11]. Solomon L, Srinivasan H, Tuli S, et al. Infection. In: Solomon L, Warwick D, Nayagam S. eds. Apley’s System of Orthopaedics and Fractures. 9th ed. London, United Kingdom: Hodder Arnold2010:29–58.
[12]. Tuli SM, Srivastava TP, Varma BP, et al. Tuberculosis of spine. Acta Orthop. 1967;38:445–58.
[13]. Banga RK, Singh J, Dahuja A, et al. Spinal tuberculosis – directly observed treatment and short course or daily anti tubercular therapy – are we over treating? Open Orthop J. 2018;12:380–8.
[14]. Pomerantz F, Durand E. Spinal orthotics. In: R. Frontera W, Delisa JA, Gans BM, Walsh NE, Robinson LR, eds. Delisa’s Physical Medicine and Rehabilitation Principle and Practice. 5th ed. Philadelphia, PA: Lippincot Wiliiams & Wilkins2010:2081–2095.
Keywords:

Pott’s disease conservative management; spinal TB rehabilitation

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