Case of the Month
Section Editor: Nicholas Stence, MD
Children's Hospital Colorado, Aurora, CO
September 2021
Next Case of the Month Coming October 5...
Spinal/Skeletal Tuberculosis
- Biopsy Results:
- Direct and cultural exam negative for acid-fast organisms/mycobacteria
- Pathologic exam: epithelioid granulomas with a positive search for acid-fast organisms, compatible with tuberculosis (TB)
- A positive epidemiologic history was further assessed: She had contact with a colleague with tuberculosis 1 and 2 years before in-hospital admission. At that time, chest x-ray was unremarkable and IGRA was inconclusive. She underwent tuberculosis treatment with isoniazid and pyridoxine for less than 1 month after the second contact, prior to the beginning of the complaints. It should be noted that she had no history of fever, weight loss, or sudoresis.
- Background:
- Tuberculosis incidence is increasing.
- Skeletal tuberculosis accounts for 10–20% of all extrapulmonary cases, and the spine is involved in up to 50% of these.
- MRI detects spine TB early changes and is the modality of choice for determining the extent of soft-tissue involvement.
- An infiltrative pattern of TB osteomyelitis may be seen with a pattern resembling Ewing sarcoma, fungal infection, chronic pyogenic osteomyelitis, and lymphoproliferative disorders like in lymphomas.
- Clinical Presentation:
- In this case, the chronic clinical picture and epidemiologic contact were critical to the diagnosis.
- Active pulmonary disease is present in less than 50% of skeletal tuberculosis cases.
- Key Diagnostic Features:
- The anterior portion of the vertebral body is most commonly involved in TB; with disease progression, the cortex gets disrupted, and the infection spreads to the adjacent soft tissue.
- In a series of pediatric patients with spinal TB, contiguous involvement of 2 or more vertebral bodies was present in 85% of cases, while an intraspinal or paraspinal soft-tissue mass or abscess was present in 98%.
- The posterior elements are seldom involved, but when they are, this finding favors TB instead of pyogenic infections.
- Epidural masses and extension of the infection into paravertebral soft tissue are commonly seen.
- Differential Diagnoses:
- Lymphoproliferative disorders (including leukemia/non-Hodgkin lymphoma)
- Granulomatous disease (including tuberculosis)
- Metastatic disease
- Langerhans cell histiocytosis
- Ewing sarcoma
- Treatment:
- ​Usually conservative
- Surgical drainage is indicated when large abscesses or impending neurologic complications are present.