AN INTERESTING PRESENTATION OF TB WITH DYSPHAGIA

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Tuberculosis (TB) is a global pandemic, but the incidence of TB is low in the United States. Hence, the diagnosis of TB can be frequently delayed, especially with the extrapulmonary manifestations. Here we present a case of skeletal tuberculosis which had to be worked up extensively before the diagnosis. CASE PRESENTATION: 57 year-old-woman, an immigrant from Nepal presented with complaints of excruciating chest pain, dysphagia and back pain. She had similar complaints for 4 months and had an extensive workup done including bloodwork, X-rays of chest, abdomen, thoracic spine, Electrocardiogram, stress test, Esophagogastroduodenoscopy and Gastric Emptying Study, all being unremarkable. 2 weeks prior, she had presented to an acute care with similar complaints where she had a Computed tomography (CT) of Chest without contrast done which showed a lucent foci in anterior vertebral body in T6. This new lesion made concerns about malignancy and she had an appointment with oncology upcoming, when with worsened symptoms, she presented to us. After presentation, she disclosed additional complaints of recent weight loss, night sweats, dry cough and a history of untreated latent tuberculosis. Magnetic Resonance Imaging of spine showed abnormal marrow signal in T4-T6 with disc narrowing and multiloculated paraspinal mass suggestive of Tubercular spondylitis and paraspinal/paravertebral abscess (fig-1). CT guided aspiration of the paraspinal abscess in T6 was done and sent for workup. Acid Fast Bacilli stain of abscess was positive, also the culture later grew Mycobacterium tuberculosis. With her dysphagia, chest CT with contrast was done which showed mass effect and erosion on the posterior esophageal wall anterior to T3-T4 vertebra which explained her dysphagia (fig-2). She was started on treatment with Rifampin, Isoniazid, Ethambutol and Pyrazinamide. DISCUSSION: Pott’s spine is the commonest form of skeletal TB and presents with local pain accompanied by fever, weight loss, sometimes with rare presentations like dysphagia. With progression of infection, spinal cord compression can occur causing paraplegia. Diagnosis is often delayed with its subacute course and with its rarity in non-endemic areas, especially in absence of active chest symptoms. Diagnosis is usually established by microscopy and culture of infected material obtained by aspiration and/or biopsy. Medical management is done with anti-tubercular drugs for 9-12 months. Sometimes with complications, surgical treatment can also be warranted. CONCLUSIONS: Skeletal TB can be rare in non-endemic areas like the United States, however, questions including country of origin, history of travel, prior infection or exposure should always be sought to make a timely diagnosis. Reference #1: Fuentes Ferrer M et al: Tuberculosis of the spine. A systematic review of case series. International orthopaedics. 2012;36(2):221-31. Reference #2: Trecarichi EM, Di Meco E, Mazotta V, Fantoni: M Tuberculous spondylodiscitis : epidemiology, clinical features, treatment and outcome Eur Rev Med Pharmacol Sci. 2012 Apr;16 Suppl 2:58-72. Reference #3: Nussbaum ES, Rockswold GL, Bergman TA, Erickson DL, Seljeskog EL: Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg. 1995;83(2):243. DISCLOSURES: No relevant relationships by Rakshya Sharma, source=Web Response No relevant relationships by Ananta Subedi, source=Web Response