Case (71)

[Dr.Habiib]

Isniina is 24 year old female came to outpatient clinic complaining of pain in lower back. The condition was accompanied by low grade fever and night sweats. By examination, there was tenderness over lower thoracic vertebrae.
Investigations:
X-ray  of spine: The disc space between T12 and L1 was narrow.
There was bone destruction seen as osteolytic areas of both T12 and L1 and there was a soft shadow surrounding the two vertebral bodies.
X-ray of chest reveals radiolucent shadow surrounding area the apex of right lung suggestive of cavity.

1. What is the possible diagnosis?

2. Biopsy from the bone was taken to confirm the diagnosis. What is the microscopic picture of histopathology?

3. IF I sent sample to microbiology Lab. What I see under the microscope, what is the specific stain you will use?

4. What is the soft shadow showing the x-ray?

5. Why is -the radiolucent area at the apex of right lung is suggestive?

6. Give two other possible differential diagnoses for spine lesion.

7. What are complications of this condition?



 

[drboqolsoon]

first of all I'm sorry fore less history and investigation(laboratory (ESR,white cell count )
1. the most possible diagnose is -Tuberculosis of Spine (tuberculous spondylitis)
    there are other possible such as:Suppurative spondylitis,Leukemia.
2.There is giant cells and caseating granulomatous inflammation with bone necrosis, resulting in the destruction of bone.
3. use see rods  2-4 micrometers in length and 0.2-0.5 um in width.
   you will do acid first stain using ether Two media are used to grow MTB Middlebrook's medium which is an agar based medium and Lowenstein-Jensen medium which is an egg based medium. MTB colonies are small and buff colored when grown on either medium.
4.there pus formation because of distraction of wbs
5. may be there is primary lung tb-infection
6.    * Suppurative spondylitis
    * Leukemia
    * Hodgkin’s disease
    * Eosinophilic granuloma
    * Aneurismal bone cyst
    * Ewing’s sarcoma.
7. complication: paralysis,neurological problem,Abscesses from dorsolumbar
    

NB:
this is for educational purpose not for treatment
please contact your doctor  .

[Dr.Habiib]

Thank you    drboqolsoon   for you answer.

Really there is no more investigation but I believe that you can reach the diagnosis for these view investigations stressing the following:

- Two or more adjacent vertebral discs as well as vertebral disc are destroyed. It is worth noting that destruction of the disc is an important radiological sign that distinguishes Tb of vertebrae from metastases.
- Night sweating.
- Large apical cavity in the lung.


 For more details let me to make more explaining for this case.


Answers:

1. Diagnosis: Pott`s disease (TB) of bones T12 and L1 vertebrae secondary to chronic fibrocaseous pulmonary TB of right lung.




2. Microscopic picture of biopsy bone shows in histopathology lab:

- Large areas of homogenous pink caseation and destroyed bone and cartilage.

- Recent tubercles are present which consist of:

a. Caseation necrosis: which appears in the center of tubercle as pink structure less material? It is surrounded by epithelioid cells, lymphocytes and giant cells.
b. Epithelioid cells: large altered macrophages with abundant pink cytoplasm indistinct cell bounders and large vesicular nuclei.
c. Langhan`s gaint cells: These are large cells with pink cytoplasm and several peripheral located nuclei forming circle or U-shaped arch (Horse shoe pattern).
They engulf bacteria and caseous material.
d. Lymphocytes (mainly T- cells) from peripheral zone.

   





3. in microbiology lab:

Smears prepared directly from sputum or sediment after concentration is subjected to one of the following acid-fast staining methods:
a. Zeihl-Neelsen or kinyoun method, using the carbol-fuchsin dye.
  In ziehl-Neelsen method, heat is used to help penetration of carbol-fuchsin.
In Kinyoun method, heat is not used but phenol is added to carbol-fuchsin.
Under the ordinary light microscope, acid fast bacilli appear pink in blue background.

B.Fluorochrome staining with auramine-rhodamine stain.
Under the UV microscope, acid fast bacilli fluoresce orange yellow in black background.




4. Soft shadow showing x-ray is cold abscess: Caseous materials collected under anterior vertebral ligament and squeezed into different places according to site of accumulation.




5. Always if we suspect any patient to Tb infection we make chest X-ray which is very important to know if there is pulmonary Tb or no:
The pulmonary Tb may be primary or secondary; any of both have a definite x-ray which suggests them.
In secondary there are two forms:
A. acute caseous bronchopneumonia which is acute fatal course.
B. chronic fibrocaseous pulmonary tuberculosis which has chronic course and the most common.
In chronic fibrocaseous of tuberculosis is essentially characterized by a cavity (or some times more than one cavity), the most common located in one or both lung apices.

This is due to the following reasons:

a. More common in right lung because it has wider bronchus.
 b. The apices have more oxygen and less blood supply.
c. Mycobacterium tuberculosis is a strict aerobe.
All of this reasons facilitate the formation of large cavity in the apices of lung which very important for diagnosis chronic fibrocaseous pulmonary TB, in addition night sweating which another factor that help you.




5. Two other differential diagnoses for spine lesion:

    a. Aortic aneurysm: Destroys the vertebral bodies and spares the intervertebral disc (because it is vascular).
  b. Spine tumor metastases: destroys the vertebral bodies but to destroy the intervertebral take long time and becomes late due to vascularity of intervertebral cartilage.





7. Complication of this condition:

a. Kyphosis: due to the caseous destruction of vertebrae and intervertebral discs.

b. Cold abscess: Caseous material collects under anterior vertebral ligament and squeezed into different places according to site of accumulation:
- TB of cervical vertebrae: the cold abscess acquires retropharyngeal position. It may appear at the posterior border of sternomastiod and may sometimes reach the axilla.
-TB of thoracic vertebrae: the abscess appears in posterior mediastinum.
- TB of lumbar vertebrae: the cold abscess may appear lumbodorsal triangle. The caseous materials may reach the psoas sheath and appear in femoral triangle (psoas cold abscess).

c. Paraplegia develops in 10% of cases due to:
-  Spinal cord compression.
- Ischemia: caused by endarteritis obliterans and sometimes thrombosis.
-Traumatic cord injury by fractured vertebrae.


Dr.Habiib