Clin Rheumatol (2009) 28 (Suppl 1):S23–S26 DOI 10.1007/s10067-008-1055-1
CASE REPORT
Multilevel vertebral body tuberculosis: a case report Yousra Ibn yacoub & Bouchra Amine & Najia Hajjaj-Hassouni
Received: 6 September 2008 / Accepted: 13 November 2008 / Published online: 4 December 2008 # Clinical Rheumatology 2008
Abstract We report a rare case of multifocal vertebral body tuberculosis with an isolated affection of vertebral bodies and uncommon findings in radiographies that were more suggestive of vascular or tumor lesion. This case is reported to illustrate the complexity of diagnostic procedures necessary to reveal multilevel vertebral body tuberculosis and the place of modern imaging, especially computed tomography and magnetic resonance imaging, to differentiate vertebral tuberculosis from other differential diagnosis. Keywords Multilevel . Tuberculosis . Vertebral
Introduction Skeletal tuberculosis occurs in 1% of all tuberculosis, and the spine is involved in approximately one-half of these cases [1]. Tubercular spondylitis (Pott’s disease) is the most common form and accounts for about 25–60% of all cases of skeletal tuberculosis [2]. However, the atypical forms like the isolated involvement of one or more vertebral bodies are rare and misdiagnosed [2]. Multilevel vertebral body tuberculosis is an exceptional clinical case that may not have significant symptoms initially and radiographic changes are not specific [3]. It is often mistreated and exposed to complications particularly compression of the spinal cord with the risk of neurological deficit [4]. We report a rare case with multilevel vertebral bodies’ involvement by Mycobacterium tuberculosis and discuss Y. Ibn yacoub : B. Amine (*) : N. Hajjaj-Hassouni Department of Rheumatology, El Ayachi Hospital, University Hospital of Rabat-Sale, 11000 Sale, Morocco e-mail:
[email protected]
difficulties in the diagnosis of uncommon findings in radiographies and atypical aspects in computed tomography (CT) mimicking vascular or tumor lesion of the spine.
Observation A 29-year-old man presented with a 4-month history of an acute lumbar backache that spontaneously appeared associated to remittent fever, sweating, anorexia, weight loss (10 kg in 2 months), and general asthenia. No tuberculosis exposure history was mentioned. He had no underlying debilitating disorders. On physical exam, the patient had a decline in general health with height=1.82 m, weight= 62 kg, and high-grade fever (38.7°C). He had pain and limitation of all lumbar spinal movements. He had also elective pain in the pressure of L3, L5, and S1. There was no neurological deficit. Laboratory exams showed that erythrocyte sedimentation rate and C-reactive protein were elevated to 53 mm/h and 60 mg/L, respectively. Leukocyte count was 6,500/mm3 and hemoglobin was 11.3 g/dL. Hemocultures, intradermal tuberculin test, and cultures searching M. tuberculosis in spit and urine were all negative. Radiography of the spine showed a complete collapse of L5 lumbar vertebra (Fig. 1). The posterior half of the vertebral body was respected and there were no other signs of malignancy. CT of the lumbar spine revealed a unique osteolytic lesion in the vertebral body of L3 and multiple osteolytic lesions over the vertebral body and posterior elements of L5 with thin calcifications inside (Fig. 2). There was no involvement of the intervertebral disc or soft tissue. We have discussed above that those osteolytic lesions may contain calcifications, vascular lesions (angiomas), a neoplasm, a tuberculous infection, or pyogenic spondylitis. Magnetic resonance
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Antituberculous medication (rifampicin, isoniazid, pyrazinamide, and streptomycin) was given for 6 months and a Jewett’s corset was applied. The evolution was marked by a nonproductive cough 3 days after starting treatment. A chest X-ray revealed a pleural effusion suggesting a tuberculous pleuritis. The treatment was prolonged to 9 months. Symptoms improved markedly after several weeks and the patient recovered well.
Discussion
Fig. 1 Lumbar spine X-ray showing a collapse of L5 lumbar vertebra
imaging (MRI) revealed hypointense signal on the T1W images and hyperintense signal on T2W images within the vertebral bodies of T10, T11, L2, and L3 thoracic and lumbar vertebrae, enhanced after intravenous contrast administration of gadolinium (Fig. 3). MRI also revealed the presence of an enhancing small paravertebral abscess with cortical bone erosion. There was no involvement of the intervertebral disc. Vascular disease and metastasis were eliminated. Thus, pyogenic or tuberculous spondylitis was discussed. The presence of paraspinal abscess was more suggestive of tuberculous spondylitis than of pyogenic spondylitis. Histological study of percutaneous vertebral biopsy specimens revealed granuloma and giant cells with necrotic tissue likely related to an infection by M. tuberculosis. Microbiology result was negative. A diagnosis of multilevel vertebral bodies’ tuberculosis with paravertebral abscess was established. He had no underlying debilitating disorders and HIV serology was negative.
The spine is involved in approximately 50% of all cases of skeletal tuberculosis, and tubercular spondylitis is the most common form [5]. Multilevel vertebral tuberculosis is an exceptional form and it is observed more frequently among African adult patients [5]. In our observation, we report a rare case of multifocal vertebral body tuberculosis with an isolated affection of vertebral bodies. Intervertebral discs are totally respected. This entity constitutes a rare, misdiagnosed, and mistreated form of vertebral tuberculosis [2]. Tuberculous spondylitis is the most common form and it is easily recognized [2]. Classically, tuberculous spondylitis is related to the implantation of mycobacteria in the vertebral body and its development with the involvement of two adjacent vertebrae and disc involvement due to hematogenous spread of organisms through one arteria intervertebralis feeding the lower half of one vertebrae and the upper half of the adjacent one [6]. In multilevel vertebral body tuberculosis, after the hematogenous dissemination of mycobacterium, the paravertebral venous plexus of Batson provides the primary pathway for the dissemination of the infection in the vertebral column [2]. An early focus of infection lies in the anterior vertebral endplate. The infection spreads gradually throughout the involved vertebra and into the adjacent vertebra via subligaments [2].
Fig. 2 CT showing a unique osteolytic lesion in the vertebral body of L3 and multiple osteolytic lesions over the vertebral body and posterior elements of L5 with thin calcifications inside
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Fig. 3 MRI showing hypointense signal on the T1W images and hyperintense signal on T2W images within the vertebral bodies of T10, T11, L2, and L3 thoracic and lumbar vertebrae, enhanced after intravenous contrast administration
Vertebral tuberculosis may have varied manifestations [7]. Generally, the initial subjective symptoms are back pain, vertebral tenderness, fever, and a decline in general health [7]. Underlying debilitating disorders are often present, such as malnutrition, low socioeconomic status, corticosteroid therapy, HIV infection, and immunodepressed states [2]. In our patient, clinical, biological, and radiographic findings were nonspecific. Clinical and laboratory data found no signs of immunodepression. Laboratory exams were not specific and the intradermal tuberculin test was negative. In fact, 14% of patients with spinal tuberculosis had negative tuberculin tests [5]. Radiologic aspects in our patient were not very suggestive. CT is unable to show the early changes of the vertebral marrow and discs, and differentiating infectious disease from neoplastic involvement or vascular tumors may be impossible on the basis of CT images [8]. MRI has proved to be more sensitive for differentiation of spinal tuberculous infection from other differential diagnosis [9]. MRI is preferred to plain radiography and CT when detecting the abnormalities of bone marrow and soft tissues [2]. It is considered as an ideal modality in cases of suspicious diagnosis, demonstrating the extent of disease, identifying complications, and assessing response to treatment [10].
However, MRI images of isolated vertebral body involvement can be confused with plasmacytoma, lymphoma, primary neoplasm, vascular lesions, or eosinophilic granuloma [11]. These conditions have a similar appearance to tuberculosis on MRI with decreased signal intensities on T1W images and increased signal intensities on T2W images [2]. When MRI demonstrates a focal osteolytic lesion with low signal intensity on T1W and high signal intensity on T2W without vertebral compression or disc abnormality, metastasis should be strongly considered [2]. Secondary considerations include myeloma, lymphoma, and leukemia. The presence of an adjacent soft tissue component, MRI-enhancing abscesses may be suggestive of tuberculous etiology [8, 9]. Predominant involvement of the posterior half of the vertebral body favors the diagnosis of the metastasis. However, anterior half involvement is more common in tuberculosis [9]. The presence of paravertebral abscesses in our patient’s case was very suggestive. Percutaneous vertebral biopsy was very useful to confirm the diagnosis. Histological study can be performed in 80% of cases by a highly experienced radiologist [5]. Those aspects illustrate the complexity of the diagnosis in our patient and the interest of the combination of MR findings, clinical symptoms, and histological lesions, which
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were highly suggestive of the presence of vertebral tuberculosis.
Conclusion The case reported in this paper showed the complexity of diagnostic procedures necessary to reveal multilevel vertebral body tuberculosis and the importance of modern imaging especially MRI to differentiate vertebral tuberculosis from neoplasms. Also, it illustrates the interest of epidemiological, clinical, and histological data to establish the diagnosis and introduce an early treatment. However, confirmation was possible only by imaging-guided biopsy and response to antituberculous therapy.
Disclosures None.
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