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Case Report

Spondylitis Tuberculosis

Andriyani (1608437590)
Try Intan Kartini (1608437603)
Wilda Septi Pratiwi (1508434475)

Supervisor : dr. Riza Iriani, Sp.A

Department of Pediatric-Medical School Riau University


Arifin Achmad Riau Province General Hospital
Introduction

TUBERCULOSIS

Morbidity & mortality in children (especially developing countries)

Spondylitis TB is involved in 50% of extrapulmonary TB

Problem ? diagnose, treatment and prevention

Early diagnosis and prompt treatment -> prevent permanent


neurological disability
Literatur review
Definition & Etiology Mycobacterium Tuberculosis
Spondylitis TB

Spondylitis TB is
infectious disease
- Acid-fast bacillus
caused by - obligat aerob
M.tuberculosis - Destroyed in boilled
that involve water or ultraviolet
spine.
Primary
Happens within
infection is
the third years
from lung or
after primary
genitoutinary
infection
system.
Pathophysiology
Phagocytosis M. tb by
Inhalation of Alveolus macrophage
M. tb

M. tb breed/replication
Destruction of
M. tb
Macrophage lysis
Resolution

Spread to lymph
Tubercle formation nodes
Calcification
hematogen
Caseous
center

Secondary lesion in
the lung
Lesion in hepar,
kidney, spine,
brain, etc
Diagnosis

Criteria Spondylitis TB General TB :


- Weight loss
- Fever (>2 weeek)
Clinical manifestation - Cough (>3 week)
- Anorexia, failure to thrive
- Malaise
- Diarrhea (>2 week)
Radiography Spondylitis TB :
- Back pain and gibbus
- Spine deformity (kyphosis)
Microbiologic evidence of - Cold abscess
m.tuberculosis - Spinal movement is restricted
(and other test)

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Diagnosis

Criteria Spondylitis TB

Clinical manifestation

Radiography
- lateral x-rays shows severe kyphosis
with destruction of vertebral bodies
Microbiologic evidence of - lateral x-rays shows widening of
m.tuberculosis prevertebral soft tissue.
(and other test)
Diagnosis

Criteria Spondylitis TB

Clinical manifestation

Radiography

Microbiologic evidence of
m.tuberculosis
(and other test) - Found acid-fast bacilli smear
- Cultures for mycobacteria
- Tuberculin skin test

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Treatment
Dose Maximum dose
Drug name Side effects
(mg/kg/day) (mg per day)
Hepatitis, neuritis perifer,
Isoniazid (H) 5 15* 300
hipersensitivity

GIT disorder, trombositopenia,


Rifampisin (R) 10 20 600
increase liver enzime, red urine

hepatotoxic, artralgia,
Pirazinamid (Z) 15 30 2000
gastrointestinal disorder

Neuritis optic, decrease visus,


Etambutol (E) 15 20 1250
hipersentivity, GIT disorder

Streptomisin (S) 15 40 1000 ototoxic, nefrotoxic.

Prednisone 12 60
Treatment
Guideline treatment antituberculosis

Intensive phase : INH, RIF, PZA, EMB/STREP (2 month)


Continuation phase : INH and RIF (10 month)
Prednisone : 2 - 4 week and tappering off 2 6 week

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Decubitus ulcer : Pressure ulcer is an area of unrelieved
pressure usually over a bony prominence, resulting in ischemia
and tissue necrosis.
CLASIFICATION

Stage I - Intact skin with signs of impending ulceration, initially


presenting blanchable erythema indicating reactive hyperemia

Stage II - A partial-thickness loss of skin involving epidermis


and dermis

Stage III - A full-thickness loss of skin with extension into


subcutaneous tissue but not through the underlying fascia

Stage IV - A full-thickness tissue loss with extension into muscle,


bone, tendon, or joint capsule
MANAGEMENT DECUBITUS ULCER

For stage I and II, wound care is usually conservative


For stage III and IV, surgical intervention (eg, flap reconstruction)
may be required, though some of these lesions must be treated
conservatively because of coexisting medical problems.

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Case Report

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Patient identity

Name / No. MR : FE / 790798


Age : 16 y.o
Parents name : B / M
Ethnic : Melayu
Adress : Teratak Buluh, Kampar
Date of admitted : 18 October 2016
Anamnese
Chief complain :
Weakness of the limbs
since 5 months ago 5 months before admission

- Weakness of the limbs and then could not walk.


- Back pain and stiffness so activities interfered.
- Chronic cough, fever, night sweat and weight lose
- Diagnosed spine tumor on May 2016

2 months before admission

- Wound in back and buttocks, there was pus and itching.


- Cough isnt reduced, decreased of appetite (+), weight loss (+),
malaise (+) vomit-nausea (-)
- The general state got worse so patient entered to AA Hospital.
Anamnese

Past illness history


- No complaint about the same illness before
- No history of trauma

Family history
- Grandmother also cough for a long time and untreated
- No history of cancer

Parents history
Parents occupation: father is an enterpreneur and mather is a housewife

Pregnancy history
Patient was born spontaneusly helped by midwife, aterm, directly crying.
During pregnancy mother wasnt illness and unregular ANC.
Anamnese
Feeding history
0-6 months old : breastfeeding
6 24 months old: breastfeeding +weaning food
24 months now : regular food

Immunization history
Never got immunization

Growth history
Birth weight : 3000 gr Admission weight : 28 kg
Birth height : - Admission height : 145 cm

Development history House and living situation


Walk : 10 m.o - Permanent house, 6 people at home
Speak a few word : 12 m.o - Good ventilation
- The distance between houses 10 m
- The distance to public health 15 km
- Drinking water source: gallons of water
- Sanitation source: well water
Physical examination (17 November 2016)

General appearence : Moderate illness


Alertness : Composmentis
HR : 98 x/minute, regular
RR : 22 x/minute
T : 37,8 oC

Nutritional status
Height : 145 cm
Weight : 28 kg

Weight/Height (%) : Admission Weight/Ideal Weight x 100 %


28/36 x 100% = 77%
(malnutrition)
Physical examination
Head : Normocephali Hair : Within normal limit
Eyes
Conjungtiva : Pale -/- Sclera: Icteric -/- Pupil : Round, isokor
Light reflex : Direct +/+, indirect +/+
Ear : Within normal limit
Nose : nostril breath (-)
Mouth : Within normal limit
Neck : No enlargement of lymph nodes, Neck stiffness (-)
Thorax : Pulmo : simetris, retraction (-/-), fremitus N/ N, sonor (+/+)
vesiculer (+/+), Rhonki (-/-), Wheezing (-/-)
Cor : within normal limit
Abdomen : Within normal limit, psoas mass (-)
Genitalia : Within normal limit
Extremity : Warm, CRT < 2 s, edema (-), atrophy (-)
Localist Status (vertebra)

- Inspection :
Kyphosis 100, gibbus (-). Mass at
paravertebrae dextra, the size of
a tennis ball and the color same
as the skin.
Ulcer, hiperemis, the size 5x2
x0,2 cm at vertebra and
10x5x0,5 cm at gluteus, on the
basis of the subcutaneous
tissue with pus and surrounded
by necrotic tissue.

- Palpation :
Mass at paravertebrae dekstra
palpable soft, immobile, firm
boundaries, tenderness (-)
Neurologic Status

Sensoric Right Left Interpre Motoric Right Left Interpre


tation tation

Upper Upper
Extremity Extremity
Touch Normal Normal Normal Power 5 5 Normal
Painful Normal Normal Tonus Normal Normal
Temperature Normal Normal Involuntary (-) (-)

Lower Lower
Extremity Hip- Extremity Para
Touch estesia Power 1 1 parese
Painful at level Tonus Spastic Spastic Inferior
Temperature T-VII Involuntary (-) (-)
Neurologic Status
Reflex Right Left Interpretation

Physiologic
Biseps (+) (+) Physiologic reflex
Triseps (+) (+) is increase at
Autonomic system :
KPR (++) (++) lower estremity Miction and defecation
APR (++) (++) are normal

Pathologic Meningeal sign :


Negative
Babinski (+) (+) Pathologic reflex
Chaddock (-) (-) (+)
Gordon (-) (-)
Oppenheim (-) (-)
Klonus (-) (-)
Laboratory findings

Blood (18/10/2016) Urine (19/10/2016)


Hemoglobin : 7,9 g/dl () Colour : Yellow
Hematocrit : 26,2 % Protein/glucose : Negative
WBC : 25.140/Ul ( ) pH :6
PLT : 110.600 /mm3 Eritrocyte : 0-1/LPB
MCV : 69,3 fL () Leukocyte : 0-2/LPB
MCH : 20,9 pg () Epitel cell : 2-3/LPB
MCHC : 30,2 g/dl () Bacteria/fungi : 0/LPB

Feces (19/10/2016)
Egg of parasite : Negative
Epitel cell : 0-2/LPB
Cylinder : 0/LPB
Eritrocyte : 0-1/LPB
Leukocyte : 0-3/LPB
Amoeba/cyst : Negative
Laboratory findings

Blood Chemistry (19/10/2016) Albumin : 1,8 mg/dl ()


Ureum : 12 mg/dl Na : 137 mmol/l
Creatinin : 0,38 mg/dl K : 4,2 mmol/l
SGOT : 16 mg/dl Cl : 103 mmol/l
SGPT : 13 mg/dl
CRP : reactive,192 mg/l
Rontgen thorax AP (18 October 2016)
Cor and pulmo : within normal limit
MRI (29/5/2016 in Santa Maria Hospital)
Compression fractures in the VT 7-8 accompanied by signs of destruction of the
vertebral body and there is a pressing paravertebral abscess as high as the level of
the spinal canalis. Overview according to spondylitis tuberculosis.
Working Diagnose : Susp. Spondilitis TB + Paraparese inferior
+ Decubitus ulcer grade II
Nutritional diagnose: Malnutrition

Suggest examination
Mantoux test
Peripheral blood smear
Spinal biopsy
CT scan thorax with contrast
Treatment
1. O2 2 lpm by nasal canule
2. IVFD KAEN 1B 20 gtt/minute makro
3. Paracetamol tab 4 x 500 mg
4. PRC transfusion 3 x 200 cc
5. Rifampisin tab 1 x 450 mg
6. Isoniazid tab 1 x 400 mg
7. Pirazinamid tab 1 x 1000 mg
8. Inj. Streptomisin IM 1 x 500 mg
9. Prednison tab 5 mg 2-2-1
10. Wound care/day
11. High-calorie high-protein dietary

Nutrition :
RDA x BBI = (50-60) x 36 = 1800-2160 kcal

PROGNOSIS:
Quo ad vitam : Dubia ad malam
Quo ad fungsionam : Dubia ad malam
Follow up
Hb / Ht / WBC / PLT Hb / Ht / WBC / PLT
12,3/39,9/15.000/ 927.000 12/38,7/15.850/556.000
Ur / Cr / AST / ALT Prednison tapp. off 2-1-1
12 / 0,01 / 19 / 13

Mantoux test Hb / Ht / WBC / PLT


positive 13/42,6/15.740/ 769.000

22/10 29/10 3/11 22/11


20/10 24/10 31/10 7/11 2/12
CT scan: No pus in ulcer
Same w/ before
Spondylitis TB Hb / Ht / WBC / PLT
Fever (-), PRC transfusion stop
11.6/37/15.680/558.000
Hb / Ht / WBC / PLT Biopsy: Consul to Sp.OT & Sp.RM
12,5/38,6/16.820/874.000 Sel datia langhans,
Peripheral blood smear:
anemia microcytic,leukocytosis
D/ : Spondylitis TB
right shift, trombocytosis ec infection
CT scan with contrast (31/12/16):
Hipodense lesion in the VT 5-6 that direct gibbus and destruction of the
vertebral body in VT 7-8.
Biopsy (7/11/16) : Appear a granuloma with caseose necrosisin the central
and datia langhans cell.
Decubitus ulcer (18/10/16) Decubitus ulcer (2/12/16)
Discussion
Weakness of limb,
Fever, Fatigue
- Cold abscess Anamnesis Weight loss, Cough,
and kyphosis Contact TB (+),
- Deficit Physical examination No imunization
neurologic
-Ulcer with pus
at gluteus and Supporting examination
vertebra

-Anemia, leukocytosis,
trombocytosis, CRP
reactive
-Mantoux test : (+)
-MRI and CT scan
-Spinal biopsy

Diagnosis :
Spondylitis TB + Paraparese inferior + Decubitus ulcer grade II
Treatment If deficit neurologic (+) : operatif

2 RHZS +
10 RH

Prednisone 1-2mg/Kg/day
Steroid 2 - 4 week and tappering off 2 6
month

Improvement clinical manifestation


Evaluation
Weight gain

Allowed to go home and


keep control
Thank you