Tuberculous spondylitis following intravesical bcg-instillation in the treatment of transitional cell carcinoma: Case report and systematic review.

OBJECTIVES: Tuberculous spondylitis (TS), also known as Pott's disease (PD), is a form of tuberculosis in which the vertebral column is affected. Since the first description by Katz et al. in 1992, it became clear that Bacillus Calmette-Guérin (BCG) instillations in the treatment of superficial transitional cell carcinoma (TCC) form a plausible way in which PD is introduced. Nowadays, BCG forms the most effective treatment modality for superficial TCC. The incidence of other than minor complications have been estimated under five per cent. Here we report a case of TS after BCG-instillation in the treatment of TCC. Furthermore, all available literature concerning this topic was gathered into a systematic review. The primary objective was to create an overview of all available literature concerning TS after intravesical BCG-instillations, with an emphasis on the neurosurgical approach of these patients, forming a scaffold at which future case reports can be compared. As a secondary objective, we tried to raise the awareness concerning this very rare complication of intravesical BCG-instillation as a possible cause of low back pain (LBP). PATIENTS AND METHODS: We performed a systematic review, in which patients who developed TS after intravesical BCG-therapy in the treatment of TCC, were examined. A total of twenty-three articles (twenty-four cases) obtained from MEDLINE were included. Search terms included: "tuberculous spondylitis", "Pott's disease", "vertebral osteomyelitis", "intravesical", "Bacillus Calmette-Guérin" and "transitional cell carcinoma". Additional studies were identified by checking reference lists. Furthermore, we present a case concerning one of our own patients who consulted our Neurosurgical department with a similar clinical presentation. This systematic review is in conformity with the PRISMA-guidelines. The case report is in accordance with the CARE statement guidelines. RESULTS: Results are based on twenty-five cases (twenty-four cases extracted from previous literature and our case report). All included articles are case reports written in English. Publication year and recruitment time varies from 1992 to 2018. Mean age at clinical presentation varies from 35 to 94 years old (mean 74). All patients were male. Surgery was performed in 17 out of 25 cases (68%). A posterior approach was performed in seven cases (41%), zero anterior approaches (0%), a combined approach in five cases (29%) and not specified in five cases (29%). All patients received intravesical BCG-instillation in the treatment of TCC, ranging from one month to twelve years before clinical presentation (mean 26). Radiographic abnormalities were seen in thoracic vertebral segments in thirteen cases (52%), eleven cases in lumbar segments (44%), one at the thoracolumbar transition level (4%) and not in cervical vertebral segments. CONCLUSION: Although very rare, TS should be part of the differential diagnosis in patients with LBP, even years after BCG-instillation for TCC. It mostly affects elderly men and involves the thoracolumbar spine through hematogenous spread via Batson's plexus. Antitubercular therapy remains the mainstay in the treatment of TS. A posterior surgical approach, with debridement and stabilization, should be preferred when surgical intervention seems necessary. To our knowledge, this systematic review forms one of the first comprehensive reviews evaluating neurosurgical intervention for PD following intravesical BCG-therapy in the treatment of TCC.

Vertebral tuberculosis as a paradoxical reaction to the treatment of pulmonary and meningeal tuberculosis in an immunocompetent patient: A case report.

INTRODUCTION: Paradoxical reaction in tuberculosis (TB) is defined as the reappearance of general symptoms, aggravation of pre-existing diseases, or appearance of new lesions despite adequate anti-TB therapy. It may result from the hyperactivity of the immune response, resulting in an intense inflammation. There are few cases of vertebral TB reported as paradoxical reaction, mainly among immunocompetents patients. PATIENT CONCERNS: We describe a male immunocompetent patient with confirmed pulmonary and meningeal TB. He was readmitted after 60 days of adequate treatment, with vertebral TB and paravertebral abscess, despite clinical improvement of the other locations. We defined as an uncommon case of a paradoxical reaction, confirmed by nuclear magnetic resonance and molecular rapid test for TB. DIAGNOSIS: Mycobacterium tuberculosis (MTB) was detected in cerebrospinal fluid by molecular rapid test (Gene Xpert MTB/ rifampicina method). Sputum research and culture were positive for the same agent. Lumbosacral spine nuclear magnetic resonance revealed bone destruction from T8 to T11, and a paravertebral collection was found. Gene Xpert MTB/rifampicina and culture were positive for M tuberculosis in the drained material of the paravertebral abscess. INTERVENTIONS: The paravertebral abscess was drainage by tomography-guided. Treatment with 4 anti-TB drugs was extended for 60 days and 2 anti-TB drugs was maintained for 10 months. There was a complete clinical improvement. OUTCOME: After draining the paravertebral abscess, the patient progressively improved and was discharged for outpatient follow-up. He was on antituberculous drugs for 1 year; subsequently, complete resolution of the infection was reported. CONCLUSION: Paradoxical reaction may be a difficult diagnosis in immunocompetent patient. Vertebral TB as a paradoxical reaction is an uncommon presentation. Therapeutic failure or resistance to treatment should be ruled out to confirm the diagnosis of paradoxical reaction.

Extrapulmonary tuberculosis: a debilitating and often neglected public health problem.

We report a case of a 33-year-old woman from Nepal who presented to a hospital with paraplegia. She was found to have pulmonary tuberculosis (TB) with lumbar spine involvement, and bilateral psoas abscesses. She had no initial symptoms attributable to pulmonary involvement. Her delayed presentation to the hospital led to complication of TB spine, which compromised the life of this woman working as a labourer. Early diagnosis and treatment of extrapulmonary TB is essential. Awareness regarding symptoms of different forms of extrapulmonary TB and making diagnostic modalities such as CT scan, MRI or biopsy readily available through insurance schemes are some important measures to minimise the problem so that complications like paraplegia as in our patient with spinal TB can potentially be avoided.

Tuberculous spondylitis after vertebral augmentation: A case report with a literature review.

Tuberculous spondylitis of vertebral augmentation following percutaneous vertebroplasty or kyphoplasty is rare. We report an unusual case of tuberculous spondylitis diagnosed after percutaneous kyphoplasty (PKP). A 54-year-old woman presented to hospital complaining of back pain following a fall 20 days prior. Radiology showed an acute osteoporotic compression (L3 fracture). The patient denied a history of pulmonary tuberculosis and there were no signs of infection. The patient was discharged from hospital 2 days after undergoing L3 PKP with a dramatic improvement in her back pain. The patient was readmitted 10 months later with a history of recurrent back pain and low-grade fever for 3 months. Imaging examinations showed severe spondylitis at the L2-L3 level, with paravertebral abscess formation and bony destruction of L2 and L3. A positive result of the T-SPOT test preliminarily confirmed the diagnosis of tuberculous spondylitis. The tuberculosis test was positive, and serum C-reactive protein levels and erythrocyte sedimentation were relatively high. Treatment for tuberculous spondylitis was started. She underwent posterior fusion and instrumentation from T12-L5 after markers for infection returned to normal. After surgery, the patient continued antituberculous and anti-osteoporosis treatments. Her low back pain was relieved and low-grade fever and sweating disappeared.

Atlantoaxial tuberculosis: Outcome analysis.

BACKGROUND: Tuberculous (TB) spondylitis occurs in <1% of patients with TB. Atlantoaxial involvement is extremely rare amounting to 0.3%-1% cases of TB spondylitis. The management of this entity has been fluctuating with time. Various classifications and management protocols have also evolved. We present our experience in managing this entity in 8 patients. MATERIALS AND METHODS: Retrospective follow-up study of eight patients with atlantoaxial TB over 2 years. They ranged in age from 14 to 33 years with male preponderance. Four required surgical intervention on initial presentation, 2 were successfully treated conservatively, and 2 had to undergo surgery after a trial of conservative management. All of them were started on antituberculous therapy (ATT) for 18 months. Patients were followed up for 8-29 months. RESULTS: Neck pain and restriction of neck movements were standard presenting features. All patients had pulmonary TB confirmed by sputum examination. Radiological investigations formed an integral part of the evaluation of disease, treatment plan, and prognosis. Improvement in symptoms has been documented in all eight. CONCLUSION: The involvement of the most mobile spinal segment and the potential cervicomedullary compression makes it a disease of utmost importance. Although ATT remains the mainstay of treatment, surgical intervention is needed for stabilizing the joint and decompressing the cervicomedullary junction. Strict adherence to medical advice and optimum surgical intervention tailored for each patient results in the successful management of the disease.

Spinal tuberculosis with severe neurological symptoms as a complication of intravesical BCG therapy for carcinoma of the bladder.

INTRODUCTION: Non-invasive bladder cancer is effectively treated with intravesical BCG therapy. The administration of the BCG vaccine is to destroy the neoplastic lesion or prevent further recurrences. The activity of the vaccine involves boosting the immune system through the stimulation of the inflammation in the bladder. Adverse reactions after this immunotherapy are rare. The aim of the study was to present complications in the form of spinal tuberculosis and serious neurological symptoms that occurred during intravesical BCG immunotherapy for carcinoma of the bladder. The manuscript also describes a method for neurosurgical spinal cord decompression of the thoracic spine. MATERIAL AND METHODS: In the first patient, aged 66, after intravesical BCG therapy for bladder carcinoma, back pain and spastic paralysis of the lower limbs were observed. The MRI and CT revealed destruction of the intervertebral disc and vertebral endplates Th11-Th12. Mycobacterium tuberculosis complex bacilli were cultured from the material obtained by puncture aspiration. In the second patient, aged 35 years, during intravesical BCG immunotherapy for carcinoma of the bladder, girdle thoracic spine pain was observed. The MRI and CT of the spine showed visible lesions characteristic of tuberculosis. Immobilization in a plaster corset and implementation of antituberculous treatment resulted in quick relief of the pain and healing of the tuberculosis focus in the spine. CONCLUSION: The cases described in the work are the first documented reports in the Polish literature of spinal tuberculosis which occurred as a complication of intravesical administration of bacilli Calmette-Guérin. The diagnosis was based on the finding of BCG vaccine bacillus with molecular methods or PCR. Full antimycobacterial treatment was implemented.

Absceso del psoas como presentación de tuberculosis vertebral: reporte de un caso / Psoas abscess as spinal tuberculosis presentation: case report

Introducción: El absceso del psoas es un cuadro infrecuente cuyo principal agente etiológico es el Staphyloccocus aureus, y que con baja frecuencia puede ser de etiología tuberculosa como complicación de una afección vertebral por Mycobacterium tuberculosis. Presentación del caso: Mujer de 58 años, mapuche, con antecedentes de enfermedad pulmonar obstructiva crónica y alcoholismo crónico, consultó por cuadro de dos meses de evolución de dolor lumbar, baja de peso y paresia de extremidad inferior derecha que impedía la marcha. Tomografía computada (TC) de columna evidenció espondilodiscitis y absceso del psoas derecho, iniciándose tratamiento antibiótico cubriendo Staphyloccocus aureus. Los hemocultivos y los cultivos de la colección resultaron negativos por lo que se decidió mantener tratamiento ambulatorio. Paciente consultó cuatro meses después por exacerbación de su disnea basal de dos semanas de evolución, radiografía de tórax y TC de tórax de alta resolución compatibles con tuberculosis pulmonar con diseminación miliar bilateral, por lo cual, se inició tratamiento antituberculoso, realizándose baciloscopías que resultaron negativas. Además, se solicitó identificación del bacilo de Koch mediante reacción de polimerasa en cadena que resultó positiva, con lo que se confirmó el diagnóstico de tuberculosis miliar y mal de Pott. Se decidió reevaluar con TC de columna una vez finalizado el tratamiento antituberculoso para decidir conducta quirúrgica. Discusión: Es importante la sospecha activa de etiología tuberculosa ante una espondilodiscitis y un absceso del psoas, pese a su baja frecuencia. El inicio del tratamiento en forma precoz puede modificar la progresión de una infección que puede ser invalidante e incluso mortal.

Introduction: The Psoas abscess is an infrecuent condition which main ethiology is the Staphyloccocus aureus and with less frequency can be a vertebral tuberculosis complication caused by Mycobacterium tuberculosis. Case Report: a 58 years old female, Mapuche, with Chronic Obstructive Pulmonar Disease and chronic alcoholism antecedents, was admitted in the emergency room with a two month old lumbar pain, loss of weight and right inferior extremity paresia which didn't allowed her to walk. The column's Computed Tomography (CT) showed spondylodiscitis and a right psoas abscess, the antibiotherapy, covering Staphyloccocus aureus, was started. The hemoculives and abscess' cultives were negative, so it was decided to continue with ambulatory treatment. The patient was admitted four month later because of two weeks of exacerbation of her basal dysnea. The thorax Radiography and high resolution CT were compatibles with pulmonary tuberculosis with bilateral miliar disemination. Antituberculosis treatment was started, bacilloscopies were negative, also, a Polymerase Chain Reaction identification of Koch's bacillus was performed, resulting positive, confirming the diagnosis of miliar tuberculosis and Pott's disease. Once antituberculosis treatment was finished, a new column's CT was requested to decided surgical conduct. Discussion: Is important to actively suspect of tuberculosis ethiology in presence of spondylodiscitis and psoas abscess, despite it's low frequency. The early treatment start may modify the progresion of an infección that can be invalidating and even mortal.

Functional polymorphisms of Monocyte Chemoattractant Protein-1 gene and Pott's disease risk.

OBJECTIVE: Monocyte Chemoattractant Protein-1 (MCP-1/CCL2), a key player in immune-mediated responses against Mycobacterium tuberculosis, is encoded by a polymorphic gene. Functionally relevant polymorphic variations in the MCP-1 gene have been associated with both susceptibility to and protection against tuberculosis-related disorders. Here, we investigated the potential impact of some of these polymorphisms on Pott's disease risk in a patient cohort from Algeria. METHODS: DNA from 132 Algerian patients with exclusive Pott's disease and 204 healthy controls, included under a case-control design, were analyzed for the MCP1 -2518A/G (rs1024611), -362G/C (rs2857656) and int1del554-567 (rs3917887) polymorphisms. PHASE software was used for haplotype reconstruction. Genetic associations were examined using chi-square tests. RESULTS: We found that the rs1024611 -2518 GG, rs2857656 -362 CC and rs3917887 int1del554-567 del/del homozygous genotypes each were significantly more prevalent in patients than in controls (respective corrected p value [Pc]=0.01, 0.04 and 0.04) Haplotype distribution profile further confirmed this, as the homozygous combination of GCdel haplotype was also found with raised susceptibility to Pott's disease (Pc=0.03). CONCLUSION: Our findings confirm and replicate the recent data from China (which dealt essentially with rs1024611 and rs2857656) and also reinforce them by providing trans-ethnic evidence and extending the genetic association to the rs3917887.

A thoracic tuberculous spondylodisctis after intravesical BCG immunotherapy of bladder cancer - Case report and literature review.

We report a rare case of tuberculosis of the thoracic spine caused by Mycobacterium bovis infection as a complication of BCG (Bacillus Calmette-Guérin) intravesical immunotherapy, which is a well known and acknowledged treatment of superficial bladder cancers applied since 1976. Although this therapy is broadly used in urology and considered to be safe and well tolerated, one should be aware of the potential local and systemic side effects as in the case of our patient, who developed tuberculous spondylodiscitis after intravesical BCG therapy.

Management of spinal tuberculosis - a metropolitan city based survey among orthopaedic and neurosurgeons.

OBJECTIVE: To explore the core understanding of spinal tuberculosis and its current management plans by orthopaedics and neurosurgeons. METHODS: The questionnaire-based study was conducted from July 2011 to November 2012 in Karachi and comprised consultant orthopaedics and neurosurgeons belonging to 4 private and 3 government tertiary care teaching hospitals and having a minimum five years of post-fellowship experience. A pre-designed questionnaire was used to explore the current practice in spinal tuberculosis regarding its clinical presentation, diagnosis and treatment. SPSS 15 was used for statistical analysis. RESULTS: There were 48 subjects in the study; 24(50%) orthopaedic surgeons and 24(50%) neurosurgeons. According to 44(91.70%) respondents, common age for spinal tuberculosis was second and third decades of life, and 37(77.08%)reported refractory back pain with or without neurological deficits as the commonest clinical finding. Typical magnetic resonance imaging findings was the uniform observation of all the 48(100%) respondents. Diagnosis was made by histopathological findings by 39(81.25%) respondents. Anti-tuberculosis therapy was started empirically on the basis of clinical, laboratory and radiological findings by 33(68.75%) respondents. Those in favour of giving anti-tuberculosis therapy for 18 months were 32(66.7%) respondents, and 33(68.75%) thought surgery does not expedite recovery. CONCLUSIONS: Extremely variable tools of diagnosis and diversified approaches for the treatment are alarming signs for the possible development of resistant strains and complications of spinal tuberculosis.

Spinal tuberculosis of the lumbar spine after percutaneous vertebral augmentation (vertebroplasty or kyphoplasty).

BACKGROUND CONTEXT: Spinal tuberculosis occurring after percutaneous vertebral augmentation has rarely been described. To date, only two such cases have been documented in the literature. Vertebral augmentation may reactivate a quiescent tuberculous lesion and promote the infective process in elderly patients with or without immunosuppression, thereby resulting in poor outcomes. PURPOSE: The purposes of this study were to present two cases in which spinal tuberculosis occurred after vertebroplasty or kyphoplasty, to highlight the clinical features and need for early diagnosis of this pathology, and to postulate probable reasons for this association. STUDY DESIGN: This study is based on a clinical case series and literature review. METHODS: In this report, we review the clinical histories of two old women undergoing vertebral augmentation with subsequent spinal tuberculosis. RESULTS: The first patient responded favorably to conservative treatment with multidrug antitubercular therapy and spinal braces. The second patient underwent surgical debridement through a posterior approach alone, without instrumentation, combined with adjuvant chemotherapy. By 1 year after treatment, both patients had experienced almost complete recovery and continued to be seen for follow-up visits. CONCLUSIONS: Suspicion should be high, and magnetic resonance imaging is warranted in cases with deteriorating clinical symptoms and signs of acute infection after vertebral augmentation. We propose obtaining exhaustive microbiologic and histologic evidence via needle biopsy or open surgery in a timely fashion to establish an accurate diagnosis because tubercular spondylitis occurring in such a situation may progress rapidly.

A confounding coincidence: epidural anesthesia and paraplegia due to intramedullary tuberculoma in a patient who underwent cholecystectomy.

BACKGROUND: Paraplegia associated with epidural anesthesia or caused by intramedullary spinal tuberculoma is rare but catastrophic. We present a case of paraplegia following epidural anesthesia in a patient with an undiagnosed intramedullary spinal tuberculoma. CASE PRESENTATION: A 42-year-old man developed paraplegia after an open cholecystectomy under epidural anesthesia. Spinal cord infarction, acute transverse myelitis, and intramedullary neoplasms were ruled out by histopathologic examination, and intramedullary spinal tuberculoma at the T6-T7 level was identified. Despite surgical treatment and subsequent antituberculous therapy, the patient retained some disability attributable to the delay in diagnosis. CONCLUSION: Physicians should be aware of coexisting disease as a cause of paraplegia following procedures using epidural anesthesia. Magnetic resonance imaging is the most sensitive diagnostic test, although it is still difficult to differentiate spinal cord infarction, myelitis, intramedullary spinal tuberculoma, and neoplasms from imaging features alone.

Pott's paraplegia secondary to Scrofuloderma is a rare association.

STUDY DESIGN: Spinal tuberculosis as all other osteoarticular tuberculosis occurs as a result of hematogenous dissemination of Mycobacterium tuberculosis from a primarily infected visceral focus mainly lungs, but Pott's paraplegia occurring secondarily to Scrofuloderma has not been reported till date. PURPOSE: To document such an association of Pott's paraplegia and Scrofuloderma. METHODS: A 29-year-old female presented to us with low backache and paraplegia of 1 month duration. Clinical examination showed multiple healed Scrofuloderma lesions over sterum and neck (Figure 1). Magnetic resonance imaging (Figure 4), computed tomography (Figure 3) and X-ray (Figure 2) showed Pott's spine involving dorsal vertebrae (D8-10) with pre and paravetebral abscess with intraspinal extension. She was treated by minimally invasive surgery to drain pus and granulation tissue by resecting transverse process of D9 vertebra. Drained material was sent for histopathological examination, Zielh-neelsen (ZN) staining, culture and sensitivity for M. tuberculosis. Patient completely recovered neurologically after 1 month of surgery. RESULTS: Patient completely recovered neurologically after surgery and is presently on multidrug chemotherapy and spinal brace. CONCLUSIONS: Pott's paraplegia can occur secondary to Scrofuloderma and it can be managed by multidrug antitubercular therapy and minimally invasive surgical procedure.

Spine infections.

Infections of the spine represent a rare but potentially debilitating and neurologically devastating condition for patients. Early diagnosis, imaging, and intervention may prevent some of the more critical complications that may ensue from this disease process, including alignment abnormalities, central canal compromise, nerve root impingement, vascular complications, and spinal cord injury. This article reviews the underlying pathophysiologic basis of infection, clinical manifestations, and imaging modalities used to diagnose infections of the spine and spinal cord.

[Pott's disease (about 16 cases)]. / Mal de Pott (à propos de 16 cas).

INTRODUCTION: Pott's disease or spinal tuberculosis is rare, but represents the most common form of osteo-articular tuberculosis in endemic countries. MATERIAL AND METHODS: [corrected] From January 2000 to December 2010, we collected 16 cases of Pott's disease. We analyzed clinical and radiological profile, means of confirmation and treatment. RESULTS: Spinal and chest pain were the most frequent signs. Four patients had neurological signs. The diagnosis was made by the detection of bacillus in the pus of paravertebral abscess in six cases, by histological study of vertebral biopsy in five cases, biopsy of another associated lesion in one case and in front of radio-clinical arguments with good clinical evolution under antibacillary treatment in four cases. The antibacillary treatment associating four drugs was indicated and correctly followed by all patients. Surgical drainage was associated in five cases. The evolution was good in all cases. DISCUSSION: Diagnosis of Pott's disease is late when there is no neurological sign. Imaging allows to make early diagnosis with MRI. Prognosis is good when treatment is started early.