Images in medicine. Double gibbus due to spinal tuberculosis

S R Ahuja, S Karande, A A Thadhani
Journal of Postgraduate Medicine  
A 2-year-old girl presented with fever, anorexia and progressive spinal deformity for the past two months, and cough and breathlessness for the past two weeks. There was no apparent contact with a case of tuberculosis (TB). BCG scar was absent. Gibbus deformities were seen at the thoracic and lumbar regions (Figure 1 ). The child was tachypneic with reduced air entry on the right side of the chest. The central nervous system examination was normal. Mantoux test was positive (15 mm). Chest
more » ... raph revealed right paratracheal lymphadenopathy, right lower zone collapse / consolidation with compensatory hyperinflation of the right upper and middle zones. CT scan of the chest confirmed these findings, and also revealed a calcified lymph node in the right paratracheal and subcarinal regions. X-ray spine showed loss of disc spaces between dorsal 6-7 and lumbar 3-4 vertebrae. MRI spine revealed multifocal spondylitis involving the dorsal 6-7 and lumbar 3-4 vertebrae ( Figure 2) , with abnormal prevertebral and paravertebral soft tissue shadows with smooth margins suggesting the presence of cold abscesses at these levels. Bronchoscopy revealed caseous material in the right middle bronchus suggestive of endobronchial TB. HIV-ELISA test was negative. A nine-month course of anti-TB therapy (for the first two months isoniazid, rifampicin, pyrazinamide and ethambutol, followed by isoniazid and rifampicin for the next seven months) along with oral prednisolone (for the first six weeks) was started. Orthopaedic surgeons advised conservative management and weekly follow-up to detect any neurological abnormality. The patient was lost to further follow-up. Discussion The clinical symptoms of spinal TB in a child are often insidious and include back pain, fever, paraparesis, sensory disturbance and bowel and bladder dysfunction. 1 Histological proof of TB spine by isolation or culture of Mycobacterium tuberculosis is obtained only in a few patients who undergo surgery. 2 In the majority of the cases of TB spine, the diagnosis is confirmed on characteristic MRI findings along with other posi-tive findings (namely, insidious clinical history of fever and anorexia; positive Mantoux test; suggestive chest radiography/ CT scan chest findings; and/or a positive response to anti-TB drug therapy). 2 MRI is an ideal modality for detecting TB spine disease early, assessing the extent of disease, identifying complications such as kyphosis and cord compression, and for assessing response to treatment. 2 MRI features pointing to TB are soft-tissue masses/abscesses, involvement of multiple vertebral segments of the spine and absence of reactive sclerosis. 2 When there is a para-or pre-vertebral abscess or disc involvement, the MRI
pmid:14699236 fatcat:f63owzf4s5frxmadmpvgnmadse