Scandinavian Journal of Infectious Diseases, 2014; 46: 543–544
LETTER TO THE EDITOR
Tubercular vertebral osteomyelitis
Scand J Infect Dis Downloaded from informahealthcare.com by Imperial College London on 04/06/15 For personal use only.
AJAZ NABI KOUL & GULAM NABI DHOBI From the Division of Infectious Diseases, Department of Medicine, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India
To the Editor, The article entitled “Vertebral osteomyelitis: Retrospective review of 11 years of experience” [1], is an excellent retrospective study that emphasizes the staphylococcal etiology as a causative agent in the majority of vertebral osteomyelitis (VO) cases. In our part of the world we see cases of VO that have a differing etiology from that of developed countries. In our clinical practice we have seen Mycobacterium tuberculosis as a cause of VO more frequently than reported in the literature. During the past 5 y we have admitted and treated 12 cases of VO caused by Mycobacterium tuberculosis. In these cases, the disease process was localized to the thoracic and lumbosacral spine. The patients presented with fever and limitations of ambulation. Scanning and work-up indicated VO compounded by paraspinal abscess formation. The patients were given an extended course of anti-tubercular drug therapy (ATT) along with steroids; the duration of ATT was individualized, with all patients receiving 18 to 20 months of therapy. The sequelae of this disease remained even after a full course of ATT and compliance with the directly observed therapy short-course (DOTS) regime along with regular physiotherapy. In endemic areas of the world, especially India, any patient with fever coupled with limitation of movement should be investigated for a suspected infected spine disease. In such patients, apart from suspecting staphylococcal sepsis or septic VO, tuberculosis (TB) must also be considered. The typical features of spinal TB have been identified in Egyptian mummies dating back to almost 4000 BC [2]. TB is following human history like a shadow. The reservoirs of this chronic debilitating disease remain in the under-developed and developing world, but immune suppression in various forms
has made TB a threat to the developed world too. Proper introspection and early institution of ATT ameliorates the burden of TB to a great extent. Spinal TB (Pott disease) most often affects the lumbar and lower thoracic region; upper thoracic and cervical disease is less common but is potentially more disabling [3,4]. Tuberculous abscess, a complication of spinal TB, is frequently bilateral. The goal of achieving a lesser burden of TB is hampered by delays in diagnosis together with a lack of drug compliance. Insufficiencies in the identification of the attainment of complete cure among TB patients and their care-givers affect the achievable targets in the management of TB. Areas affected by TB such as the vertebrae add to the challenges of treating the VO secondary to TB effectively. The value of the conventional Mantoux test is high in spinal TB, with sensitivity ranging from 92% to 94% [5]. Radiologically, magnetic resonance imaging (MRI) remains the gold standard in establishing the anatomy of the spine and surrounding structures with precision. It provides a reasonable description of the vertebrae, disc, disc spaces, neuro-anatomy, and surrounding structures, especially the localization of abscesses and neural disruption [6–8]. Although aspiration from the infected vertebrae, disc, or paraspinal collection helps in establishing the etiology of VO, computed tomography (CT)-guided aspiration of VO is difficult in practice. In those cases of VO that are complicated with a paraspinal collection, ultrasound-guided or CT-guided aspiration helps in documenting the tuberculous etiology. These patients often require a neurosurgical intervention to relieve the acute neural or myelitic compression. In such cases, establishing the tissue diagnosis is less taxing.
Correspondence: A. N. Koul, Department of Infectious Diseases, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India. Tel: ⫹ 91 97 97023527. E-mail: [email protected] (Received 25 February 2014 ; accepted 27 February 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.901556
Scand J Infect Dis Downloaded from informahealthcare.com by Imperial College London on 04/06/15 For personal use only.
544
A. N. Koul & G. N. Dhobi
Another sensitive issue that we feel needs to be addressed is drug resistance in tubercular osteomyelitis. Although, as yet we have seen no documented case of multidrug-resistant (MDR) TB VO, we feel there may be more than anticipated. As newer and more rapid sensitivity testing for smear-positive TB has been implemented in recent years, we have been able to identify mono-resistance to INH or RMP, and the more dreaded MDR TB. Unfortunately as clinicians we do not have this capability in skeletal TB, and in the present context of VO, the scenario for establishing MDR TB remains bleak. The diagnostic and sensitivity tool applications in tubercular vertebral osteomyelitis need to be revisited. Declaration of interest: We declare no conflict of interest. We declare no funding.
References [1] Weissman S, Parker RD, Siddiqui W, Dykema S, Horvath J. Vertebral osteomyelitis: retrospective review of 11 years of experience. Scand J Infect Dis 2014;46:193–9. [2] Daniel TM, Bates JH, Downes KA. History of tuberculosis. In: Bloom BR, editor. Tuberculosis: pathogenesis, protection, and control. Washington DC: American Society for Microbiology; 1994. p. 13. [3] Weaver P, Lifeso RM. The radiological diagnosis of tuberculosis of the adult spine. Skeletal Radiol 1984;12:178–86. [4] Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am 1985;67:1405–13. [5] Berney S, Goldstein M, Bishko F. Clinical and diagnostic features of tuberculous arthritis. Am J Med 1972;53:36–42. [6] Chapman M, Murray RO, Stoker DJ. Tuberculosis of the bone and joints. Semin Roentgenol 1979;14:266–82. [7] Yao DC, Sartoris DJ. Musculoskeletal tuberculosis. Radiol Clin North Am 1995;33:679–89. [8] Shanley DJ. Tuberculosis of the spine: imaging features. AJR Am J Roentgenol 1994;164:659–64.
LETTER TO THE EDITOR
Tubercular vertebral osteomyelitis
Scand J Infect Dis Downloaded from informahealthcare.com by Imperial College London on 04/06/15 For personal use only.
AJAZ NABI KOUL & GULAM NABI DHOBI From the Division of Infectious Diseases, Department of Medicine, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India
To the Editor, The article entitled “Vertebral osteomyelitis: Retrospective review of 11 years of experience” [1], is an excellent retrospective study that emphasizes the staphylococcal etiology as a causative agent in the majority of vertebral osteomyelitis (VO) cases. In our part of the world we see cases of VO that have a differing etiology from that of developed countries. In our clinical practice we have seen Mycobacterium tuberculosis as a cause of VO more frequently than reported in the literature. During the past 5 y we have admitted and treated 12 cases of VO caused by Mycobacterium tuberculosis. In these cases, the disease process was localized to the thoracic and lumbosacral spine. The patients presented with fever and limitations of ambulation. Scanning and work-up indicated VO compounded by paraspinal abscess formation. The patients were given an extended course of anti-tubercular drug therapy (ATT) along with steroids; the duration of ATT was individualized, with all patients receiving 18 to 20 months of therapy. The sequelae of this disease remained even after a full course of ATT and compliance with the directly observed therapy short-course (DOTS) regime along with regular physiotherapy. In endemic areas of the world, especially India, any patient with fever coupled with limitation of movement should be investigated for a suspected infected spine disease. In such patients, apart from suspecting staphylococcal sepsis or septic VO, tuberculosis (TB) must also be considered. The typical features of spinal TB have been identified in Egyptian mummies dating back to almost 4000 BC [2]. TB is following human history like a shadow. The reservoirs of this chronic debilitating disease remain in the under-developed and developing world, but immune suppression in various forms
has made TB a threat to the developed world too. Proper introspection and early institution of ATT ameliorates the burden of TB to a great extent. Spinal TB (Pott disease) most often affects the lumbar and lower thoracic region; upper thoracic and cervical disease is less common but is potentially more disabling [3,4]. Tuberculous abscess, a complication of spinal TB, is frequently bilateral. The goal of achieving a lesser burden of TB is hampered by delays in diagnosis together with a lack of drug compliance. Insufficiencies in the identification of the attainment of complete cure among TB patients and their care-givers affect the achievable targets in the management of TB. Areas affected by TB such as the vertebrae add to the challenges of treating the VO secondary to TB effectively. The value of the conventional Mantoux test is high in spinal TB, with sensitivity ranging from 92% to 94% [5]. Radiologically, magnetic resonance imaging (MRI) remains the gold standard in establishing the anatomy of the spine and surrounding structures with precision. It provides a reasonable description of the vertebrae, disc, disc spaces, neuro-anatomy, and surrounding structures, especially the localization of abscesses and neural disruption [6–8]. Although aspiration from the infected vertebrae, disc, or paraspinal collection helps in establishing the etiology of VO, computed tomography (CT)-guided aspiration of VO is difficult in practice. In those cases of VO that are complicated with a paraspinal collection, ultrasound-guided or CT-guided aspiration helps in documenting the tuberculous etiology. These patients often require a neurosurgical intervention to relieve the acute neural or myelitic compression. In such cases, establishing the tissue diagnosis is less taxing.
Correspondence: A. N. Koul, Department of Infectious Diseases, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India. Tel: ⫹ 91 97 97023527. E-mail: [email protected] (Received 25 February 2014 ; accepted 27 February 2014 ) ISSN 0036-5548 print/ISSN 1651-1980 online © 2014 Informa Healthcare DOI: 10.3109/00365548.2014.901556
Scand J Infect Dis Downloaded from informahealthcare.com by Imperial College London on 04/06/15 For personal use only.
544
A. N. Koul & G. N. Dhobi
Another sensitive issue that we feel needs to be addressed is drug resistance in tubercular osteomyelitis. Although, as yet we have seen no documented case of multidrug-resistant (MDR) TB VO, we feel there may be more than anticipated. As newer and more rapid sensitivity testing for smear-positive TB has been implemented in recent years, we have been able to identify mono-resistance to INH or RMP, and the more dreaded MDR TB. Unfortunately as clinicians we do not have this capability in skeletal TB, and in the present context of VO, the scenario for establishing MDR TB remains bleak. The diagnostic and sensitivity tool applications in tubercular vertebral osteomyelitis need to be revisited. Declaration of interest: We declare no conflict of interest. We declare no funding.
References [1] Weissman S, Parker RD, Siddiqui W, Dykema S, Horvath J. Vertebral osteomyelitis: retrospective review of 11 years of experience. Scand J Infect Dis 2014;46:193–9. [2] Daniel TM, Bates JH, Downes KA. History of tuberculosis. In: Bloom BR, editor. Tuberculosis: pathogenesis, protection, and control. Washington DC: American Society for Microbiology; 1994. p. 13. [3] Weaver P, Lifeso RM. The radiological diagnosis of tuberculosis of the adult spine. Skeletal Radiol 1984;12:178–86. [4] Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am 1985;67:1405–13. [5] Berney S, Goldstein M, Bishko F. Clinical and diagnostic features of tuberculous arthritis. Am J Med 1972;53:36–42. [6] Chapman M, Murray RO, Stoker DJ. Tuberculosis of the bone and joints. Semin Roentgenol 1979;14:266–82. [7] Yao DC, Sartoris DJ. Musculoskeletal tuberculosis. Radiol Clin North Am 1995;33:679–89. [8] Shanley DJ. Tuberculosis of the spine: imaging features. AJR Am J Roentgenol 1994;164:659–64.
