TUBERCULOUS SPONDYLITIS

Supervisor: Dr. Wisman Dalimunthe, Sp.A (K)

Presenters: M.ARIPANDI WIRA 080100054 SHALINI SHANMUGALINGAM 080100402

INTRODUCTION

In 2011, nearly 9 million people around the world become sick with TB disease.

Annually, 250.000 new cases of tuberculosis in Indonesia and approximately 100.000 death because of tuberculosis

Children below the age of 15 years old contribute 15% of the total tuberculosis case

INTRODUCTION

Report on children in Indonesia are rarely obtained, but it is estimated number of TB cases in children is about 5% -6% of the total TB cases.
Tuberculous spondylitis (TS) or spinal tuberculosis is usually secondary to pulmonary or intestinal tuberculosis and may also be the first manifestation of tuberculosis (TB).

According WHO, November 2004 it has been estimated that about 2,5% - 5% of spinal TB from the total TB cases occurs in children.
The epidemiology of spinal TB in Indonesia has not been obtained but they are many cases of tuberculous spondylitis among children has been reported.

DEFINITION
Infectious

disease of the spine which is typically caused by an extraspinal infection. typical site of involvement is the anterior aspect of the vertebral body adjacent to the subchondral plate and occurs most frequently in the lower thoracic vertebrae. possible effect of this disease is vertebral collapse and when this occurs anteriorly, anterior wedging results, leading to kyphotic deformity of the spine.

The

EPIDEMIOLOGY

In developed countries musculoskeletal TB is often a disease in older adults.

It is mainly a disease in children, with 50% of all cases reported in children less than 10 years of age, and young adults in developing countries with a high TB incidence. The spine is involved in approximately 50% of musculoskeletal TB. Thoracic spine involvement accounting for 25-50%. Lumbar and lumbosacral spine for 25-50% Cervical for 5-25%.

ETIOLOGY

M.

tuberculosis complex, subspecies M. tuberculosis.

RISK FACTOR
Trauma Low social economy status Age Previous infection of pulmonary tuberculous Immune deficiency

PATHOGENESIS
Primary or reactivated focus
extension of an abscess beneath the anterior longitudinal ligament and the periosteum haematogenous spread "anterior type" of vertebral body "paradiscal" lesions of vertebral body 3 types

"central type" of vertebral body

Spread infection along Batsons plexus of vein.

Spread of disease via the arteries

loss of the periosteal blood supply and destruction of the anterolateral surface of many contiguous vertebral bodies

DELAYED HYPERSENSITIVITY Caseous necrosis muscle, tendon, ligament and bone destroyed

CLINICAL MANIFESTATION

Gibbus Back pain

Weakness or paralysis of lower extremities

During the late stages of the disease the two main complications remain: deformity and paraplegia

DIAGNOSIS

HISTORY

Average duration of symptoms at the time of diagnosis is 3-4 months and back pain is the earliest and most common symptom. Constitutional symptoms. Neurological symptoms weakness.

PHYSICAL EXAMINATION

Localised tenderness Paravetebral muscle spasm Kyphotic deformity Cervical spine TB is a less common pain and stiffness with dysphagia or stidor (LOWER CERVICAL SPINE).

INVESTIGATION
Hematological ESR elevated, generalized lymphocytosis Skin test A positive Mantoux test can be observed, one to 3 months after infection. Microbiology test Ziehl-Neelsen staining IFN- release assay (IGRAs) can measure T-cell release of IFN in response to stimulation with highly specific tuberculosis antigen ESAT-6 and CFP-10.

IMAGING

PLAIN RADIOGRAPH

The classic roentgen triad in spinal tuberculosis is primary vertebral lesion, disc space narrowing and paravertebral spacing. More than 50% of bone has to be destroyed before a lesion can be seen on X-ray. Typical tuberculous spondylitis features in long standing paraspinal abscess :

concave erosion around the anterior margin of the vertebral bodies producing a scalloped appearance called the aneurysmal phenomenon. fusiform paraspinal soft tissue shadow with calcification.

CT-SCAN

Bone destruction is seen but nerve involvement is not clear. Abscess with calcification is diagnostic for spinal TB.

MRI

bone marrow oedema and enhancement. posterior element involvement canal stenosis spinal cord or nerve root compression. Inter-vertebral disc enhancement, vertebral collapse and kyphosis deformity are particularly suggestive of tuberculosis.

MANAGEMENT

Standard drug anti-tuberculous therapy:

usually administered with isoniazid, rifampicin, ethambutol and pyrazinamide.

Aggressive surgery approach.

Prevent deformity. Expect good outcome.

INDICATION OF SURGERY TYPE

PROGNOSIS
Patients

with dorsolumbar lesions have the worst prognosis ;

as they tend to collapse more during the active phase of the disease and even more during the growth period.

Those

with lumbar lesions have the best prognosis;

with the least deformity at presentation, a lesser increase during the active phase, and also a tendency for substantial decrease during the growth period.

CASE REPORT
since 3 months ago.

a hump on the back since one year ago

Major Complaint: BACK PAIN

and the pain has deteriorate since one week ago.

Decrease in limb coordination (+) since 2 months ago

Analgesic drugs are effective (+).

But patient was noncompliant because after 2 months.

medication anti tuberculosis ( RHZE2 months & RH 4 months)

Patient was never brought to Hospital for evaluation until on the 5th November

dry coughs one week later, the cough productive but phlegm of the cough was repeatedly swallow .

2 years ago, patient was diagnosed with pulmonary tuberculosis

history of expose with a person who had prolonged cough and coughing out blood.

chief complaint of coughing for almost 6 months.

History of Birth: spontaneous labor, first child, birth weight: 2900 gram, birth length: 48cm, immediate crying (+), cyanosis (-) Feeding History From birth to 6 months : Breast milk only From 6 months to 9 months : Milk Porridge + Breast milk From 9 months to 12 months : Baby rice + Breast Milk From 12 months to now : Family food + formula milk

History of Growth and Development: The patient could hold head steady when held sitting by the age of 2 months. The patient was able to sit without support by the age of 7 months. The patients is able to crawl by the age of 8 months. The patient is able to imitates speech sounds by the age of 9 months. The patient is able to stand by herself without guidance at the age of 11 months. The patients uses mama and dada specifically for parents at the age of 11 months. The patient could walk with guidance since age 12 months. The patient is able to walk without guidance at the age of 15 months. The patient was able to talk in a complete sentence at the age of 24 months. The patient is able to use toilet with guidance at the age of 36 months.

History of Immunization : None History of previous illness : Pulmonary Tuberculosis History of previous medications : Isoniazid, Rifampicin, Pyrazinamid, Ethambutol

Physical Examination : Generalized status Body weight: 12.0 kg, Body length: 89 cm Body weight in 50th percentile according to age: 16.0 kg Body length in 50th percentile according to age: 103 cm Body weight in 50th percentile according to body length: 16.0 kg BW/BL: 14.5/16.0 x 100% = 90.6 % (normo weight) BW/age: 14.5/16.0 x 100% = 90.6 % BL/ age : 89/103 x 100% = 86.4 %

Presence Status :

Sensorium : Compos Mentis, Blood Pressure : 100/70 mmHg Temperature : 36.3C, HeART Rate : 90 bpm, Respiratory Rate : 20 tpm, Dyspnea (-), Edema (-), Cyanosis (-), Icteric (-), Anemic (-)

Localized Status : Head : Eye

Ear Mouth Nose

Neck

Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-). Nose : nasal flare (-), NGT (-), nasal canul (-). Ear and mouth: within normal limit.

Lymph node enlargement (-), jugular vein pressure: R2 cmH2O

Localized Status : Chest : Gibbus, kyphosis, chest retraction (-).RR: 20 tpm, regular, crackles (-/-), HR: 90 bpm, regular, murmur (-)., stridor (-) : Tender , peristaltic (+) N, Hepar and Lien wasn't palpable

Abdomen

Extremities :

Pulse: 90 bpm, regular, adequate pressure/volume, CRT<3", warm, BP : 100/70 mmHg Female, within normal range (-)

Urogenital

Localized Status :

Physiological Reflex :

KPR (+), APR (+)

Pathological Reflex :

Oppenheim (-), Hoffman (-), Babinsky (-),Chaddock (-), Gordon (-), Nuchal Rigidity (-) Ankle clonus (+)

Hemoglobin (Hb) Erytrocyte (RBC)

Complete blood count 05/11/2012 06/11/2012 10.70 g% 10.50 g% 4.48 x 106/mm3 4.42 x 106/mm3 9.72 x 103/mm3

Leukocyte (WBC) 9.77 x 103/mm3

Hematocrite 32.60 % 32.60 % Trombocyte (PLT) 422 x 103/mm3 420 x 103/mm3 MCV MCH MCHC Neutrofil Lymphocyte Monocyte Eosinophil Basophil

Natrium (Na) Kalium (K) Chloride (Cl)

70.60 fL 70.60 Fl 23.60 pg 23.50 pg 33.70 g% 33.30 g% 65.60 % 63.90 % 26.90 % 26.00 % 7.70 % 7.40 % 1.00 % 1.00 % 0.20 % 0.10 % Electrolyte 05/11/2012 135 mEq/L Natrium (Na) 3.8 mEq/L Kalium (K) 104 mEq/L Chloride (Cl) Phosphor Magnesium (Mg) Albumin

07/11/2012 10.50 g% 4.45 x 106/mm3 9.54 x 103/mm3 30.10 % 418 x 103/mm3 70.40 fL 23.50 pg 32.90 g% 61.60 % 21.30 % 6.70 % 1.30 % 0.10 %

27/11/2012 11.50 g% 4.60 x 106/mm3 9.04 x 103/mm3 31.30 % 455 x 103/mm3 81.40 fL 26.50 pg 31.30 g% 38.60 % 30.60 % 7.70 % 1.00 % 0.06 % 27/11/2012 131 mEq/L 5.0 mEq/L 104 mEq/L 5.1 mEq/L 2.30 mEq/L 3.8 g/dl

29/11/2012 12.70 4.76 x 106/mm3 7.08 x 103/mm3 37.20 % 430 x 103/mm3 82.50 fL 26.70 pg 31.40 g% 66.40 % 25.60 % 7.50 % 0.30 % 0.200 %

Alkaline phosphate AST/SGOT ALT/SGPT

Liver function test 06/11/2012 174 U/L 24 U/L

5 U/L

Bilirubin Total Bilirubin direct Alkaline phosphate AST/SGOT ALT/SGPT Ureum

0.20 mg/dl 0.12 mg/dl 151 U/L 27 U/L 13 U/L

Ureum Creatinine Blood urea nitrogen

Renal function Test 10.0 mg/dl 0.32 mg/dl 8.0 mg/dl

Creatinine

22.60 mg/dl 0.24 mg/dl Blood urea 7.5 mg/dl nitrogen Waktu protrombin APTT Waktu trombin 1.13 detik

Ferritin

Homeostatic function test 260.40 ng/ml INCREASE

Iron (Fe) TIBC

16 mg/dl 215 g/dl

Other test 06/11/2012 0.5g/L 06/11/2012 1.5 mmol/L 05/11/2012 60 mg/dl

0.85 detik 0.92 detik

Procalcitonin Lactic Acid Blood glucose

Procalcitonin Lactic Acid Blood glucose

0.15 g/L 1.8 mmol/L 105.0 mg/dl

SENSITIVITY TEST 11TH NOVEMBER 2012

Type of examination : Bactec culture Type of specimen Microorganism

NO 1 2 3 4 5

: Blood : Staphylococcus saprophyticus

ANTIBIOTIC Ampicillin Amoxylin Amoxyclav Chloramphenicol Cefotaxim CONC. DISK 10g 20g 20g 30g 30g RESULT R R S R R

6
7 8 9 10 11 12 13 14

Cefepime
Cefuroxime Erythromycin Tigecycline Linezolid Netilmicin Imipenem Sulfamethoxazole Cefoperazone

30g
30 g 15 g 15 g 30 g 30 g 10 g 100 g 75 g

R
R S S S S R R R

SENSITIVITY TEST 11TH NOVEMBER 2012

Type of examination : Bactec culture

Type of specimen
Microorganism

: Blood
: Mycobacterium Tuberculosis

NO

ANTIBIOTIC

CONC. DISK

RESULT

Rifampicin

10 g

Isoniazid

15 g

Ethambutol

20 g

Pyrazinamid

30 g

THORAX X-RAY RESULT (NOVEMBER 5TH 2012)

Interpretation of x-ray : Position asymmetrical with inspiration not enough. Aorta is normal, superior mediastinum is not widen. Trachea is in a medial position.

Deformity of thoracal was found.

Infiltrate in right lung was found. The shape and size of the heart is difficult to be determined. The hilus cant be evaluate. Costa phrenicus sinus and diaphragm is normal. The ribs is in a good condition. Normal vascular and bronchus pattern. Conclusion: Deformity in thoracal. N/B: Spinal TB causes unsually shaped with opacification of right middle lobe and lingula.

THORAX X-RAY RESULT (NOVEMBER 5TH 2012)

Interpretation of x-ray: Shape and density of the corpus vertebra bone is in a good condition. Destruction of corpus vertebra Th 9 until Th 12 and narrowing of discus causes the vertebra thoracalis to be unaligned. kyphosis and medial costa of Th 9 until Th 12 shaped like spide leg. Osteophyte was not found. Space of intervertebralis is not narrowed. Pedicle is still intact. Soft tissue is normal. Conclusion: Spondylitis thoracalis.

THORAX X-RAY RESULT (DECEMBER 1ST 2012)

Interpretation of x-ray : Position asymmetrical with inspiration not enough. Aorta is normal, superior mediastinum is not widen.

Trachea is in a medial position.

Infiltrate in right lung was found. The shape and size of the heart is difficult to be determined. The hilus cant be evaluate. Costa phrenicus sinus and diaphragm is normal. The ribs is in a good condition. Normal vascular and bronchus pattern. Conclusion: Normal lung with suspect pneumonia dd/ deformity in thoracal (opacification of right lobe)

MRI RESULT (NOVEMBER 10TH 2012)

MRI RESULT (NOVEMBER 10TH 2012)

MRI RESULT (NOVEMBER 10TH 2012)

MRI RESULT (NOVEMBER 10TH 2012)

Interpretation of MRI: MRI lumbal spine `with sagittal plane T1W, T2W and axial plane T1W, T2W,TSE without IV contras. Destruction of vertebra T10,T11, T12 and L1 with the discus and signal of marrow is hypointense at T1 with paravertebral soft tissue mass. Kyphosis of thoraco-lumbalis. There is no pathology signal on other corpus vertebra. Other discus lumbal intervertebralis has normal signal. There was no disc prolapsed found. Pedicles, lamina and ligamentum flavum is normal. Caliber of medulla spinalis is normal and there is no abnormal signal. Medulla spinalis conus ia at level L1. Conclusion: Destruction of corpus vertebra T10,T11,T12,L1 and discus with paravertebral abscess, ec suggestive spondylitis TB with kyphosis thoraco-lumbalis.

Working Diagnostic

Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Injection ceftriakson 400mg /12 hours/IV Paracetamol 3 x 150mg

Management

Diagnostic Planning

Complete blood count ESR and CRP Anemia profile Sensitive test oral anti tuberculosis

S O Head

Back pain (+) Sens: CM, BP: 100/70 mmHg, HR: 90 bpm, RR: 24 tpm, Temp: 36.3C, body weight: 14.5 kg : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck Thorax

: Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 24 tpm, regular,

crackles (-), murmur (-), stidor (-) .

HR: 90 bpm, regular, murmur (-) RR :24 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse: 90 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Injection ceftriakson 400mg /12 hours/IV Paracetamol 3x 150 mg X-Ray in PA position suggest there is deformity in thoracal X-Ray in lateral position suggest that there is spondylitis thoracalis. Complete blood count shows that patient has anemia microcytic and hypochromic. Homeostatic function test: Ferritin increase; suggest anemia of chronic disease Electrolyte, liver function test, renal function test, random blood glucose, procalcitonin, lactic acid is normal. Planning: Sensitive test oral anti tuberculosis for Mycobacterium Tuberculosis and other antibiotic for Staphylococcus

6th 8thNovember 2012 S O Back pain (+) Sens: CM, BP: 110/70 mmHg, HR: 88 bpm, RR: 20 tpm, Temp: 36.3C, body weight: 14.5 kg Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit. Neck Thorax : Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 20 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :20 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse: 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Injection ceftriakson 400mg /12 hours/IV Injection ampisilin 400mg/6 hours/IV (visit of dr.Rini Daulay, Sp.A(K) ) Paracetamol 3 x 150mg Complete blood count: anemia microcytic and hypochromic Planning: MRI lumbal spine with saggital and axial plane.

9thNovember 2012 S O Back pain (+) Sens: CM, BP: 110/70 mmHg, HR: 88 bpm, RR: 20 tpm, Temp: 36.3C, body weight: 14.5 kg

Head

: Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: within
normal limit. Mouth: within normal limit.

Neck Thorax

: Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 20 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :20 tpm, regular, ronchi (-)

Abdomen Extremities

: Tender (+), peristaltic (+), liver and spleen not palpable : Pulse: 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-).

Genital
A

: Male
Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Injection ceftriakson 400mg /12 hours/IV Injection ampisilin 400mg/6 hours/IV Paracetamol 3 x 150mg MRI: Destruction of corpus vertebra T10,T11,T12,L1 and discus with paravertebral abscess, ec suggestive spondylitis TB with kyphosis thoraco-lumbalis.

10thNovember 2012 S O Back pain (-)

Sens: CM, BP: 110/70 mmHg,

HR: 88 bpm, RR: 20 tpm, Temp: 36.3C, body weight: 14.5 kg

Head

: Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck Thorax

: Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 20 tpm, regular,

crackles (-), murmur (-), stidor (-) .

HR: 88 bpm, regular, murmur (-) RR :20 tpm, regular, ronchi (-)

Abdomen
Extremities

: Tender (+), peristaltic (+), liver and spleen not palpable

: Pulse: 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-).

Genital A

: Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Injection ceftriakson 400mg /12 hours/IV Injection ampisilin 400mg/6 hours/IV Paracetamol 3 x 150mg

11thNovember 2012 S O Back pain (-) Sens: CM, BP: 110/70 mmHg,

HR: 88 bpm, RR: 20 tpm, Temp: 36.3C, body weight: 14.5 kg

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit. Neck Thorax : Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 20 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :20 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse: 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Paracetamol 3 x 150mg Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg Sensitive test for Mycobacterium Tuberculosis: Rifampicin, Isoniazid, Pyrazinamid, Ethambutol is still sensitive. Sensitive test for Staphylococcus saprophyticus: Erythromycin, Tigecycline, Linezolid, Netilmicin, Amoxylin is

12th-22thnovember 2012 S O Back pain (-) Sens: CM, BP: 110/70 mmHg, HR: 88 bpm, RR: 20 tpm, Temp: 36.3C, body weight: 14.5 kg Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck
Thorax

: Lymph node enlargement (-), R-2cmH20.

: gibbus, kyphosis, retraction (-), RR; 20 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :20 tpm, regular, ronchi (-)

Abdomen Extremities

: Tender (+), peristaltic (+), liver and spleen not palpable : Pulse: 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-).

Genital A

: Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of

chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Paracetamol 3 x 150mg Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg

23rd November 2012 S O Back pain (-) Sens: CM, BP: 110/70 mmHg,

HR: 84 bpm, RR: 24 tpm, Temp: 36.8C, body weight: 14.5 kg

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit. Neck Thorax : Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 24 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 84 bpm, regular, murmur (-) RR :24 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 84 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Paracetamol 3 x 150 mg Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg Patient is to be consult to orthopedics for further proceeding.

24rd November 2012 S O Back pain (-) Sens: CM, BP: 110/70 mmHg,

HR: 84 bpm, RR: 24 tpm, Temp: 36.8C, body weight: 14.5 kg

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit. Neck Thorax : Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 24 tpm, regular,

crackles (-), murmur (-), stidor (-) .

HR: 84 bpm, regular, murmur (-) RR :24 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 84 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Paracetamol 3 x 150 mg Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg Orthopedic department : Laminectomy to avoid further complication to the neurological system.

24rd November 2012 S O Back pain (-) Sens: CM, BP: 110/70 mmHg,

HR: 84 bpm, RR: 24 tpm, Temp: 36.8C, body weight: 14.5 kg

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit. Neck Thorax : Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 24 tpm, regular,

crackles (-), murmur (-), stidor (-) .

HR: 84 bpm, regular, murmur (-) RR :24 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 84 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Paracetamol 3 x 150 mg Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg Patient is moved to orthopedic department for preperation before surgery.

26th November 2012 S O Back pain (-), Preparation for surgery Sens: CM, BP: 110/70 mmHg,

HR: 88 bpm, RR: 23 tpm, Temp: 36.7C, body weight: 14.5 kg

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit. Neck Thorax : Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 23 tpm, regular,

crackles (-), murmur (-), stidor (-) .

HR: 88 bpm, regular, murmur (-) RR :23 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm,

capillary refill time (CRT) <3, clubbing finger (-).

Genital A : Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive + Anemia of chronic disease. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Paracetamol 3 x 150 mg Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg Patient is consult to anesthesic department for anesthesia during surgery.

27th November 2012 S O Back pain (-), Preparation for surgery. Sens: CM, BP: 110/70 mmHg, HR: 96 bpm, RR: 24 tpm, Temp: 36.5C, body weight: 14.5 kg Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit. Neck Thorax : Lymph node enlargement (-), R-2cmH20. : gibbus, kyphosis, retraction (-), RR; 24 tpm, regular, crackles (-), murmur (-), stidor (-). HR: 96 bpm, regular, murmur (-) RR :24 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 90 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive.

Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Paracetamol 3 x 150 mg Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg 1. Patient started to fast and given dulcolax tablet at 00.00 am and is given dulcolax suppository at 04.00 2. Preparation of transfusion PCR 150cc 3. Preparation of laminectomy and all procedure is sterile. 4. Surgery area is shaved and marked. 5. Patient is later anesthesia by the anesthesia specialist. 6. Orthopedic surgeon wash their hand so that its sterile. 7. Sterile dapping is done. 8. Incision is started. 9. Pedicle screw is implant in the posterior vertebra to stabilize the vertebra; T10 and L2. 10. Surgery is done. 11. Wound is closed with sterile gauze. 12. Patient is then cleaned. 13. Intervention proceed. 14. Patient is moved to the ward of orthopedic in RB 1 because patients parent refuse that patient is to be moved in PICU. Results: complete blood count normal, electrolyte normal, liver function test normal, blood glucose ad random normal, procalcitonin normal,

S O

28th November 2012 Observation post surgery, patient still in pain (crying). Back pain (+) Sens: CM, BP: 110/60 mmHg, HR: 88 bpm, RR: 23 tpm, Temp: 36.9C, body weight: 14.5 kg

Head

: Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck Thorax

: Lymph node enlargement (-), R-2cmH20. : gibbus smaller, retraction (-), RR; 23 tpm, regular,crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :23 tpm, regular, ronchi (-)

Abdomen Extremities

: Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-).

Genital A

: Male Post laminectomy of tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro NGT with sonde food 1500kkal/24 hours Paracetamol 3 x 150 mg Ketorolac 0.5 cc/ 8jam Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg Patient regain consciousness 6 hours after surgery but she was still irritable and still in pain. After 6 hours of surgery patient was given sonde food through NGT.

S O

29th November 2012 30th November 2012 Observation post surgery, patient is fully conscious and not irritable anymore. Back pain (-) Sens: CM, BP: 110/70 mmHg, HR: 88 bpm, RR: 24 tpm, Temp: 36.3C, body weight: 14.5 kg

Head

: Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck Thorax

: Lymph node enlargement (-), R-2cmH20. : gibbus smaller, retraction (-), RR; 24 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :24 tpm, regular, ronchi (-)

Abdomen Extremities

: Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-).

Genital A

: Male Post laminectomy of tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive.

Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro NGT with sonde food 1500kkal/24 hours Paracetamol 3 x 150 mg Ketorolac 0.5 cc/ 8jam Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg Complete blood count results: normal.

S O

1st December 2012 Observation post surgery, patient is fully conscious and was not able to sit, before surgery patient was able to walk by herself. Back pain (-) Sens: CM, BP: 110/70 mmHg, HR: 94 bpm, RR: 23 tpm, Temp: 36.3C, body weight: 14.5 kg

Head

: Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck Thorax

: Lymph node enlargement (-), R-2cmH20. : gibbus smaller, retraction (-), RR; 23 tpm, regular, crackles (-), murmur (-), stidor (-) .

HR: 94 bpm, regular, murmur (-)

RR :23 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 94 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Post laminectomy of tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive. Bed rest IVFD D5% NaCl 0.45% 50 gtt/i/micro NGT with sonde food 1500kkal/24 hours Paracetamol 3 x 150 mg Ketorolac 0.5 cc/ 8jam Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg Planning: Physiotherapy

S O

2nd December 2012 Observation post surgery. Back pain (-). Sit (-). Stand (-). Walk (-). Sens: CM, BP: 110/70 mmHg,

HR: 88 bpm, RR: 22 tpm, Temp: 36.5C, body weight: 14.5 kg

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit. Neck Thorax : Lymph node enlargement (-), R-2cmH20. : gibbus smaller, retraction (-), RR; 22 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :22 tpm, regular, ronchi (-) Abdomen Extremities : Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-). Genital A : Male Post laminectomy of tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive. P Bed rest Physiotherapy for gross motoric IVFD D5% NaCl 0.45% 50 gtt/i/micro NGT with sonde food 1500kkal/24 hours Paracetamol 3 x 150 mg Ketorolac 0.5 cc/ 8jam Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg

S O

3rd December 2012- 5th December 2012 Observation post surgery. Back pain (-). Sit (+), Stand (-), Walk (-) Sens: CM, BP: 100/70 mmHg, HR: 88 bpm, RR: 22 tpm, Temp: 36.9C, body weight: 14.5 kg

Head

: Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck

: Lymph node enlargement (-), R-2cmH20.

Thorax

: gibbus smaller, retraction (-), RR; 22 tpm, regular,

crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :22 tpm, regular, ronchi (-)

Abdomen Extremities

: Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-).

Genital A

: Male Post laminectomy of tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive.

Bed rest Physiotherapy gross motoric IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein / 1500kkal Paracetamol 3 x 150 mg Ketorolac 0.5 cc/ 8jam Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg

S O

6th December 2012 13th December 2012 Observation post surgery. Back pain (-). Sit (+), Stand (+), Walk (-) Sens: CM, BP: 110/70 mmHg, HR: 88 bpm, RR: 24 tpm, Temp: 36.7C, body weight: 14.5 kg

Head

: Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck
Thorax

: Lymph node enlargement (-), R-2cmH20.

: gibbus smaller, retraction (-), RR; 24 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 88 bpm, regular, murmur (-) RR :24 tpm, regular, ronchi (-)

Abdomen Extremities

: Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 88 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-).

Genital A

: Male Post laminectomy of tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to thrive.

Bed rest Physiotherapy gross motoric IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein 1500kkal/24 hours Paracetamol 1 x 150 mg (given when needed only) Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg

S O

14th-15thDecember 2012 Observation post surgery. Back pain (-). Sit (+), Stand (+), Walk (+) Sens: CM, BP: 110/80 mmHg, HR: 94 bpm, RR: 25 tpm, Temp: 36.7C, body weight: 14.5 kg

Head

: Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-) Ear: within normal limit. Nose: within normal limit. Mouth: within normal limit.

Neck Thorax

: Lymph node enlargement (-), R-2cmH20. : gibbus smaller, retraction (-), RR; 25 tpm, regular, crackles (-), murmur (-), stidor (-) . HR: 90 bpm, regular, murmur (-) RR :20 tpm, regular, ronchi (-)

Abdomen Extremities

: Tender (+), peristaltic (+), liver and spleen not palpable : Pulse = 90 bpm, regular, adequate pressure/volume, warm axilla, BCG scar (-) right arm, capillary refill time (CRT) <3, clubbing finger (-).

Genital A

: Male Post laminectomy of tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia + Failure to

thrive.
P Bed rest Physiotherapy gross motoric IVFD D5% NaCl 0.45% 50 gtt/i/micro Normal food diet with high protein 1500kkal/24 hours Paracetamol 3 x 150 mg (given when needed only) Isoniazid 150 mg Rifampicin 150 mg Pyrazinamide 400 mg Ethambutol 275 mg

Patient is advised to go back home and control regularly to the polyclinic of pediatrics respirology and polyclinic of orthopedic. Patient went back home on 15th December 2012 at 22.00 WIB. IVFD was taken out at 18.00 WIB. The medication given are Isoniazid 150mg, Rifampicin 150 mg, Pyrazinamide 400mg, Ethambutol 275mg and Paracetamol 150mg (given when needed only). Patients family is educated to control regularly to polyclinic pulmonary in Adam Malik General Hospital and physiotherapy twice/ week. Patients family is advised to take anti-TB medication everyday for 12 months.

DISSCUSION
THEORY
Potts Disease is a combination of osteomyelitis and arthritis which involves multiple vertebrae. The typical site of involvement is the anterior aspect of the vertebral body adjacent to the subchondral plate and occurs most frequently in the lower thoracic vertebrae. The thoracic spine involvement accounting for 25-50%. The lumbar and lumbosacral spine for 2550%. The cervical for 5-25%. Risk factor for tuberculous spondylitis : trauma, low social economy age previous infection of pulmonary tuberculosis

CASE In our patient, tuberculous spondylitis involves 4 vertebras (multi vertebrae) which are T10, T11, T12, L1. The site involved is the 10th thoracal until 1st lumbal which is the lower thoracic vertebra. In this case, the spine thats involved are thoracal-lumbal.

In this patient, the risk factor thats been identified are low social economy, young age which is only 4 years old and previous infection of pulmonary tuberculosis.

DISSCUSION
THEORY The most common mode of presentation in a child less than 5 years old is development of a gibbus. Patient of tuberculous spondylitis may complaint back pain. Weakness and paralysis of lower extremities may occur early during the course of the disease. The most common mechanism is haematogenous spread from a primary or reactived focus in another body part, mainly the lungs. CASE This case patient had gibbus by the age of 3 years old. In our patient, the main complaint was having back pain. Patient also had neurological problems whereby patient tend to limb while walking Patient had history of pulmonary tuberculosis when patient was 2 years old.

In the juvenile and adolescents, sufficient bony destruction must have happened to be visible on the X-ray. Inter-vertebral disc enhancement, vertebral collapse and kyphosis deformity are particularly suggestive

In this case, the X-ray in this patient shows deformity of thoracal-lumbal. MRI of this patient shows destruction of corpus vertebra T10,T11,T12,L1 and discus with paravertebral abscess.

DISSCUSION
THEORY CASE

Patient with spondylitis TB is given anti tuberculosis drugs and the kyphotic deformity is handled by using of more sophisticated equipment like the pedicle screw system.

In this case patient was give anti tuberculosis drugs and went through laminectomy with a pedicle screw on posterior vertebra of T10 and L2.

SUMMARY
NHE, female, 4 years old was admitted to Pediatrics Department of RSUP HAM Diagnosed with tuberculous spondylitis stage IV with stadium I (negligible) of tuberculous paraplegia and failure to thrive and anemia of chronic disease. Patient was discharged from hospital on the 15th December 2012 . Patient was advised to control regularly to the polyclinic of orthropedics and polyclinic of pediatrics respirology.

PRE-SURGERY

GIBBUS

POST SURGERY

QUESTIONS ???

WEEK 1: bagaimana setelah pemberian oat masih terjadi penyebaran?

WEEK 2:mengapa diberikan ampicilin dan ceftriaxone pada awal follow up? Apakah setelah laminektomi berkurangnya gibbus terjadi progresif?prognosa pada pasien?

WEEK 3:pada waktu pemeriksaan refleks patologi (-), apakah memang pada sondilitis tb tidak ada terjadi kelainan neurologis?
WEEK 4: apakah indikasi pembedahan pada sponilitis tb? Kenapa pasien tidak bisa duduk setelah paska operasi? WEEK 6: bagaimana penegakan diagnosis spondilitis tb?

THANK YOU
HOPEFULLY THIS PRESENTATION IS INFORMATIVE FOR ALL OF US.