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A CASE REPORT ON POTTS'S SPINE (TUBERCULOSIS OF SPINE) WITH DRUG

INDUCED HEPATOTOXICITY: A RARE CASE REPORT

Article  in  International Journal of Scientific Research · October 2017

DOI: 10.21276/IJIPSR.2017.05.10.585

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CASE REPORT ARTICLE Shaistha et.al / IJIPSR / 5 (10), 2017, 27-32
Department of Pharmacy Practice ISSN (online) 2347-2154
DOI: 10.21276/IJIPSR.2017.05.10.585

International Journal of Innovative

Pharmaceutical Sciences and Research
www.ijipsr.com

A CASE REPORT ON POTTS’S SPINE (TUBERCULOSIS OF

SPINE) WITH DRUG INDUCED HEPATOTOXICITY: A RARE
CASE REPORT
1
Md.Tarique Nadeem, 2Khaleequa Tabassum, 2Shaistha Afreen*, 2Uma Maheshwari C,
2
Syed Shabbir Hussain
1
Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and
Research, INDIA
2
Department of pharmacy practice, Smt.sarojini ramulamma college of pharmacy, INDIA

Abstract
Pott’s disease also known as tuberculosis spondylitis is a rare form of extra-pulmonary tuberculosis
which affects musculo skeletal system in which delay in diagnosis and management cause spinal cord
compression and deformity. Drug induced hepatotoxicity also occurs rarely on use of AKT4.This is a
case of 60 years old male patient presented with complaints of lower back pain which was severe and
gradually increasing in density with no history of trauma. He was apparently alright 6 months back
when he developed sudden sensation of pain in lower back region along with difficulty in standing. He
also noticed weight loss prior to admission. For diagnosis of pott’s disease CT, MRI, Monteux test.,
CBP were done. To rule out drug induced hepatotoxicity LFT was done.CUE was also done which
showed that patient also has UTI. Electrolytes, Thyroid profiles were also checked. The treatment
given was Ethambutol (800mg), streptomycin (750mg), levofloxacin (500mg), ursodeoxycholic acid
(300mg), Nitrofurantion (100mg) for 10 days and then discharged. The purpose of the author was to
present a rare case of pott’s spine and make the people of medical field familiar with the disease and
its related complications.
Keywords: Potts spine, TB, CT, MRI.

Corresponding Author:
Shaistha Afreen
Department of pharmacy practice,
Smt.Sarojini Ramulamma College of Pharmacy,
Mahabubnagar, T.S., INDIA
E-mail: shaistaafreen1993@gmail.com
Phone: +91- 8143212957

Available online: www.ijipsr.com October Issue 27

CASE REPORT ARTICLE Shaistha et.al / IJIPSR / 5 (10), 2017, 27-32
Department of Pharmacy Practice ISSN (online) 2347-2154
DOI: 10.21276/IJIPSR.2017.05.10.585
INTRODUCTION
Pott’s disease also known as tuberculosis spondylitis is a rare form of extra-pulmonary
tuberculosis which affects musculo skeletal system in which delay in diagnosis and management
cause spinal cord compression and deformity [1-2]. Spinal infection result via haematogenous or
lymphatic spread by mycobacterium tuberculosis which involve paravertebral soft tissues,
vertebral body, epidural space and intervertebraldisc [3]. Tubercular spondylitis accounts for 50%
of cases of articulo-skeletal infections of TB and 1-5% of all TB cases. Risk factors mainly
involve diseases such as Diabetes Mellitus and chronic renal failure in 5-25% and 2-31%
respectively along with prolonged corticosteroid therapy in 3-13% of patients [4]. Advanced
imaging techniques such as MRI helps in early diagnosis of spinal TB and effective treatment of
neurological deficits where as atypical CT is especially useful for those suffering from multiple
organ tuberculosis patients. Frequency of infection in immunodeficient individuals and
development of multi drug resistant TB with advances in spinal reconstruction techniques
improved the management of spinal TB [5-6]. Patients from vertebral collapse and appearance of
neurological deficits can be protected by early medical treatment however TB Spondylitis could
be treated with medical treatment alone if there is no evidence of compressive effect on spinal
cord and absence of vertebral collapse. If progression of signs occurred such as large abscess,
neurological impairment or vertebral fractures then surgical approach is necessary to abscess
draining and setting correct medical treatment [7]. The principal treatment of pott’s spine is
conservative treatment along with combination of anti-TB drugs such as isoniazid (INH),
rifampicin(RIF), ethambutol, and pyrazinamide (PZA).INH and RIF are more effective at
preventing resistance to other drugs this is why multi drug therapy is important. The duration of
drug therapy is controversial, but some National and International guidelines recommend 6
months of duration which may be prolonged to 9-12 months in complicated cases [8-9]. Anti
tuberculosis drug induced hepatotxicity has wide range of symptoms which varies from acute
hepatitis to liver failure. Usually 20% of patients experience mild elevated levels of amino
transferases and hence are asymptomatic [10].Clinical hepatitis/Jaundice is seen in 1-6% patients
who take isoniazid alone or in combination [11]. After diagnosing drug induced hepatotoxicity
the 3 major hepatotoxic drugs namely isoniazid (INH), Rifampicin (RIF), and pyrazinamide
(PYZ) are to be withheld as soon as possible. Depending upon the severity of TB second line
drugs such as streptomycin or amikacin, ciprofloxacin or ofloxacin should be initiated [12].

Available online: www.ijipsr.com October Issue 28

CASE REPORT ARTICLE Shaistha et.al / IJIPSR / 5 (10), 2017, 27-32
Department of Pharmacy Practice ISSN (online) 2347-2154
DOI: 10.21276/IJIPSR.2017.05.10.585
CASE REPORT
A 60 Years old male patient presented with complaints of lower back pain which was severe and
gradually increasing in density with no history of trauma. He was apparently alright 6 months
back when he developed sudden sensation of pain in lower back region along with difficulty in
standing. He also noticed weight loss prior to admission .He denied cough, chest pain, fever,
chills, rigors, and any neurological deficit involving upper extremities.
On physical examination his vital signs were fluctuating as shown in given table
Table 1: Physical Examination
PARAMETERS DAY 1 DAY 2 DAY 3 DAY4 DAY 5 DAY 6 DAY 7
BP(mmHg) 110/90 120/90 90/80 130/80 120/70 110/80 120/70
Pulse bpm 120 96 92 98 87 88 94

Past Medical History

Patient has previous history of Diabetes mellitus, Hypertension (on medication) and Tuberculosis
(on medication with AKT4 ), but stopped medication. Patient was taking NSAIDS as OTC
medication for body pains frequently.
Lab investigations
Apart from the above mentioned physical examinations the patient underwent routine test as well
as definitive tests.
Routine Test
Complete blood picture revealed decrease Hb levels- 12.2 gm/dl as well as decrease RBC count -
3.9 mill/cumm, a total WBC count of 19,000/cumm with a differential count of 25%
lymphocytes, and Neutrophil 85%. The Erythrocyte sedimentation Rate (ESR) was 45mm at the
end of 1 hour, which increases chance of provisional Diagnosis. Electrolytes revealed decrease
sodium and calcium levels of 123 mEq/L and 1.06 mmol/L respectively. Patient was performed
liver function test to rule out HEPATITS and was found to have increased Total bilirubin -6.8
mg/dl, Direct Bilirubin- 4.2mg/dl, SGPT-63U/L, Total proteins- 75U/L where as Decreased
Albumin level of 2.1 gm/dl. Thyroid Profile was found to be normal. Complete Urine
Examination shows amorphophosphates with bacteria.
Difinitive Tests: CT of spine was done demonstrating destruction of right pedicle of T10
vertebrae as shown in (figure 1) given below.
MRI of the spine was performed which shows anterior scalloping of the T9 and T10 vertebral
bodies due to pulsation of the aorta transmitted through a paraspinal abscess. (Figure 2).
Available online: www.ijipsr.com October Issue 29
CASE REPORT ARTICLE Shaistha et.al / IJIPSR / 5 (10), 2017, 27-32
Department of Pharmacy Practice ISSN (online) 2347-2154
DOI: 10.21276/IJIPSR.2017.05.10.585
As a part of differential diagnosis the patient also underwent Monteux test whose result was found
to be positive.(induration-20mm).

Fig. 1: CT of spine: Fig. 2: MRI of spine

Treatment
Patient was given appropriate Rational drug treatment according to lab investigations and reports,
as the patients was diagnosed with potts spine with drug induced hepatitis ,also patients is having
urinary tract infection so drug regimen includes-Ethambutol (800mg)as first line drug for spinal
TB along with streptomycin (750mg), levofloxocin(500mg). Patient was given ursodeoxycholic
acid (300mg) as hepato –protective to treat Hepatitis. Nitrofurantion(100mg) given to reduce
urinary Tract infection. Patient was adviced to do physiotherapy and regular exercise to regain
normal life style
Discharge medication
Patient was discharged after 10 days of appropriate treatment after ruling out the disease. Patient
was advised to continue levofloxocin-500mg/PO/OD, Ethambutol-800mg/OD, and Streptomycin-
750 mg/PO/OD along with hepato protective ursodeoxycholic acid.
DISCUSSION
The present case about potts spine with drug induced hepatotoxicity may be the manifestation of
TB. Present case of Pott’s spine disease is the Extra pulmonary tuberculosis in which spine is the
common affected site in vertebral column(50%) and less frequently in Hip, Knee and Sacroiliac
joints [13,14]. It usually presents with chronic back pain and thoraco-lumbar spine is the most
frequent site of involvement and it has potential to cause severe deformities and permanent
neurological deficits [7,14]. In 2010 there is increase in incidence of TB of about 8.8 million with
mortality rate1.4 million where as in US extra pulmonary cases accounts for about 10% cases [15,

Available online: www.ijipsr.com October Issue 30

CASE REPORT ARTICLE Shaistha et.al / IJIPSR / 5 (10), 2017, 27-32
Department of Pharmacy Practice ISSN (online) 2347-2154
DOI: 10.21276/IJIPSR.2017.05.10.585
16]. Pathogenesis manly involves haematogenous and lymphatic spread with upper thorasic spine
commonly affected site in children and lower thoracic and upper lumbar in case of adults [16].
Imaging examinations such as CT and MRI is important for successful management and early
diagnosis while biopsy done to confirm diagnosis of TB [5,17]. Medical treatment with four –
drug therapy as first-line agents or combined medical and surgical strategies when necessary;
indications include neurological sequelae, spinal instability, significant kyphosis, refractory pain,
or failure of medical treatment can control the disease in most patients [1,7].
CONCLUSION
POTT’S spine also called as pott’s disease with drug induced hepatotoxicity is a important
differential diagnosis that should be diagnosed immediately. Past history of TB, use of AKT4,
OTC NSAID and radiological findings aid the diagnosis. Treatment was started based on
laboratory findings. One should have sound knowledge regarding TB and its complications to rule
out the diagnosis and provide better treatment and care to the patient. In conclusion the authors
wanted to present a rare case of Potts Disease.
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Department of Pharmacy Practice ISSN (online) 2347-2154
DOI: 10.21276/IJIPSR.2017.05.10.585
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