CASE REPORT

Respirology Division

SPONDYLITIS TUBERCULOSIS, PARAPARESIS INFERIOR DUE TO

COMPRESSION FRACTURE OF THORACIC VERTEBRA

DR. IRFADAH DINAR

C105192003

Department of Child Health

Medical Faculty of Hasanuddin University
DR. Wahidin Sudirohusodo Hospital, Makassar
2023
INTRODUCTION
Incidence of
extrapulmonary TB in
Indonesia is also
increasing, since 2000

TB Extra
Pulmonal
SPONDYLISIS
TUBERCULOSIS

Tuberculous
spondylitis
can be very
destructive
PATIENT IDENTITY
■ Name : NH
■ Gender : Female
■ Date of birth : Mar 12th 2006
■ Age : 16 years 6 month
■ Address : Polman South Sulawesi
■ Admission date : Jan 1st 2023
■ MR : 1003xxx
HISTORY TAKING:
History of present illness

• 16 years 6 month old girl was admitted to hospital with complaints of Weakness on both lower
limbs was experienced in the last 3 months and getting worse in the last 1 month before
admission.
• Initially, she felt numbness on both legs. The weakness was symmetric on both lower limbs.
• She was still able to feel tactile sensation on skin. There was a complain of backpain in the last 3
months before admission. The pain was getting worse in the last 2 weeks before admission.
• The pain appeared when she was standing and disappeared when she laid down.
• There was a history of fever in the past 3 months.
• Fever but not continuesly
• No Seizure, No Nausea and vomiting,
• She had a decrease appetite. The urine was red-colored and the stool was yellow
HISTORY TAKING:
History of present illness

History of hospitalization in W Hospital on 24 – 29 December 2022 with spondylitis

tuberculosis and treated with FDC antituberculosis drugs for intensive phase 1st month 4th
day.

History of Mantoux test (PM Hospital) and result was positive (induration ≥ 10 cm). The
patient had history of trauma (motorcycle accident), but the exact incidence was unclear
Prenatal and perinatal history
Her mother was diagnosed with lung tuberculosis 7
Pregnancy years ago (acid-fast bacilli positive) and had
completed her antituberculosis treatment
History

During pregnancy, the mother had regular check-ups with

the midwife, and was given vitamin and iron
supplementation. She never took herbs or medicines other
than those prescribed by a medical professional. She felt
quite healthy with a full-term pregnancy, and had not
experienced any trauma or other problems during
pregnancy.

PPDS IKA Unhas 6

Prenatal and perinatal history
There was no past or family history of congenital abnormalities, diabetes mellitus, hypertension,
thyroid dysfunction or tuberculosis.
At the time of admission her vitals were within normal limits.
There was no pallor, oedema, thyroid swelling or any significant lymphadenopathy.
No abnormality was detected on respiratory, cardiovascular or CNS examination.
Perinatal
history
On the prenatal care, her fetus has been diagnosed normal, There is no history of consanguinity.
Both parents are of normal stature.
Birth weight of the infant was 4000 gr with the height and head circumference unknown
Growth and Developmental History

Until the patient was 2 years old, the mother regularly took him to Posyandu, there was no Health
Card (KMS), but the mother never complained about her child's growth and development until now.
In the last 3 months before entering the hospital, the mother felt that her child was not gaining
enough weight.
Patient’s birth weight was 4000 grams, length and head was unknown.

Nutritional history
The patient has received complete
basic immunization. Patient was in oral intake condition, and
had an early parenteral nutrition.
History of basic needs fulfillment
(Love, care, stimulation)
Socio-economic, psychological
Both parents are the primary and environmental history
caretaker for the patient. Parents
Family belong to a low socio-
are able to fulfill clothing, food and
economic class.
housing needs. Medical expenses
are by BPJS.
PHYSICAL EXAMINATION
Status Present

General condition : Moderate illness

Consciousness : Glasgow coma scale 15 (E4M6V5)

Vital signs

Blood pressure : 100/60 mmHg (between P50-90)

Heart rate : 98 beat per minute, regular, adequate volume

Respiratory rate : 22 breaths per minute, regular, no chest indrawing

Oxygen saturation : 99% with room air.

Temperature : 36,7oC

Pain scale : 3 NRS (Numeric Rating Scale)

PPDS IKA Unhas 11
 PHYSICAL EXAMINATION
Nutritional State and
Antropomentri
General condition : Moderate ill

Consciousness : Glasgow coma scale 15 (E4M6V5)

Vital signs

Blood pressure : 100/60 mmHg (between P50-90)

Heart rate : 98 beat per minute, regular, adequate volume

Respiratory rate : 22 breaths per minute, regular, no chest indrawing

Oxygen saturation : 99% with room air.

Temperature : 36,7oC

Pain scale : 3 NRS (Numeric Rating Scale)

PPDS IKA Unhas 12
■ W/H: 79,6% (wasted, CDC NCHS 2000 chart) (Appendix 2)

■ H/A : 98,2% (Normal, CDC-NCHS 2000 chart) (Appendix 2)

■ W/A : 73,6% (underweight, CDC-NCHS 2000 chart) (Appendix 2)

Head circumference (HC): 54 cm (-2 SD<HC<0 SD, Nellhaus curve)
(Appendix 1)
GENERAL EXAMINATION
System Description

Skint No crazy pavement dermatosis, no cyanosis, no erythema, no purpura, good turgor, no jaundice, no pallor. BCG Scar
positive in the right deltoid.
Head Normocephalic, mesocephalic, no deformity.

Hair Black, evenly distributed, not easy to pick

Face No elderly face, no dysmorphic, no cranial nerve palsy, no erythema on the cheeks.

Eyes No palpebral edema, no anemic conjunctiva, no icteric sclera. Eye movements within normal limits, no strabismus, pupils
round, isochoric, 2.5mm/2.5mm in diameter, normal light reflex.

Nose Nasal septum in the middle, no secret, mucosa not hyperemic

Ear No secrets, tympanic membrane intact

Mouth No dry lips, no mouth ulcers, no stomatitis.

Teeth Not carrying dentis.

Throat The pharynx is not hyperemic, there is no tonsil enlargement.

Neck There is no nuchal rigidity. Jugular venous pressure is normal.

Chest Symmetrical shape and movement, no piano chest, no deformity, no chest retraction
GENERAL EXAMINATION
System Description
Vocal fremitus symmetrical, percussion sonor, vesicular breath sound, no additional
Lungs
breath sound (wheezing and rales).
Heart Ictus cordis is not visible and palpable, normal I-II heart sounds, no murmurs or gallops.

Abdomen Flexible, normal bowel sounds, no palpable liver and spleen, no ascites.
Genitals female, pubertal status A3M3P3
Lymph nodes No lymphadenopathy.

Spine There is a gibbus in the 11th thoracic region, accompanied by tenderness, without scoliosis

Ekstremity No wasting, baggy pants, and edema. Extremities warm, capillary filling time less than 2
seconds, no edema. BCG scar + 5 mm in the deltoid region of the right upper arm.
 NEUROLOGICAL STATUS
Awareness : GCS 15 (E4M6V5)

Nervus I : smell normal

Nervus II : round pupil, diameter isochor 2,5 mm/ 2,5 mm, ligh reflex
positive
Saraf III, IV, VI
: movement of the eyein all directions within normal limits
Nervus V
: refleks cornea positive
Saraf VII
: no facial nerve paresis
Saraf VIII
: normal hearing, balance is difficult to assess
Saraf IX, X, XI
: normal swallow reflex
Saraf XII
: o tongue deviation
NEUROLOGICAL STATUS
■ Meningeal sign : Negative neck rigidity

Motoric

■ Upper Extremity : 5-5-5-5/5-5-5-5

■ Lower Extremity : 1-1-1-1/1-1-1-1

■ Tonus : Decrease in the lower extremities

■ Physiology reflex : Decrease in the lower extremities

■ Pathologic reflex :Babinski negative

■ Klonus : Positive

■ Sensibiliy and system nerve otonom normal

TUBERCULOSIS SCORE = 10
■ Contact :3

■ Nutrition state :1

■ Fever :1

■ Cough :0

■ Lymphadenopathy :0

■ X Ray Thorax :1

■ Joint/bone :1

■ Tuberkulin test :3 Figure 1. Mantoux test result and Gibbus

LABORATORY EXAMINATION
(1/1/2023)

Parameter Result Normal Value

Albumin 3,5-5,0 gr/dl
HB 10,1 12-16 g/dl
MCV 65,1 80-100 µm3 Natrium 135 136-145 mmol/L
MCH 20,7 27-32 pg
Kalium 5 3,5-5,1 mmol/L
MCHC 29 32-36 gr/dl
HCT - 37-47% Klorida 94 97-111 mmol/L

Leukosit 9.930 4000-10.000 mm3 Lym 8.2 20-40 %

Trombosit 334.000 150.000-400.000/mm3 Neut 52-75 %

Mono 10.4 2-8 %

GDS 140 g/dl

Ureum 49 10-50 mg/dl

Kreatinin 0,6 L(<1,3), P (<1,1)

SGOT 84 <38 U/L

SGPT 21 <41 U/L
 RADIOLOGIC EXAMINATION
X-RAY THORAX & CT SCAN ( 20 DEC 2022 )

Impression : Pneumonia suspects to specific type Impression : Compression fracture in column vertebra thoracal
XI
MRI ( 20 DEC 2022 )

MRI Whole Spine

Non-contrast CT scan of thoracolumbar showed compression fracture in

column vertebra thoracal XI.
RESUME
A 16-year-and-9-month-old girl was admitted to the Pediatric Emergency Department of W Hospital due to
chief complaint of weakness on both lower limbs experienced in the last 3 months and getting worse in the last
1 month before admission. Initially, she felt numbness on both legs. The weakness was symmetric on both
lower limbs. She was still able to feel touch sensation on skin. There was a complain of backpain in the last 3
months before admission. The pain was getting worse in the last 2 weeks before admission. There was history
of hospitalization in W Hospital in 24 – 29 December 2022 with diagnosed of spondylitis tuberculosis and
treated with FDC antituberculosis drugs for 4th day first month of intensive phase.
The general condition of patient was moderate ill, with wasted, GCS 15, vital sign within normal limit. There
were BCG scar on right deltoid. There was gibbus in 11th thoracal region, accompanied with tenderness,
without any scoliosis. From neurologic status, nerve cranial within normal. Motoric examination revealed the
decreased of movement ability and tone normal in both lower extremities, and increased of physiology and
pathologic reflexes. The clonus was positive. Laboratory test revealed microcytic hypochromia. Chest x-ray in
PM Hospital, December 20th 2022: Pneumonia suspects to specific type. Non-contrast CT scan of
thoracolumbar showed compression fracture in column vertebra thoracal XI. Tuberculosis score was 10
Conclusion:
■ 1. Spondylitis Tuberculosis (A18.01)
■ 2. Paraparesis inferior due to compression fracture of 11th thoracic vertebra (G82.22)
■ 3. Iron deficiency anemia differential diagnose to anemia of chronic disease (D53.9)
■ 4. Wasted (E.44)
DIAGNOSIS
Primary Diagnosis : Spondylitis Tuberculosis

Secondary Diagnosis :

■ 1. Iron deficiency anemia differential diagnosis anemia of chronic disease

■ 2. Wasted

Complication :

Paraparesis inferior due to compression fracture of 11th thoracic vertebra

TREATMENT AND MANAGEMENT
■ SPONDILITIS TB
TREATMENT AND MANAGEMENT
Paraparesis inferior due to compression fracture of vertebra thoracal XI
TREATMENT AND MANAGEMENT
Differential Diagnosis Iron Deficiency Anemia and Chronic Anemia Disease
TREATMENT AND MANAGEMENT
Wasted
FOLLOW UP
Day 2 treatment (2-5 January2023)

Subject Objective Assessment Planning

Weakness in both lower  General condition : weak 1. Spondilitis Tuberkulosis  Day 3 : medicine antituberculosis
limbs.
There is back pain
 Blood pressure : 90/60 mmHg (A18.01) STOP
There is jaundice  Heart rate: 98 x per minutes
There is nausea and  Breathing : 30 x per minutes 2. Secondary diagnostic: Iron  Parasetamol 500mg/8
vomiting  Temperature : 36,5 ‘ celcius deficiency anemia differential hrs/intravena
 Oxygen Saturation : 99 % without assisted diagnosis of chronic anemia
oxygen disease (D52.9), Moderate  Acid ursodeoxyholic 250 mg/8
Malnutrition (E44.0) hrs/oral
 Pain Scale: 3 NRSLung :
 No retraction 3. Complication :Paraparesis
 Vesicular breath sounds inferior due to compression
 No ronkhi fracture of the 11th thoracic
 No wheezing vertebrae (G82.22)
 Heart: normal regular I/II heart sounds, no
heart noise
 Abdomen :
 Peristaltic sounds are normal
 hepar and lien not palpable
 Ekstremity
 warm acral, CRT <3 seconds,
 Upper motoric : 5555 5555
 Lower motoric :1111 1111
 Improve physiological reflexes
 Pathological reflex: positive
 Sensorik ordinary
 Gibbus in TXI area, softness

30
Treatment (6 – 10 January 2023)

Subject Objective Assessment Planning

- Weakness of both General condition : weak 1. Spondilitis Tuberkulosis  FDC Stop
limbs ↓
 Blood pressure: 90/60 mmHg (A18.01)
- Back pain ↓  Heart rate: 98 beats/minute  Parasetamol 500mg/8 hrs/intravena
 Breathing: 30 beats/minute 2. Secondary diagnostic:
Iron deficiency anemia 
- Increased appetite Acid ursodeoxyholic 250 mg/8 hrs/oral
 Temperature: 36.5 ºC
- Pain scale 1 NRS
 Saturation: 99% via nasal cannula differential diagnosis of
- Jaundice↓  Pain Scale: 1 NRS chronic anemia disease
 Lung : (D52.9), Moderate
 No retraction Malnutrition (E44.0)
 Vesicular breath sounds 3. Complication :Paraparesis
 No ronkhi inferior due to
 No wheezing compression fracture of
 Heart: normal regular I/II heart sounds, no heart the 11th thoracic vertebrae
noise (G82.22)
 Abdomen :
 Peristaltic sounds are normal
 hepar and lien not palpable
 Ekstremity
 warm acral, CRT <3 seconds,
 Upper motoric : 5555 5555
 Lower motoric :1111 1111
 Improve physiological reflexes
 Pathological reflex: positive
 Sensorik ordinary
 Gibbus in TXI area, softness
Laboratorium RSWS 11/5/2022
Hepatitis marker normal, RET 1,24, Ferritin 830, peripheral blood
smear: hypochromic microcytic anemia

Neonatology Division Case Report 31

Treatment (11 – 15 January 2023)

Subject Objective Assessment Planning

- Weakness of both limbs General condition : weak 1. Tuberkulosis Spondilitis  medicine antituberkulosis fase intensif:
↓  Blood pressure: 90/60 mmHg
 Heart rate: 98 beats/minute 2. Paraparesis inferior due to  Isoniazid 280 mg/24 hrs/oral
- Back pain ↓ fracture compression TXI
 Breathing: 24 beats/minute
 rifampisin 400 mg/24 hrs/oral
Increase in appetite  Temperature: 36.5 ºC
3. Chronic anemia disease
 Saturation: 99% via nasal cannula  pirazinamid 1200 mg/24 hrs/oral,
 Pain Scale: 1 NRS 4. Moderate Malnutrition
 Treatment Day-14 : Nothing jaundice  etambutol 600 mg/24 hrs/oral
 Lung :
 No retraction  Parasetamol 500mg/8 hrs/intravena
 Vesicular breath sounds
 No ronkhi  Acid ursodeoxyholic 250 mg/8 hrs/oral
 No wheezing
 Heart: normal regular I/II heart sounds, no heart
noise
 Abdomen :
 Peristaltic sounds are normal
 hepar and lien not palpable
 Ekstremity
 warm acral, CRT <3 seconds,
 Upper motoric : 5555 5555
 Lower motoric : 4444 4444
 Improve physiological reflexes
 Pathological reflex: positive
 Sensorik ordinary
 Gibbus in TXI area, softness
Laboratorium RSWS
Hb 9,0 g/dl, MCV 72,5 fl, MCV 20,3, SGPT 28 U/L SGOT
31 U/L

32
PROGNOSIS

■ Quo ad vitam : dubia ad bonam

■ Quo ad sanatorium : dubia ad bonam

■ Qua ad functionem : dubia ad bonam

DISCUSSION
SPONDILITIS TB
DEFINITION

TB spondylitis is a chronic The patient may be

granulomatous inflammatory
disease of the spine caused by
the bacterium Mycobacterium
tuberculosis. Involvement of
Mycobacterium tuberculosis
infection in the spine will
complicate management and
aggravate the clinical
condition due to potential
neurologic deficits and
permanent deformities
paralyzed due to
compression of the
The spine is the most As many as 50% of spinal cord.
frequent site of bone patients with TB Irreversible paralysis
tuberculosis infection, spondylitis have spinal not only disturbs and
with approximately lesions and 10-45% of burdens the patient
50% of osteoarthritic them have neurologic himself, but also his
tuberculosis cases. deficits family and society.5 In
this patient,
neurological deficits
were found.

Egea-Gámez, R. M., Galán-Olleros, M., González-Menocal, A., Martínez-González, C., & González-Díaz, R.
(2022). Surgical Treatment for Advanced Thoracic Spinal Tuberculosis in Infants: Case Series and Literature
Review. International Journal of Spine Surgery, 16(2), 393–403. https://doi.org/10.14444/8220
 PATHOPHISIOLOGY
The air is
Inhaled Enter the Masuk ke
polluted
airway Alveoli Alveoli
M.TB

Spread to the
vertebral Spread via the Phagocytosis
bodies of the intercostal Pulmonar by
intervertebral arteries
discs
y TB macrophages
fails

Bone destruction
and spread of
infection to the SPONDYLITIS TUBERCULOSIS
intervertebral
discs

■ Lacerda, C., Linhas, R. and Duarte, R. (2017) ‘Tuberculous spondylitis: A report of different clinical scenarios and literature update’, Case Reports in
Medicine, 2017. Available at: https://doi.org/10.1155/2017/4165301.
CLINICAL MANIFESTATION
■ 1) Cough  2 weaks

■ 2) Fever  2 weaks,

■ 3) Weight decreased or did not

increase in the previous 2 months,

■ 4) Lethargy or malaise  2 weaks,

IN THIS CASE :
■ 5) These symptoms persist despite ■ Weakness on both lower
adequate therapy. limb for 3 months
■ Back pain for 3 months
■ Prolong fever
■ decreaseBW
Source : PNPK Tatalaksana Tuberkulosis Kemenkes RI, 2020
SUPPORTING EXAMINATION
BONE
CT SCAN MRI
BIOPSY
In this Case

■ Pneumonia suspects to specific type

■ Positive tuberculin test with an induration of > 10 mm
■ Compression fracture in column vertebra thoracal XI
■ MRI examination of the thorax obtained T11 tuberculous spondylitis and severe slice deformity
TREATMENT AND MANAGEMENT
OAT Guideline for Children
SUMMARY

A case of tuberculous spondylitis in a 16-year-old girl

was reported. The diagnosis was based on history taking,
physical examination, laboratory and imaging. The
management of this patient was the administration of
anti-tuberculosis drugs and clinical observation. The
patient's prognosis was good.
FOLLOW UP
Algorithm for the Management of TB Spondylitis with Neurological Complications