PEDIATRIC DEPARMENT FACULTY OF MEDICINE UNIVERSITAS PADJADJARAN/ Dr.

HASAN SADIKIN HOSPITAL

Division : Respirology
By : Adri Zamany Anwary
Preceptor : Prof. dr. Cissy R.S. Prawira., Sp.A(K), Msc, Phd
dr.Adi Utomo Suardi, Sp.A(K)MM
Prof. Dr. dr. Heda Melinda Sp.A(K), M.Kes
dr. Sri Sudarwati, Sp.A(K)
dr. Diah Asri Wulandari, Sp.A(K)

CASE REPORT TB SPONDILITIS

Introduction
Tuberculosis (TB) is an important health problem in the world, especially developing
countries in Asia and Africa. Indonesia is one of the countries with the highest incidence and
number of cases after India. Globally, currently there is nearly 1 million new reported findings
of TB case in children. Based on WHO data in 2015, in Indonesia, 75,000 new cases of TB in
children with an increased of extrapulmonary TB incidence in Indonesia, previously 7% of TB
cases in 2015 to 8% by 2016.
Extrapulmonary tuberculosis reaches 20-40% in worldwide with 20% found in
children. Children, woman and Africa or Asian descendant have a higher risk of developing
extrapulmonary TB. Of cases with extrapulmonary TB, 10-25% are musculoskeletal TB, with
prevalence in the world estimated at about 19-38 million cases.
Spondylitis tuberculosis (TB) or known as Pott's disease is an infectious disease caused
by the bacteria Mycobacterium tuberculosis in the spine. Spondylitis TB was first discovered
in mummies from Spain and Peru in 1779. Mycobacterium tuberculosis infection of the spine
was mostly spread by infection from the disc. The mechanism of infection is mainly by
hematogenous spread

Case Illustration
The 2-year-old girl, referred to RSHS respirology clinic with complaints of a lump in
the back that emerged since last month. Initial complaint was a peanuts sized lumps which is
not painful and felt growing since 2 months ago. Lump complaints accompanied by recurrent
fever which is not too high since 1 month ago. Complaints accompanied by cough that has
been felt since more than 2 weeks ago. A positive contact history with an adult tuberculosis
patient, the grandfather of the girl who died 2 months ago. There was also complaints about
difficulty to gain weight. The patient was then admitted to Al-Ihsan Hospital, then referred to
RSHS orthopedic RSHS because of Khypotic Deformity at thoracal 10 due to TB spondylitis,
planned for body cast and consultation to Pediatric Respirology clinic.
On physical examination, the vital signs are within normal limits. From the nutritional
status of the patient was found to have short stature.There was found a multiples gland
enlargement with a diameter of 0.5- 1 cm in diameter in another physical examination . At
localized status, a spine was found as high as a thoracic 9-10. Other general examination status
is within normal limits.
The patient then diagnosed with Tuberculosis spondylitis and short stature, treated with
intensive phase of Fixed Dose Theraphy in children and ethambutol. Patients are also scheduled
for examination of BTA, Mtbc Cultures, thorax and thoracolumbal X-ray.

Discussion
Spondylitis tuberculosis (TB) or known as Pott's disease is an infectious disease caused by
the bacteria Mycobacterium tuberculosis of the spine. TB spondylitis was first discovered in
mummies from Spain and Peru in 1779. Mycobatcterium tuberculosis infection of the spine
was mostly spread by infection from the disc. The mechanism of infection is mainly by
hematogenous spread. Based on WHO data in 2015, in Indonesia, 75,000 new cases of TB in
children with an increased of extrapulmonary TB incidence in Indonesia, previously 7% of TB
cases in 2015 to 8% by 2016

Extrapulmonary tuberculosis worldwide reaches 20-40% with 20% found in children. Of

cases with extrapulmonary TB, 10-25% are musculoskeletal TB, with world prevalence
estimated at about 19-38 million cases with the most frequent was spinal infection that occurs
in almost half of extrapulmonary TB incidence of bones and joints. Complications of TB
spondylitis can result in high levels of morbidity that can arise acute or chronic. Paralysis may
arise rapidly due to abscess, whereas chronic due to the development of kiposis, vertebral
collap with retropulsion of bone and debris.

As in other extrapulmonary TB forms, the respiratory tract is the main portal of M.

tuberculosis entry that causes spondylitis. TB spondylitis is thought to occur secondary to the
occurrence of occult hematogenic spread to the bone gradually resulting in no clinical
symptoms at the time of initial lung infection, which in turn leads to local reactivation later in
life. The clinical findings are non-specific and the only early symptoms are swelling and pain
in the affected limbs.
The part of the spine that is frequently attacked is peridiscal in 33% of cases of TB spondylitis
and starts from the bone metaphysis section, with spread through the longitudinal ligament.
Radiology shows the presence of anterior vertebral scaloping, central to about 11.6% of cases
of TB spondylitis. The disease is confined to the center of the body of a single vertebra, thus
causing a vertebral collapse resulting in kipotic deformity. In these locations, TB germs will
replicate and form colonies of germs prior to the formation of cellular immunity that will limit
growth.
Clinical manifestations of patients with TB spondylitis are similar as TB patients in
general, patients experiencing the following conditions such as weight loss or difficulty to gain,
fever for no apparent reason, unpainful lymph node enlargement that, cough for more than 2
weeks. Clinical manifestations of TB spondylitis are not found in infants under 1 year. This
disease occurs only after the child learns to walk or jump. The first symptoms are usually
complained of a lump in the spine accompanied by pain. Spinal deformity of the spine
(kyphosis) occurs in 80% of cases accompanied by the occurrence of gibbus, the back that
bends and forms an angle, which is an unstable lesion and can develop progesively
The diagnosis of TB spondylitis can be established by full clinical examination including
a history of close contact with TB patients, epidemiology, clinical symptoms and neurological
examination. Modern imaging methods such as X ray, CT scan, MRI and ultrasound will
greatly help establish the diagnosis of TB spondylitis, laboratory examination with
Mycobacterium tuberculosis bacillus foundings will provide a definitive diagnosis.

Currently TB tuberculosis treatment is preferred with anti-TB drugs combined with

immobilization. Non-operative treatment using a combination of anti-tuberculosis drugs.
Treatment can be adjusted to the bacteria sensitivity information. Although some studies say it
requires only 6-9 months of treatment, routine treatment is done for 9 months to 1 year. The
duration of treatment is usually based on the improvement of clinical symptoms or patient
clinical stability. Nonoperative treatment of early-stage paraplegia will show an increased
result in half the number of patients and in the late stages occurring in a quarter of patients. If
there is Pott's paraplegia, a surgery should be done

Complications that can happen are severe kiposis. This happens because the bone damage
is so severe that the bone undergoes destruction. This will also facilitate the occurrence of
paraplegia in the inferior extremities known as Pott's paraplegia. The prognosis of TB
spondylitis varies with clinical manifestations. A poor prognosis associated with miliary TB,
and TB meningitis, can occur sequelae, among others, deafness, blindness, paraplegi, mental
retardation, impaired movements and others. Prognosis improves when treatment is done more
quickly. High mortality occurs in children aged less than 5 years to 30%

Conclusion

TB spondylitis is a complex disease problem with varying clinical manifestations.

Radiographic examination is absolutely necessary to make the diagnosis and follow up of the
disease. If the examination is normal, Biopsy tests should be done to exclude TB spondylitis.
Management is determined by the presence or absence of paralysis or paraplegi in the inferior
extremity so that surgery should be done immediately. The prognosis depends on the course of
the disease, the management and the accompanying complications