CASE REPORT

RESPIROLOGY DIVISION

SPONDYLITIS TUBERCULOSIS, PARAPARESIS INFERIOR DUE TO

COMPRESSION FRACTURE OF THORACIC VERTEBRA

Irfadah Dinar

C105192003

Supervisor :

dr. Amiruddin L, Sp.A(K)

DEPARTMENT OF PEDIATRICS

FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

MAKASSAR

2023
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 TABLE OF CONTENT

A. INTRODUCTION………………..……………………………………………………3
B. CASE REPORT………………………………………………………………………..4
I. PATIEN IDENTITY....................................................................................................4
II. PARENT IDENTITY....................................................................................................4
III. ANAMNESIS (SUBJEKTIVE)...................................................................................4
1. Personal or social history of the patient…………………………………………..4
2. Family History and socio-economic background.....................................................5
IV. DATA OF PATIENT’S CASE....................................................................................7
1. Physical Examination (Objektive)..................................................................................7
2. Supporting Examination…………………………………………………………………….8
V. RESUME.......................................................................................................................15
VI. WORKING DIAGNOSIS..........................................................................................15
VII. MANAGEMENT PLAN (PLANNING)..................................................................16
VIII. FOLLOW UP HYSTORY DISEASE.....................................................................18
IX. PROGNOSIS................................................................................................................24
X. DICSUSSION.................................................................................................................25
1. Definition..........................................................................................................................28
2. Pathophysiology...............................................................................................................29
3. Clinical manifestations....................................................................................................30
4. Supporting Examinations...............................................................................................31
5.Treatment............................................................................................................................33
XI. SUMMARY.....................................................................................................................35
REFERRENCES………………………………………………………………………………….36

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CASE REPORT

Respirology Division

SPONDYLITIS TUBERCULOSIS, PARAPARESIS INFERIOR DUE TO

COMPRESSION FRACTURE OF THORACIC VERTEBRA
Departement of Pediatric Faculty of Medicine Hasanuddin University
RSUP DR. Wahidin Sudirohusodo Makassar

A. INTRODUCTION

Tuberculosis is a direct infectious disease caused by the TB germ (Mycobacterium

tuberculosis). Most TB germs affect the lungs, but can also affect other organs. Pediatric TB
occurs in children aged 0-14 years. In developing countries, children less than 15 years of age
make up 40-50% of the general population and approximately 500,000 children worldwide
suffer from TB each year.
Tuberculous spondylitis is an infection of the spine caused by the germ
Mycobacterium tuberculosis. Since anti-tuberculosis drugs were developed and along with
improvements in public health, spinal tuberculosis has declined in industrialized areas,
although it remains a significant cause in developing countries. Tuberculous spondylitis can
be very destructive. The development of tuberculosis in the spine has the potential to increase
morbidity, including permanent neurological deficits and severe deformities. 5

World Heatlh Organization (WHO) shows that the incidence of extrapulmonary TB in

Indonesia is also increasing, in 2000 there were 833 cases, 2005 there were 6,142, 2010 there
were 11,659, 2011 there were 14,054, and 2012 there were 15,697. A study by Agrawal et al.
2010, stated that spinal TB accounted for 50% of all bone TB cases. TB spondylitis is one of
the extrapulmonary diseases. TB is frequently encountered and can cause disability and even
death. Spinal involvement is usually the result of hematogenous spread from a pulmonary
lesion or from infection of the genitourinary system This disease also has a socio-economic
impact because the patient's work and productivity will be hampered. 2

This paper reports a case of tuberculous spondylitis in a girl aged 16 years and 9 months.

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 B. CASE REPORT

I. PATIENT IDENTITY
Name : NH
Gender : Girl
Date of birth : 12 – 03 - 2006
Age at the time of case : 16 years 9 Months
Come to hospital : 1 Januari 2023
No. Medical Record : 1003xxx
Addres : Polman, Sulawesi Selatan
Start to be accepted as a case : 1 January 2023

II. PARENT IDENTITY

Father Mother

Name Mr. H Miss. M

Age 43 Years 41 Years

Jobs Enterpreuneur House Wife

Education Junior high school Junior high school

III. ANAMNESIS (SUBJEKTIVE)

Based on anamnesis and alloanamnesis from the patient's mother.

Chief complaint : Weakness on both lower limbs

1. History of present illness

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 Weakness on both lower limbs was experienced in the last 3 months and getting
worse in the last 1 month before admission. Initially, she felt numbness on both legs. The
weakness was symmetric on both lower limbs. She was still able to feel tactile sensation
on skin. There was a complain of backpain in the last 3 months before admission. The
pain was getting worse in the last 2 weeks before admission. The pain appeared when she
was standing and disappeared when she laid down. There was a history of fever in the
past 3 months. The fever was not continuous and improved with taking antipyretic
medication. There was no seizure, cough, and shortness of breath. There was no nausea
and vomiting. She had a decrease appetite. The urine was red-colored and the stool was
yellow.
There was history of hospitalization in W Hospital on 24 – 29 December 2022 with
spondylitis tuberculosis and treated with FDC antituberculosis drugs for intensive phase
1st month 4th day. There was history of Mantoux test (PM Hospital) and result was
positive (induration ≥ 10 cm). The patient had history of trauma (motorcycle accident),
but the exact incidence was unclear.

2. Personal or social history of the patient

a. History of illness in the family

Her mother was diagnosed with lung tuberculosis 7 years ago (acid-fast bacilli positive)
and had completed her antituberculosis treatment.
b. Patient's personal or social history
1) Mother’s pregnancy history
During pregnancy, the mother had regular check-ups with the midwife, and was
given vitamin and iron supplementation. She never took herbs or medicines other than
those prescribed by a medical professional. She felt quite healthy with a full-term
pregnancy, and had not experienced any trauma or other problems during pregnancy..
2) Labor History
The patient was delivered at home. She was a full-term baby, with spontaneous
vaginal delivery, assisted by a midwife. The baby cried immediately after birth without
cyanosis. Birth weight was 4000 grams, birth length and head circumference were
unknown.
3) Post birth history

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 The patient received vitamin K1 injection. Hepatitis B vaccination was given on the
first day and oral polio on the next day after birth. There was no history of cyanosis,
pallor, jaundice, seizures or bleeding.
4) Nutrition History
The patient was breastfed from birth until 2 months of age, cow's milk was given
thereafter until 2 years of age. Complementary foods were first introduced at 6 months of
age in the form of milk porridge, followed by steamed rice at 9 months of age and family
meals from 1 year of age. About 2 weeks before admission, her appetite decreased and
she ate only two meals a day, with rice, meat/chicken, fish, eggs, vegetables, fruits and
biscuits.

5) Growth and developmental history

Until the patient was 2 years old, the mother regularly took him to Posyandu, there
was no Health Card (KMS), but the mother never complained about her child's growth
and development until now. In the last 3 months before entering the hospital, the mother
felt that her child was not gaining enough weight.
The patient was able to show a responsive smile at 2 months of age, roll over at 4
months of age, sit without support at 7 months of age, stand alone at 12 months of age,
can walk well at 14 months of age and can speak at 12 months of age.We used the
Pediatric Symptom Checklist (PSC-17) to detect the risk of mental and behavioral
disorders that may occur due to the disease (appendix 3). The total score is 4.
6) Imunisation history
Immunizations that have been obtained are hepatitis B 5 times (age 0 days, 2,4,6 and 18
months), oral polio 5 times (age 2 days, 2,4,6 months and booster at 18 months), BCG at
1 month, DPT 5 times (age 2,4,6 months and booster 18 months 6 years), and measles
(age 9 months), diphtheria tetanus vaccine / Dt (6 years), diphtheria tetanus / Td (age 7
and 10 years).
7) History of basic child’s needs

 Foster care (physical-biomedical)

The patient's primary caregiver was his mother. Regarding health care, the mother
seemed worried about her child's condition. The patient was brought to W Hospital due to
weakness of both limbs.

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 The family was able to provide adequate food, however the patient had a poor
appetite in the last 3 months. Clothing needs were also met. yang buruk dalam 3 bulan
terakhir. Kebutuhan sandang juga terpenuhi.

 Care (pshycosocial)

The parent-child relationship appeared close and loving. Both mother and father loved
the patient very much. The mother was patient and tried to care more about her son's
illness..

The father is 43 years old, a Muslim, a junior high school graduate and works as a
self-employed person with a monthly income of approximately Rp 1,000,000. The mother
is 41 years old, a Muslim, a junior high school graduate, and a housewife. The patient
lives with her parents and 3 sisters in a permanent house measuring approximately 7 x 10
m2, consisting of 4 bedrooms, 1 living room, 1 kitchen, and 2 bathrooms..

The family's source of drinking water is from a well. Water for daily activities such as
washing and bathing comes from a well. The source of electricity comes from the State
Electricity Company (PLN). Ventilation and light in the house are sufficient. The closest
health facility to the patient's house is the Community Health Center (Puskesmas), which
is ± 1.5 km away. Hospital bills are covered by national health insurance.

 Hone (stimuli)

Early stimulation was provided by both parents early on which included touching and
hugging, playing together and talking. He also likes to play with his brother.

IV. DATA OF PATIENT CASE

1. Physical Examination (Objektive)

a. Status present
- General condition : moderate illness
- Awareness : GCS 15 (E4M6V5)
- Heart rate : 98 x/minutes reguler, enough volume
- Breathing : 22 x/minutes, reguler, negative retraksi
- Blood pressure : 100/60 mmHg
- Temperature : 36.7°C

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 - Saturation : 99% with room air
- Pain scale : 3 NRS
b. Nutritional state and antropometri
- Actual Weight : 39 kg
- Height : 160 cm
- Actual BW : 39 kg
- Ideal BW : 49 kg
- Body Height : 160 cm
- Head circumference (HC) : 54 cm (-2 SD<HC<0 SD, Nellhaus curve)
(Appendix 1)
- Weight-for-Height : 79,6% (wasted, CDC NCHS 2000 chart)
(Appendix 2)
- Height-for-age (H/A) : 98,2% (Normal, CDC-NCHS 2000 chart)
(Appendix 2)
- Weight-for-age (W/A) : 73,6% (underweight, CDC-NCHS 2000 chart)
(Appendix 2)
- Height Age (HA) : 14 years old.
- RDA from HA : 60 Kkal/BW/day
- Father’s height : 170 cm
- Mother’s height : 160 cm
- Genetic potential height : 150–167 cm (P3 – P65, CDC-NCHS 2000 chart)
- Mid-parental height : 158.5 cmAssessment of nutritional status based on
the CDC 2000 curve, the patient was categorized as
underweight, thin and normal stature..

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9
 c. General State

System Description

Skint No crazy pavement dermatosis, no cyanosis, no erythema, no purpura, good turgor,

no jaundice, no pallor. BCG Scar positive in the right deltoid.

Head Normocephalic, mesocephalic, no deformity.

Hair Black, evenly distributed, not easy to pick

Face No elderly face, no dysmorphic, no cranial nerve palsy, no erythema on the cheeks.

Eyes No palpebral edema, no anemic conjunctiva, no icteric sclera. Eye movements

within normal limits, no strabismus, pupils round, isochoric, 2.5mm/2.5mm in
diameter, normal light reflex.

Nose Nasal septum in the middle, no secret, mucosa not hyperemic

Ear No secrets, tympanic membrane intact

Mouth No dry lips, no mouth ulcers, no stomatitis.

Teeth Not carrying dentis.

Throat The pharynx is not hyperemic, there is no tonsil enlargement.

Neck There is no nuchal rigidity. Jugular venous pressure is normal.

Chest Symmetrical shape and movement, no piano chest, no deformity, no chest retraction

Lungs Vocal fremitus symmetrical, percussion sonorous, breath sounds vesicular, no

wheezing, There are rales in both lung fields

Heart Ictus cordis is not visible and palpable, normal I-II heart sounds, no murmurs or
gallops.

Abdomen Flexible, normal bowel sounds, no palpable liver and spleen, no ascites.

Genitals female, pubertal status A3M3P3

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 Lymph No lymphadenopathy.
nodes

Spine There is a gibbus in the 11th thoracic region, accompanied by tenderness, without
scoliosis

Ekstremity No wasting, baggy pants, and edema. Extremities warm, capillary filling time less
than 2 seconds, no edema. BCG scar + 5 mm in the deltoid region of the right upper
arm.

Status neurologis

Awareness : GCS 15 (E4M6V5)

Nervus I : smell normal

Nervus II : round pupil, diameter isochor 2,5 mm/ 2,5 mm, ligh reflex positive

Saraf III, IV, VI : movement of the eyein all directions within normal limits

Nervus V : refleks cornea positive

Saraf VII : no facial nerve paresis

Saraf VIII : normal hearing, balance is difficult to assess

Saraf IX, X, XI : normal swallow reflex

Saraf XII : o tongue deviation

Meningeal sign : Negative neck rigidity

Motoric

Upper Extremity : 5-5-5-5/5-5-5-5

Lower Extremity : 1-1-1-1/1-1-1-1

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Tonus : Decrease in the lower extremities

Physiology reflex : Decrease in the lower extremities

Pathologic reflex :Babinski negative

Klonus : Positive

Sensibiliy and system nerve otonom normal

Score tuberkulosis: 10

Contact :3

Nutrition state :1

Fever :1

Cough :0

Lymphadenopathy :0

X Ray Thorax :1

Joint/bone :1

Tuberkulin test :3

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 Figure 1. Mantoux test result and Gibbus

2. Supporting Examination

Table 1.Supporting Examination Result (1/1/2023)

Parameter Result Normal Value

HB 10,1 12-16 g/dl

MCV 65,1 80-100 µm3

MCH 20,7 27-32 pg

MCHC 29 32-36 gr/dl

HCT - 37-47%

Leukosit 9.930 4000-10.000 mm3

Trombosit 334.000 150.000-400.000/mm3

GDS 140 g/dl

Ureum 49 10-50 mg/dl

Kreatinin 0,6 L(<1,3), P (<1,1)

SGOT 84 <38 U/L

SGPT 21 <41 U/L

Albumin 3,5-5,0 gr/dl

Natrium 135 136-145 mmol/L

Kalium 5 3,5-5,1 mmol/L

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 Parameter Result Normal Value

Klorida 94 97-111 mmol/L

Lym 8.2 20-40 %

Neut 52-75 %

Mono 10.4 2-8 %

Figure 2. X Ray Thoraks 20/12/2022

Impression : Pneumonia suspects to specific type

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 Figure 3. CT scan non-kontras thoracolumbar in RS PM, 20 December 2022

Impression : Compression fracture in column vertebra thoracal XI

Figure 4. MRI Whole Spine

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V. RESUME
A 16-year-and-9-month-old girl was admitted to the Pediatric Emergency Department of
W Hospital due to chief complaint of weakness on both lower limbs experienced in the last 3
months and getting worse in the last 1 month before admission. Initially, she felt numbness
on both legs. The weakness was symmetric on both lower limbs. She was still able to feel
touch sensation on skin. There was a complain of backpain in the last 3 months before
admission. The pain was getting worse in the last 2 weeks before admission. There was
history of hospitalization in W Hospital in 24 – 29 December 2022 with diagnosed of
spondylitis tuberculosis and treated with FDC antituberculosis drugs for 4th day first month
of intensive phase.

The general condition of patient was moderate ill, with wasted, GCS 15, vital sign
within normal limit. There were BCG scar on right deltoid. There was gibbus in 11th thoracal
region, accompanied with tenderness, without any scoliosis. From neurologic status, nerve
cranial within normal. Motoric examination revealed the decreased of movement ability and
tone normal in both lower extremities, and increased of physiology and pathologic reflexes.
The clonus was positive. Laboratory test revealed microcytic hypochromia. Chest x-ray in
PM Hospital, December 20th 2022: Pneumonia suspects to specific type. Non-contrast CT
scan of thoracolumbar showed compression fracture in column vertebra thoracal XI.
Tuberculosis score was 10. Conclusion:

1. Spondylitis Tuberculosis (A18.01)

2. Paraparesis inferior due to compression fracture of 11th thoracic vertebra (G82.22)

3. Iron deficiency anemia differential diagnose to anemia of chronic disease (D53.9)

4. Wasted (E.44)

VI. WORKING DIAGNOSIS

Primary Diagnosis : Spondylitis Tuberculosis (A18.01)

Secondary Diagnosis :
1. Iron deficiency anemia differential diagnosis anemia of chronic disease (D52.9)
2. Wasted (E44.0)
Complication : Paraparesis inferior due to compression fracture of 11th
thoracic vertebra (G82.22)

VII. MANAGEMENT PLAN (PLANNING)

Spondylitis Tuberculosis

Diagnostic  History taking and physical examination

 Laboratory: Acid-fast Bacilli test and The GeneXpert test
 Chest X-Ray
 MRI whole spine

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 Therapy  Anti-tuberculosis Drugs 2 (R/H/Z/E) + 10 (R/H)  Intensive phase 1st month 5th
day (Fixed Dose Combination 4 regiments: 4 tablets/ 24 hours / oral)

Intensive phase of anti-tuberculosis drugs for 2 months with 4 regimens:
Isoniazid (dose: 10-15 mg/kg/day) 150 mg/24 hours/day
Rifampicin (dose: 10-20 mg/kg/day) 300 mg/24 hours/day
Pyrazynamide (dose: 30-40 mg/kg/day) 550 mg/24 hours/day
Ethambutol (dose: 15-25 mg/kg/day) 450 mg/24 hours/day
Followed by anti-tuberculosis drugs for 10 months with 2 regimens:
Isoniazid (dose: 10-15 mg/kg/day) 150 mg/24 hours/day
Rifampicin (dose: 10-20 mg/kg/day) 300 mg/24 hours/day

Monitoring  Result Acid-fast bacilli test and The GeneXpert test

 Result MRI whole spine
 Body weight
 General condition
 Consciousness
 Neurological status
 Vital signs
 Sign of icteric
 Side effect of anti-tuberculosis drugs

Education  Red/orange color urinary is normal

 Consume drugs before eat
 Routine controls every 2 weeks on intensive phase (first 2 months) and every
month on advanced phase (next 10 months)
 Acid-fast bacilli test on 2 months prior treatment, then 5 months and 6 months (if
there is confirmed bacteriological)

Paraparesis inferior due to compression fracture of vertebra thoracal XI

Diagnostic  History taking and physical examination

 Laboratory: Acid-fast Bacilli test and The GeneXpert test
 MRI whole spine

Therapy  Anti-tuberculosis Drugs 2 (R/H/Z/E) + 10 (R/H)  Intensive phase 1st month 5th
day (Fixed Dose Combination 4 regiments: 4 tablets/ 24 hours / oral)
 Correction after 2 weeks – 1 month of Anti-tuberculosis drugs treatment at
intensive phase

Monitoring  General condition

 Consciousness
 Neurological status
 Vital signs

Education  Inform the parents about paraparesis inferior due to compression fracture of
vertebra thoracal XI

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  Need correction after 2 weeks – 1 month of Anti-tuberculosis drugs treatment at
intensive phase

Differential Diagnosis Iron Deficiency Anemia and Chronic Anemia Disease

Diagnostic  Ferritin, reticulocytes, blood smear, complete blood count, MCV, MCH
Therapy  Wait for further result to differentiate cause of anemia
Monitoring  Vital sign
 Pale
 Signs of tissue anoxia
 Laboratory results for anemia diagnostic

Education  Inform the parents that their child’s hemoglobin level below standard from the age
of the child
 Planned to differentiate the cause of anemia with several laboratory examination
 Transfusion only needed if the patient gets tissue anoxia

Wasted

Diagnostic  Weight-for-Height based on CDC NCHS 2000 chart

Therapy  Nutritional status assessment: Wasted
 Diet according to RDA
 Energy = RDA height age x IBW = 60 x 49 = 2940 kcal/day
 Carbohydrate 50-70% of total calorie = 1470 kcal/day
 Protein 1 g/kgBW/day ≈ 49 gram/day
 Fat 30% of total calorie = 882 kcal/day
 Nutritional route per oral
 Nutritional selection: 3 times solid food and 3 times snack
Monitoring  Acceptability, tolerance. and evaluation of nutritional intake.
 Routine anthropometric measurement
Education  Inform the parents that their child’s weight for height is below standard curve.
Therefore, daily food intake should be able to meet a balanced nutritional
requirement to ensure optimal growth and development
 Inform the parents about nutritional intake (type of food, schedule and total
calories of food)

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VIII. FOLLOW UP HISTORY OF DISEASE

Treatment day 2 (2-5 january 2023)

S Weakness in both lower limbs.

There is back pain

There is jaundice

There is nausea and vomiting

O General condition : weak

Blood pressure : 90/60 mmHg

Heart rate: 98 x per minutes

Breathing : 30 x per minutes

Temperature : 36,5 ‘ celcius

Oxygen Saturation : 99 % without assisted oxygen

Pain Scale 3 NRS

Lung :

No retraction

Vesicular breath sounds

No ronkhi

No wheezing

Heart: normal regular I/II heart sounds, no heart noise

Abdomen :

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 Peristaltic sounds are normal

hepar and lien not palpable

Ekstremity

 warm acral, CRT <3 seconds,

 Upper motoric : 5555 5555
Lower motoric :1111 1111

 Improve physiological reflexes

 Pathological reflex: positive

 Sensorik ordinary

 Gibbus in TXI area, softness

Laboratorium Examination

Bilirubin total 2,78

Bilirubin direct 2,26

SGPT/ SGOT 105/78

Negative acid-resistant bacilli

GeneXpert not detected

rifampisin sensitive

X Ray Thoraks AP/Lateral: deformity CV Th 11 which causes severe

anterior angulation

Whole spine MRI: T10-T11 tuberculous spondylitis and severe wedge

deformity.

A Spondilitis Tuberkulosis (A18.01)

Secondary diagnostic: Iron deficiency anemia differential diagnosis of

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 chronic anemia disease (D52.9), Moderate Malnutrition (E44.0)
Complication :Paraparesis inferior due to compression fracture of the
11th thoracic vertebrae (G82.22)

P  Day 3 : medicine antituberculosis STOP

 Parasetamol 500mg/8 hrs/intravena
 Acid ursodeoxyholic 250 mg/8 hrs/oral

Treatment (6-10 January 2023 )

S  - Weakness of both limbs ↓

 - Back pain ↓
 - Increased appetite
 - Pain scale 1 NRS

 - Jaundice↓

O General condition : weak

Blood pressure : 90/60 mmHg

Heart rate: 98 x per minutes

Breathing : 30 x per minutes

Temperature : 36,5 ‘ celcius

Oxygen Saturation : 99 % without assisted oxygen

Pain Scale 1 NRS

Lung :

No retraction

Vesicular breath sounds

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 No ronkhi

No wheezing

Heart: normal regular I/II heart sounds, no heart noise

Abdomen :

Peristaltic sounds are normal

hepar and lien not palpable

Ekstremity

 warm acral, CRT <3 seconds,

 Upper motoric : 5555 5555
Lower motoric :1111 1111

 Improve physiological reflexes

 Pathological reflex: positive

 Sensorik ordinary

Gibbus in TXI area, softness

Laboratorium RSWS 11/5/2022

Hepatitis marker normal, RET 1,24, Ferritin 830, peripheral blood

smear: hypochromic microcytic anemia

A 1. Tuberkulosis Spondilitis
2. Paraparesis inferior due to fracture compression TXI
3. Chronic anemia disease
4. Moderate malnutrition

P  FDC Stop
 Parasetamol 500mg/8 hrs/intravena

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  Acid ursodeoxyholic 250 mg/8 hrs/oral

Treatment hari (11 – 15 januari 2023)

S  Weakness of both limbs ↓

 - Back pain ↓
 Increase in appetite

O General condition : weak

Blood pressure: 90/60 mmHg

Heart rate: 98 x per minutes

Breathing: 24 x per minutes

Temperature: 36,5 ‘ celcius

Oxygen saturation : 99 % without assist oxygen

Pain scale 1 NRS

 Treatment Day-14 : Nothing jaundice

 Motor: 5555 5555
4444 4444

 Increase phisology reflex

 Pathology reflex: positive

 Sensoric ordinary

 Gibbus in area TXI, softenness

Lung :

No retraction

23
 Breath sound vesiculer

No ronkhi

No Wheezing

Heart:

normal regular I/II heart sounds, no heart noise

Abdomen :

Peristaltic sounds are normal

hepar and lien not palpable

Ekstremity: warm acral, CRT <3 seconds,

Laboratorium RSWS

Hb 9,0 g/dl, MCV 72,5 fl, MCV 20,3, SGPT 28 U/L SGOT 31 U/L

A  Tuberkulosis Spondilitis
 Paraparesis inferior due to fracture compression TXI
 Chronic anemia disease
 Moderate Malnutrition

P  medicine antituberkulosis fase intensif:

- Isoniazid 280 mg/24 hrs/oral

- rifampisin 400 mg/24 hrs/oral

- pirazinamid 1200 mg/24 hrs/oral,

- etambutol 600 mg/24 hrs/oral

 Parasetamol 500mg/8 hrs/intravena

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  Acid ursodeoxyholic 250 mg/8 hrs/oral

IX. PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad sanatorium : dubia ad bonam
Qua ad functionem : dubia ad bonam

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X. DISCUSSION

Case Analysis

A 16-year-and-9-month-old girl was admitted W Hospital due to chief complaint of

weakness on both lower limbs experienced in the last 3 months and getting worse in the last 1
month before admission. Initially, she felt numbness on both legs. She was still able to feel
touch sensation on skin. There was a complain of backpain in the last 3 months before
admission. There was history of hospitalization in W Hospital in 24 – 29 December 2022
with diagnosed of spondylitis tuberculosis and treated with FDC anti tuberculosis drugs for
first month of intensive phase. The incidence of extrapulmonary TB (EPTB) is 3% from
pulmonary TB (PTB). Skeletal TB (STB) contributes to around 10% of EPTB, and spinal TB
has been the most common site of STB, amounting to around half of skeletal EPTB. 1 (Level
of evidence 1A) Paramarta et al, extrapulmonary TB (EPTB can occur in 25%-30% of
children who infected with pulmonary TB (PTB). TB of bones and joints occurs in 5%-10%
infected children, and most occur in 1 years, but can also be 2-3 years later. 2 (Level of
evidence 1A) Thoracolumbar junction remains to be the most affected region of the spinal
column followed by lumbar spine and the cervical spine. 1,2 In a study by Alavi et al.,
spondylitis TB in the endemic area of TB is highest in young adults, however, in developed
countries, it is more common in older age. It is probably caused by risk factors such as
nutrient deficiency, overcrowding, poor environmental hygiene, etc. which are more common
in developing countries.9
This case, the patient’s complaint of weakness on both lower limbs experienced in the
last 3 months and getting worse in the last 1 month before admission. There was a complain
of backpain in the last 3 months before admission. Neurological complications can occur
either during the early active disease or in the late healed stage. Direct compression due to
abscess, inflammatory tissue, or sequestrum and instability are the usual causes for neural
compromise in the active stage. The mechanical stretch of cord over an internal gibbus results
in delayed neurological issues even after the healing of TB. Late-onset neurological deficit
due to ossification of ligamentum flavum proximal to the kyphosis is rare, but has been
observed and believe to be due to exaggerated movements.1 (Level of evidence 1A)
There was gibbus in 11th thoracal region, accompanied with tenderness, without any
scoliosis. Chest x-ray impressed pneumonia suspect to specific type and non-contrast CT
scan of thoracolumbar showed compression fracture in column vertebra thoracal XI.
Spondylitis tuberculosis is a chronic granulomatous inflammatory disease of the spine caused

26
by the bacterium Mycobacterium tuberculosis. As many as 50% of spondylitis tuberculosis
sufferers have lesions in the spine and 10-45% of them experience neurological decline. This
splitting of Mycobacterium tuberculosis bacterial infection in the spine will complicate
management and aggravate the clinical condition because of the potential for permanent
neurological deficits and deformities.6 The spread of tuberculosis infection will cause
inflammation of the paradiscus, there is hyperemia, edema spinal cord and osteoporosis.
Destruction of bone loss occurs progressively, due to lysis of bone tissue in part anterior, as
well as the presence of secondary ischemia, periarthritis and endarteritis, will cause the
collapse of the section. This will cause a loss of mechanical strength bones to hold weight so
then collapse of the vertebrae with the intervertebral joints with the posterior neural arch
remaining intact, so it will progressive kyphotic deformity develops (posterior angulation)
depending on the degree of damage, level the lesion and the number of vertebrae involved are
frequently referred to as gibbous. When this deformity arises, then it is a sign that this disease
has extends.3,4,5 Neurological deficits occur in 12–50 percent of sufferers. Possible deficits
include: paraplegia, paresis, hypesthesia, radicular pain and/or cauda equina syndrome.
Radicular pain indicates interference with the roots (radiculopathy). 3 To reduce pain, the
patient will be reluctant to move his back, so that it seems stiff. The patient will refuse if
ordered to bend down or lift objects from the floor. The pain will decrease if the patient rests.
Complaints of deformity of the spine (kyphosis) occur in 80% of cases accompanied by the
appearance of gibbus. Old disorders may be accompanied by paraplegia or without
paraplegia. Paraplegia in spondylitis tuberculosis patients with active disease or known as
Pott's paraplegia, there are 2 types of neurological deficits found in the early stages of the
disease which is known as early onset, and paraplegia in recovered patients which usually
develops several years after the primary disease is cured which is known with slow onset. 2
The children with spondylitis tuberculosis usually present with persistent localized back pain,
loss of appetite, weakness of both lower limb and inability to walk. The child is usually pale,
listless, and anemic. They also have a cautious gait and tend to walk keeping both hands at
thigh to support the trunk. If the cervical spine is involved, they walk supporting the head
with both hands.
This case, the diagnosis of spondylitis tuberculosis can be established by a complete
clinical examination including a history of close contact with tuberculosis patients,
epidemiology, clinical symptoms, and neurological examination. Modern imaging methods
such as X ray, CT scan, MRI from patient help establish the diagnosis of spondylitis
tuberculosis.2,8 Patient have positive Mantoux test. The gold standard for the traditional
27
diagnosis is the examination of clinical samples of the patients, namely a blood smear test for
Mycobacterium tuberculi, along with typical histological examinations and laboratory tests
including complete blood count, ESR and CRP, as well as further auxiliary examinations to
diagnose the corner curriculum. However, due to the growth requirements and slow growth
rate of TB bacilli, their culture is challenging. The TST is frequently performed, but its
sensitivity and specificity are limited, even in high-incidence areas of TB; even after in
individuals with repeated exposure to TB bacillus, a ~20% negative rate of the TST has been
estimated.14,15 Spondylitis tuberculosis in children is suspected clinically and the diagnosis
can be confidently made on plain X‐rays and magnetic resonance imaging (MRI)
observations supported by raised ESR and positive Mantoux test. When clinic-radiological
diagnoses are doubtful, the fine‐needle aspiration cytology/biopsy for a histopathological
diagnosis is indicated.
The goals of treatment in spinal TB are to eradicate the disease and to prevent and/or
correct spinal deformity and neurological deficits.1 TB of the spine is a medical disease;
surgical intervention is indicated for spinal deformity, neurological complications, instability,
large abscesses and to obtain tissue in a case of diagnostic dilemma and suspected MDR TB. 8
(Level of evidence 1A) The clinical appearance of kyphotic deformity has been classified as
knuckle (one vertebral involvement), gibbus (two vertebrae) and rounded kyphus (more than
three vertebrae). Patient has gibbus and paraperese inferior. This patient had 4 types of anti-
drugs tuberculosis (2RHZE/10RH). Multidrug antitubercular treatment (ATT) is the mainstay
of treatment in both complicated and uncomplicated TB.1(Level of evidence 1A) Treatment
INH and rifampicin should be administered during the entire treatment. A 4-drug regimen
usually includes INH, rifampicin, and pyrazinamide and ethambutol. Long treatment is still
controversial. Although some research says it requires medication only 6-9 months, routine
treatment is carried out for 9 months to 1 year. Treatment duration usually based on
improvement in clinical symptoms or clinical stability of the patient. 2,13,17 Drugs commonly
used for the treatment is as shown in Table 1. (Level of evidence 1A)
The patient treated with FDC antituberculosis drugs for first month of intensive phase.
But then, in 7th day of hospitalization instruction for the patients is stop antituberculosis drugs
because of icterus, elevated liver enzyme and cholestasis. Patient then have drug induced
liver injury (DILI). Based on DILI expert working group DILI is defined as an elevation in
the serum concentration of alanine aminotransferase (ALT) ≥ 3x ULN and total bilirubin >2x
ULN.15 The FDC ATT was stopped then she was given ursodeoxycholic acid.
Ursodeoxycholic acid in DILI was largely demonstrated by case reports and observational
28
studies, it appears to be safe and leads to a reduction in bilirubin. 18,19 Level of evidence 1A)
After the symptom’s improved ATT was reintroduce with separate regimen simultaneously.
A study in India revealed that there was no difference in the recurrence rate of hepatotoxicity
between reintroduction ATT simultaneously nor separatedly. 19 The patient has severe TB
such as spondylitis TB, thus the ATT cannot be stopped completely. Hepatotoxic ATT such
as INH, rifampicin and pyrazinamide were switched to less hepatotoxic ATT such as
levofloxacin and amikacin until hepatitis is resolved, while ethambutol was continued. 20,21
Once liver functions were normal the original drugs can be reintroduced sequentially in the
order: INH, rifampicin, and pyrazinamide with daily monitoring of her clinical condition and
liver function.13 The liver function and clinical condition were monitoring periodically. There
was no yellowish appearance, no icteric and liver functions within the normal limit during the
reintroduction of antituberculosis drugs.
The hypochromic microcytic anemia found in this case might still be caused by iron
deficiency anemia or chronic disease due to TB infection. Another possibility of anemia
experienced by patients is chronic disease due to TB infection. Examination of the iron
profile that has been done and ferritin was high. Patient was diagnosed anemia of chronic
disease.
The prognosis for spondylitis tuberculosis varies depending on the clinical
manifestations that occur. Poor prognosis associated with miliary tuberculosis and meningitis
tuberculosis, sequelae can occur including deafness, blindness, paraplegia, mental retardation,
movement disorders and others. Prognosis improves if treatment is carried out sooner. High
mortality occurs in children aged less than 5 years to 30%. 8 Prognosis in this patient was: 1)
quo ad vitam was ad bonam, since the manifestations during hospitalization this patient has a
significant improvement; 2) quo ad functionam was ad malam because the motoric
examination revealed the decreased of movement ability and tone in both lower extremities;
3) quo ad sanactionam was ad bonam, because the patient had improvement appetite and the
patient feel better.

Spondylitis Tuberculosis

1. Definition

TB spondylitis is a chronic granulomatous inflammatory disease of the spine caused by

the bacterium Mycobacterium tuberculosis. Involvement of Mycobacterium tuberculosis

29
infection in the spine will complicate management and aggravate the clinical condition due to
potential neurologic deficits and permanent deformities. The spine is the most frequent site of
bone tuberculosis infection, with approximately 50% of osteoarthritic tuberculosis cases. As
many as 50% of patients with TB spondylitis have spinal lesions and 10-45% of them have
neurologic deficits.5

If the Mycobacterium tuberculosis infection affects the vertebral corpus, the damage
causes spinal instability and disruption of surrounding structures. The patient may be
paralyzed due to compression of the spinal cord. Irreversible paralysis not only disturbs and
burdens the patient himself, but also his family and society.5 In this patient, neurological
deficits were found.

2. Pathophisiology

TB spondylitis can result from direct infection (primary), where the bacteria directly
infect the corpus, or indirect infection (secondary), where the bacteria spread hematogenously
or lymphogenously from the site of infection elsewhere to the spinal corpus. Most TB
spondylitis is a secondary infection of the lungs, but in some cases it is a primary infection.
Anatomically the intervertebral disc is an avascular structure and the paradiscus artery
divides on both sides of the disc and reaches the subchondral region of the upper and lower
endplate of each disc. This supply of vertebral arteries favors subchondral bone involvement
on both sides of the disc, paradiscal, which is the most common type encountered in
tuberculous spondylitis. TB causes granulomatous inflammation characterized by infiltration
of lymphocytes and epithelioid cells, which can combine to form classical Langhans-type
giant cells and end in caseous necrosis of the affected tissue forming an abscess. With
progressive destruction of the vertebral bodies, deformation of the spine leads to kyphosis. 6

The lungs are the port d'entree for more than 98% of TB infection cases, as the size of
the bacteria is very small at 1-5 μ, inhaled TB germs reach the alveolus and are immediately
overcome by nonspecific immunological mechanisms. Alveolus macrophages will
phagocytize TB germs and are able to destroy most TB germs. In a minority of cases,
macrophages are unable to destroy TB germs and the germs replicate in the macrophages.
The TB germs in the macrophage continue to multiply, eventually causing the macrophage to
lyse, and the TB germs form colonies at that site. The first location of a TB germ colony in
lung tissue is called the primary focus of Ghon.7

30
 The most common form of hematogenous spread is occult hematogenic spread, where
TB germs spread sporadically and gradually, causing no clinical symptoms. TB germs will
then reach various organs throughout the body. The target organs are those that are well
vascularized, such as the brain, bones, kidneys, and the lungs themselves, especially the lung
apex or upper lobe of the lung. The part of the spine that is often attacked is the peridiscal,
which occurs in 33% of cases of TB spondylitis and starts from the metaphyseal part of the
bone, with spread through the longitudinal ligament. Anterior occurs in about 2.1% of cases
of TB spondylitis. Disease starts and spreads from the anterior longitudinal ligament.
Radiology shows scaling of the anterior vertebrae, central occurring in approximately 11.6%
of cases of TB spondylitis. Disease is confined to the center of a single vertebral body,
resulting in vertebral collapse and kyphosis deformity. At these various sites, TB germs will

replicate and form germ colonies before cellular immunity is established to limit growth. 4

3. Clinical manifestation

Clinical symptoms may be systemic/general or organ-specific. Clinical symptoms of

TB in children are not typical, as similar symptoms can also be caused by various diseases
other than TB. Typical symptoms of TB are as follows:
1) Cough  2 weaks
2) Fever  2 weaks,
3) Weight decreased or did not increase in the previous 2 months,
4) Lethargy or malaise  2 weaks,
5) These symptoms persist despite adequate therapy. 3

Like the clinical manifestations of TB patients in general, the patient experienced the
following conditions: weight loss for 3 consecutive months without apparent cause,
prolonged fever without apparent cause, enlarged superficial lymph nodes that did not hurt,
cough for more than 30 days, recurrent diarrhea that did not recover with diarrhea treatment
accompanied by lumps / masses in the abdomen and signs of fluid in the abdomen..5

Clinical manifestations of TB spondylitis only appear after the child has learned to walk
or jump. The first symptom is usually a lump on the spine accompanied by pain. To reduce
the pain, the patient will be reluctant to move their back, making it seem stiff. The patient
will refuse if ordered to bend over or lift things from the floor. The pain will decrease if the

31
patient rests. Complaints of deformity in the spine (kyphosis) occur in 80% of cases
accompanied by the onset of gibbus, which is a back that bends and forms an angle, is an
unstable lesion and can develop progressively. There are two clinical types of kyphosis:
mobile and rigid. In 80% of cases, kiposis occurs 20% of cases have more than 10 kiposis
and only 4% of cases more than 30%. Long-standing disorders may be accompanied by
paraplegia or without paraplegia. Abscesses may occur in the spine which may radiate to the
lower thoracic cavity or down the inguinal ligament.5

Paraplegia in patients with TB spondylitis with active disease, known as Pott's

paraplegia, has two types of neurological deficits found in the early stages of the disease,
known as early onset, and paraplegia in patients who have recovered, which usually develops
several years after the primary disease has resolved, known as late onset. The usual routine
test to determine the presence of Mycobacterium tuberculosis infection is the tuberculin test
(Mantoux test). The tuberculin test is a test that can detect infection in the absence of disease
manifestations, and can be negative due to severe anergy or protein energy deficiency. This
tuberculin test cannot determine the presence of active TB. A blood erythrocyte
sedimentation rate (ESR) test is performed and an elevated ESR with a result of >100
mm/hour. Radiologic examination of the spine is essential to see the infected vertebral
column in 25%-60% of cases. The first lumbar vertebra is most commonly infected.
Radiologic examination can find foci of infection in the anterior part of the corpus vertebre
and spread to the subchondral layer of the bone. 6

In this case, the clinical symptoms found were weakness in the lower limbs There was a
history of fever for the last 3 months. She had decreased appetite.

4. Supporting Examination

In some cases infection occurs in the anterior part of the vertebral body up to the
intervertebral disc characterized by the destruction of the end plate. Posterior elements are
usually also affected. Spread to the intervertebral discs occurs directly resulting in erosion of
the anterior vertebral bodies caused by soft tissue abscesses. The widespread availability of
computerized tomography scan (CT scan) and magnetic resonance scan (MR scan) has
increased their use in the management of spinal TB. CT scans are performed to elucidate
spinal sclerosis and destruction of the vertebral bodies so as to determine damage and
posterior extension of the inflamed tissue, bone material, and to diagnose posterior spinal

32
involvement as well as involvement of the sacroiliac join and sacrum. This can help guide
biopsy and surgical planning interventions. CT scan examination is indicated if the radiology
examination results are doubtful. CT scan images of TB spondylitis show calcifications in the
psoas accompanied by periperal calcifications. Magnetic resonance imaging (MRI) is
performed to detect tissue mass, appendicular TB, extent of disease, and subligamentous
spread of tuberculous debris. The gold standard for diagnosis of bone and joint tuberculosis is
mycobacterium culture of bone tissue or synovial fluid. Needle aspiration and biopsy (CT-
guided) are recommended for confirmation of TB spondylitis. Peripheral joint fluid analysis
is usually not helpful. Suspicion of TB infection is an indication for synovial biopsy.
Antimicrobial sensitivity testing of isolates is important.3

Bone biopsy can also be useful in difficult cases, but requires a high degree of skill and
experience as well as a good histology examination. Histologic examination will reveal
caseous necrosis and giant cell formations, while acid-resistant bacteria are not found and
cultures are often negative. There are no radiologic findings pathognomonic for bone and
joint TB. In early infection there may be soft tissue swelling, osteopenia and bone
destruction. In advanced infection there may be structural collapse, sclerotic changes and soft
tissue calcification. In TB spondylitis, pure osteolytic lesions without disc space involvement
may be seen and may be seen in multiple sites. Paravertebral abscesses may be seen on plain
photographs. In arthritic TB, Phemister's triad can be seen, namely juxtaposed-arthritic
osteopenia, peripheral bone erosion and gradual narrowing of the disc space. tuberculous
dactylitis of the hands or feet can show a balloon-like appearance in the phalanges. A thoracic
photograph can be done to determine former TB or pulmonary TB. MRI examination can
determine the extension of the infection to the soft tissues and structures around the bone
such as the spinal cord. 3In this case, the patient underwent a thoracic X-ray, thoracic MSCT
scan, and thoracic MRI.

TB spondylitis can be differentiated from pyogenic infections which show symptoms of

pain in the area of more severe infection. In addition, there are symptoms of swelling, redness
and the patient will appear more toxic with a shorter course and affect more than 1 level of
vertebrae. However, specific features are not present so TB spondylitis is difficult to
distinguish from pyogenic infections clinically. In addition, TB spondylitis can also be
differentiated from tumors, which show nonspecific symptoms. more than 1 level of
vertebrae. But specific features are not present so TB spondylitis is difficult to distinguish

33
from pyogenic infections clinically. TB spondylitis can also be differentiated from tumors,
which show nonspecific symptoms. 2

In this case, supporting examinations were performed to support the diagnosis, namely
there was a positive tuberculin test with an induration of > 10 mm (20 mm), on MRI
examination of the thorax obtained T10-T11 tuberculous spondylitis and severe slice
deformity.

5.Treatment

Currently, treatment of TB spondylitis based on therapy is primarily based on the

administration of anti-TB drugs combined with immobilization using a corset. Non-operative
treatment uses a combination of at least 4 types of anti-tuberculosis drugs. Treatment can be
adjusted according to information on germ sensitivity to drugs. INH and rifampicin treatment
should be given during the entire course of treatment. Therapy is usually given for 9-12
months considering the weak penetration of drugs into bone and fibrous tissues and the
difficulty of monitoring treatment response. Clinical response is best assessed through
clinical indicators such as pain, constitutional symptoms, mobility and neurological signs. 3

The most important complication of TB spondylitis is spinal cord compression. Patients

with TB spondylitis have a risk of paraparesis or paraplegia which is divided into:

1. Rapid-onset paraplegia, is the active phase of vertebral disease beginning within the
first 2 years. The pathology that occurs is inflammatory edema, tubercle granulation
tissue, tubercle abscess, tubercle embryonic tissue or rarely found in ischemic spinal
cord lesion
2. Late-onset paraplegia, appearing more than 2 years after the disease is found in the
vertebral column. Neurologic complications may be related to disease or mechanical
compression of the spinal cord. Pathologies that may occur are adipose tissue,
tubercle debris, internal gibus, vertebral canal stenosis or severe deformity. The
severity of the neurological deficit depends on the degree of motor impairment.

In joint TB, early diagnosis and effective treatment are essential to save the joints, as
the findings early in the course of the disease are non-specific. Treatment uses standard OAT,
2 RHZE 10-16 RH, should be given 1 year to 18 months in some cases. It is recommended

34
for all patients to use traction, preferably skeletal traction. If necessary, traction on other
extremities can also be used to stabilize the pelvis..5

Drug administration when combined between INH and rifampicin, the dose of INH

should not be more than 10 mg / kgBB / hr and the dose of rifampicin should not be more

than 15 mg / kgBB / hr and in compounding should not be compounded in one puffer but

when taking the drug can be together. As an additional therapy, non-steroidal anti-

inflammatory drugs may be used early in diseases with non-specific superficial membrane

inflammation to inhibit or minimize the bone destruction effect of prostaglandins.In addition

to providing medication, immobilization of the spinal region must be carried out. There are at

least 3 thoughts on the treatment of Potts paraplegia. According to Boswots Compos (cited in

10) the most important treatment is immobilization and early posterior arthrodesis. It is said

that 80% of patients who are detected early will be detected early; will recover after

arthrodesis. In his opinion, anterior decompression is indicated only in those few patients

who do not recover after arthrodesis. If this treatment does not provide improvement and

recovery, brainstem decompression will occur. In general, arthrodesis is performed on the

spinal column only after complete recovery.. 4

Tabel 1. OAT Guide for childrean

35
 Non-operative treatment of early-stage paraplegia will show improved outcomes in
half of patients and late-stage in a quarter of patients. If Pott's paraplegia occurs then surgery

should be performed. Indications for surgery include. 3

A. Absolut Indication
Paraplegia with onset during conservative treatment, paraplegia worsening or
persisting after conservative treatment, complete loss of motor strength for 1 month after
conservative treatment, paraplegia with uncontrolled spasticity due to a malignancy and
immobilization is impossible or there is a risk of necrosis due to pressure on the skin, severe
paraplegia with rapid onset, may indicate severe pressure due to mechanical accident or
abscess may also be the result of vascular thrombosis but this cannot be diagnosed, other
severe paraplegia, flaccid paraplegia, paraplegia in flexion, complete sensory loss or impaired
motor strength for more than 6 months. 4

B. Relative Indication
Recurrent paraplegia which is often accompanied by paralysis so that the initial attack
is often not recognized, paraplegia in old age, paraplegia accompanied by pain caused by
spasm or nerve root compression and complications such as stones or urinary tract infections.
Surgical procedures performed for TB spondylitis with paraplegia are costrotransversectomy,
anterolateral decompression and laminectomy. A complication that can occur is severe
kyposis. This occurs because the bone damage is so great that the bone that undergoes
destruction is very large. This will also facilitate the occurrence of paraplegia in the inferior
extremities known as Pott's paraplegia. The prognosis of TB spondylitis varies depending on
the clinical manifestations. A poor prognosis is associated with miliary TB and TB
meningitis, with sequelae including deafness, blindness, paraplegia, mental retardation and
movement disorders. The prognosis improves with earlier treatment. Mortality is high in

children less than 5 years of age, up to 30%. 1

In this case, the patient was given Anti-Tuberculosis Drug therapy 2 (R/H/Z/E) + 10
(R/H), Intensive phase month 1 day 5 (Fixed Dose Combination of 4 regimens: 4 tablets/24
hours/orally).

XI. SUMMARY

36
 A case of tuberculous spondylitis in a 16-year-old girl was reported. The diagnosis was based
on history taking, physical examination, laboratory and imaging. The management of this
patient was the administration of anti-tuberculosis drugs and clinical observation. The
patient's prognosis was good.

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