P O T T S

DISEASE

Pembuat : TONDO BAYU (11-2011-048) MERCY SYLVIA (11-2012-009) Pembimbing : dr. Suhana, SpOT

POTTs DISEASE
Definition
Potts disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. It is named after Percivall Pott (1714-1788), a London surgeon who trained at Barts. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. AKA: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's disease

POTTs DISEASE
Etiology
Potts disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott'sdisease often develops kyphosis, which results in a hunchback.

Pathophysiology Of Tuberculous Spondylitis

Tuberculous spondylitis
Cold Abscesses
Not as hot, warm or painful as other abscesses

Hidden deep inside the body

May burst out leaving behind a track, or sinus, which discharges pus

POTTs DISEASE
Epidemiology
Approximately 1-2% of total tuberculosis cases are attributable to Potts disease. The incidence rate here in the Philippines is approximately 20-30% of the entire patient diagnosed to have Tuberculosis. Most of the cases of the Pott's disease in the Philippines are caused by the non-compliance of the treatment regimen of TB. Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of TB occurs in poorer countries, but a global resurgence is affecting richer ones. The disease affects males more than females in a ratio of between 1.5 and 2:1. In the USA it affects mostly adults but in the countries where it is commonest it affects mostly children.

POTTs DISEASE
Risk Factors
Tuberculosis/Endemic TB Poor socioeconomic conditions Diabetes Steroid Use Chronic Disease Immunosuppression IV drug Abuse Rheumatoid Arthritis

POTTs DISEASE
Signs and Symptoms
Localized back pain Paravertebral swelling Systematic signs and symptoms of TB Neurological signs may occur leading to paraplegia Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of the leg

POTTS DISEASE

POTTS DISEASE

POTTS DISEASE

PHYSICAL ASSESSMENT

Body Parts Height

Actual Findings Change of shape of back Weight loss

Analysis kyphosis

Weight

Anorexia

Vital signs
Temperature

Normal Findings 36.5-37.5 degrees Celsius

Actual Findings Increase in temperature

Analysis

Febrile

General Survey
Body built Overall hygiene and grooming Normal Findings mesomorph clean and neat Actual Findings Ectomorph Self bathing hygiene deficit Analysis Deviation from Normal Deviation from Normal

POTTS DISEASE

PHYSICAL ASSESSMENT
Assessment of the Skin
Normal Findings Actual Findings Analysis

Skin color

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive -Fundamentals of Nursing 8th edition Kozier and Erbs page 579

redness

erythema

No edema Presence of edema -Fundamentals of Nursing 8th edition Kozier and Erbs page 579 with edema edema

Uniform: within normal range Skin temperature -Fundamentals of Nursing 8th edition Kozier and Erbs page 579 Warm skin temperature

Febrile
Deviation from Normal

PHYSICAL ASSESSMENT
Assessment of the Nose

Palpate the maxiliary and frontal sinuses for tenderness

Not tender

Tenderness in one or more sinuses

Deviation from normal

Assessment of the Thorax

Posterior Thorax Normal Findings Spine is vertically aligned. Spinal column is straight, right and left shoulder and hips are at the same height. - Fundamentals of Nursing 8th edition Kozier and Erbs page 614 No tenderness, no masses Actual Findings Analysis

Inspect the spinal alignment for deformities.

Exaggerated spinal curvatures

Kyphosis due to gibbous formation

Palpate the posterior thorax

Pain with palpation over the spine

Deviation from normal

PHYSICAL ASSESSMENT
Assessment of the Musculoskeletal System
Normal Findings Equal in size on both body parts. Inspect the muscle for size. - Fundamentals of Nursing 8th edition Kozier and Erbs page 640 Equal strength on each body sides ( sternocleidomastoid, trapezius, deltoid, biceps, triceps, wrist and finger, grip strength, hip and hamstring. - Fundamentals of Nursing 8th edition Kozier and Erbs page 640 Varries in accordance to a person genetic make-up Fundamentals of Decrease range of motion. Pain in movement Nursing 8th edition Kozier and Erbs page 641 Muscle atrophy Deviation from Normal Actual Findings Analysis

Test muscle strength.

Weakness

Deviation from Normal

Assess range of motion

Deviation from Normal

Bones
Inspect the skeleton for structure No deformities Bones misaligned Presence of tenderness or swelling Deviation from normal Deviation from normal

Palpate the bones to locate any No tenderness or swelling areas of edema or tenderness

Joints
Inspect the swelling. Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence of nodules. No swelling No tenderness, crepitation or nodules Joints move smoothly Varies to some degree in accordance with persons genetic make-up and degree of physical activity Swelling joints Deviation from Normal

Assess joint range of motion

Decreased range of motion

Deviation from normal

DIAGNOSTICS

Diagnosis
Blood cp( ESR) Range of motion in the spine. A series of neurological tests complete medical history blood immunoglobin profile X-rays magnetic resonance images (MRIs)

CT scan guided biopsy

Bone scans

DIAGNOSTIC PROCEDURE
Blood Test- elevated ESR Tuberculine Test Radiographs of the spine Bone Scan CT of the Spine Bone biopsy

MICROBIOLOGY
Needle biopsy Acid-fast strain and culture

DIAGNOSTIC PROCEDURE
Imaging Studies
CT scanning
CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference. Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal areas.

MRI
MRI is the criterion standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression.

LABORATORY RESULTS:
Laboratory Studies
Tuberculin skin test (purified protein derivative [PPD]) Results are positive in 84- 95% of patients with Pott disease who are not infected with HIV

The erythrocyte sedimentation rate (ESR)

May be markedly elevated (>100mm/h).

Microbiology studies
Are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. These study findings are positive in only about 50% of the cases.

LABORATORY RESULTS Aspirate from joint space & abscess

Transparency: turbid. Colour: creamy. Consistency: cheesy. Fibrin clot: large. Mucin clot: poor. WBC: 25000/cc.mm.

LABORATORY RESULTS
Imaging Studies
Radiography
Radiographic changes associated with Pott disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain radiography: Lytic destruction of anterior portion of vertebral body Increased anterior wedging Collapse of vertebral body Reactive sclerosis on a progressive lytic process Enlarged psoas shadow with or without calcification

Additional radiographic findings may include the following:

Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or destroyed. Vertebral bodies show variable degrees of destruction. Fusiform paravertebral shadows suggest abscess formation. Bone lesions may occur at more than one level.

LABORATORY RESULTS
Imaging Studies
X-Ray spine
Early: Narrowed joint space. Diffuse vertebral osteoporosis adjacent to joint. Erosion of bone. Fusiform paraspinal shadow of abscess in soft tissue.
Late: Destruction of bone. Wedge-shaped deformity (collapse of vertebrae anteriorly). Bony ankylosis.

LABORATORY RESULTS
Imaging Studies
CT SCAN CT scanning reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses. In contrast to pyogenic disease, calcification is common in tuberculous lesions.

MRI MRI findings useful to differentiate tuberculous spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.

DIFFERENTIAL DIAGNOSIS
Osteitis Piogen Poliomielitis Skoliosis idiopatik Metastasis spinal cord
Pulmo infection after empiema

Kifosis senilis

Complication
Spinal cord injury Empyema tuberculosis

Treatment
Drug treatment Bed rest Spinal braces Surgery