1. A case of extra-pulmonary MDR TB presenting as Pott’s disease. Presented by : Dr. Jalal Mohsin Uddin DTCD, FCPS(Pulmonology)

2. Particulars of the patient : Name : Shair Uddin Age : 30 yrs Sex : Male Occupation : Shop-keeper Marital status : unmarried Religion : Islam Address : Shalgaria, Durgapur, Rajshahi

3. Chief complaints : Back pain for nine months Appearance of swelling at the back at the level of middle part of the chest for seven months Weakness and burning sensation in both lower limbs for six months Development of retention of urine and constipation for five days.

4. H/O present illness : According to the statement of the patient he was reasonably well before the year of 2002. Then he was diagnosed as a case of right sided pleural effusion and received cat-1 anti-TB drug. In the year of 2007, he developed swelling at the back and diagnosed as pott’s disease in Rajshahi Medical College and again he received cat-1 anti-TB drug with continuation phase for nine months.

5. But during this period he developed weakness and burning sensation in both lower limbs. Then decompression and stabilization with plate was performed at the level of D 12.

6. In the year 2009, there was recurrence of pott’s disease, patient received Cat-ll for eight months. Decompression was again performed at the level of D 9 and D 10 ► site of lesion. ►

7. Nine months back he again developed pain at the back at the middle part of the chest, dull aching in nature, gradually increasing in severity, was radiating from back to the both sides of the chest. The pain aggravated with movement or during cough and sneezing. Later on he developed a swelling at the back. The swelling was gradually increasing in size. One month later he developed burning sensation and weakness of both lower limb. In the course of disease, suddenly he developed retention of urine and constipation.

8. After development of retention of urine and constipation, an emergency operation was performed. Again Transpedicular decompression of spinal cord with laminectomy at D 5 and D 8 level with bone grafting and stabilization with screw was done.

9. After operative procedure biopsy was taken from operation site and sent for histopathological examination, AFB culture and DST. The histopathological report was granulomatous lesion with caseation necrosis. With this report he was referred to our NIDCH.

10. H/O past illness, personal history, contact history, socio-economic status and immunization history : He was not suffering from hypertension and DM. He was a non-smoker. He never came into contact with the person, suffering from tuberculosis. He was from a lower middle class family. All other family members are in good health. He was immunized with BCG vaccine at his childhood.

11. General examination : Patient was anxious, his built was average, he was cooperative, conscious and was comfortable in supine position, his nutritional status was good. He was moderately anemic, not icteric, not cyanosed. JVP was not raised and there was no lymphadenopathy in accessible site. There was no bony tenderness, edema or dehydration. Pulse was 76/min, BP-110/70 mm of Hg, Respiratory rate was 16 breaths/min and recorded temperature was 98°F. Weight of the patient was 58 kg.

12. Examination of respiratory system Inspection: RR- 16/min; shape of the chest was normal; movement of the chest was symmetrical; there were three incisional scar marks at the back. Two longitudinal incision marks along the right paravertebral region and another incision mark along the leftt 9 th intercostal space. Palpation: Trachea was centrally placed; apex beat was in 5 th intercostal space just medial to the mid clavicular line, 9 cm away from mid sternal line ; movement of the chest was symmetrical; chest expansion was normal ; vocal fremitus was normal in both sides. Percussion note was normal in both side, liver dullness was present in right 5 th inter costal space. Breath sound was vesicular, there was no added sound, vocal resonance was normal in both sides. ► ► ►

13. Neurological examination of lower limbs: Both lower limbs were in flexion position. The limbs were involuntarily flexed in hips and knees. There were slight wasting of muscles of thigh and leg of both lower limbs. There was no fasciculation and involuntary movement. Hypertonia was present in both lower limb.

14. There was weakness of extensor muscles of lower limbs. Knee and ankle jerks on both sides were exaggerated. Plantar response was extensor on both sides. Ankle clonus was present in both sides. Co-ordination movement could not be examined. There was sensory impairment from D 10 (at the level of umbilicus) downwards at both sides. There was spastic type of gait. Examination of other systems reveled normal findings. 

15. Provisional diagnosis : Pott’s disease with spastic paraplegia.

16. Differential diagnosis : Primary tumor(eg.myeloma, lymphoma, leukaemia) Metastatic lesion in spine Pyogenic infection (Staphylococcal) of spine.

17. Investigations: Total count of WBC : 6000/cu mm Differential count : N- 65%, L-25%, M-7%, E- 3%. Hb – 9gm/dl. ESR- 80 mm in 1 st hr. Sputum for AFB(3 samples)- Negative. Sputum for AFB-CS : Negative S bilirubin, SGPT, Blood urea, S creatinine- within normal limit. Chest X-ray P-A view was normal USG of whole abdomen was normal Anti HIV antibody – negative MT : 15 mm (positive)

18. Initial management before AFB-C/S and DST report : Modified Cat-II was started on 06-01-2011 Inj. Streptomycin 1gm I/M daily Tab 4 FDC 4 tab daily Tab Ofloxacin 200 mg 4 tab daily Tab Pyruvit 25 mg 1 tab daily Physiotherapy

19. Culture report : Specimen was collected on : 09.01.11 Specimen type : Tissue (collected during operative procedure) Investigation done : Conventional Culture (LJ media) for Mycobacteria. Culture : positive Reporting date : 06.03.11

20. DST report : Specimen type : Tissue (collected from para vertebral abscess) Collection date : 09.01.2011 Reporting date : 06.04.2011 Results: STR: S INH : R RIF : R ETB: R

21. Confirmatory diagnosis Multi drug resistant tuberculosis causing tubercular spondylitis (Pott’s disease) with spastic paraplegia

22. Review pannel decided to treat the patient : Their comments was as follows : NIDCH, giving treatment to only Pulmonary MDR-TB as approved by GLC(WHO). This patient is Extra-pulmonary (Tubercular Spondylitis), and is DST proven MDR-TB(EP). As every MDR-TB patient has got the right to get treatment free of cost, so this case is enrolled for CAT lV regimen.

23. Cat-IV was initiated on 10/04/2011 His Cat-IV registration number was 528 59/2011 Inj Kanamycin 1gm 1 vial I/M daily Tab Ofloxacin 200mg 4 tab daily Tab Pyrazinamide 500 mg 3 tab daily Cap cycloserine 200 mg 4 cap daily Tab Ethionamide 200 mg 4 tab daily Intensive phase was continued for six month. Continuation phase continued for 18 months.

24. Ancillary treatment : Tab Pyridoxine 100 mg Tab Amitryptiline 25 mg Tab Gabapentine 300 mg Tab Beclofen Tab B 1 + B 6 + B 12 Cap Omeprazole 20 mg and Phyosiotherapy During the period of his hospital admission, we have received consultation from the Orthopedic surgeon and Neurosurgeon. Patient was gaining muscle strength, he could make straight the lower limbs and could walk with support. He was discharged from our institute after completion of 6 month intensive phase.

25. Brief discussion : Extra-pulmonary or non- respiratory tuberculosis is rising in both developed and developing countries. In one observation Pulmonary- 79% and Extra-pulmonary-21% Within extra-pulmonary: Lymph node-41%, pleural - 19%, bone and joint- 11%, Genito-urinary- 7%, Abdominal tuberculosis- 5%, CNS- tuberculosis – 5%, other- 12%.

26. Bone tuberculosis presents typically 3-5 years after the initial respiratory infection, with the haematogenous spread at that initial infection, which has a predilection for the spine and growing ends of long bones, then lying there dormant until clinical disease occur. Spinal sites account for approximately half of all bone disease, but any bone and joint can be involved. Tubercular spondylitis in 70% case involve two vertebral bodies and in 20% case affect three or more.

27. Tuberculous disease of spine is not seen in the first year of life. It begins to appear after child has learnt to walk and jump. Tuberculosis begins in the anterior-superior or anterior- inferior angle of the body and spreads to an adjacent vertebra. The disc becomes involved and the disc space becomes narrowed. Later there may be a visible lump or bend in the spine (gibbous) showing where the vertebral bodies have collapsed.

28. As the disease progresses an abscess forms and this may track to sites such as the lower thoracic cage or below the inguinal ligament (psoas abscess). If the abscess tracks it may pass to the right or to the left round the chest and appear as a soft swelling on the chest wall. If it presses to the back it can compress the spinal cord and cause paralysis.

29. Conclusion : Pott’s disease due to MDR-TB is a very rare case. Exact prevalence is not known.There may be some sporadic cases. It was the first case MDR-TB of spine, treated under DOTS-Plus project. So it may be beneficial in case of recurrence of extra-pulmonary tuberculosis to send biopsy material for AFB-C/S and DST. Gibbous

30. Recent advancement in detection of extra-pulmonary MDR TB : In some cases where we can collect aspirate or pus from extra- pulmonary site, we can send the sample for Gene X- pert examination to the NTRL for early detection of MDR- TB.

31. Take home messages : Non-healing and relapsing extra-pulmonary tuberculosis should be suspected as MDR tuberculosis. After excisional biopsy or fine needle aspiration, sample should be sent for AFB, AFB-c/s and DST beside histopathological examination. For early detection of MDR TB we can send pus or aspirate material for Gene X-pert examination in NTRL (National Tuberculosis Research Laboratory).

32. Our people is struggling in many aspects of their life. They are also struggling against tuberculosis. May Allah give us victory over tuberculosis! Thank You All