Letter to the Editor
Tuberculous spondylodiscitis with a cervicothoracic spinal cord compression
Mielopatía compresiva cérvico-torácica por una espondilodiscitis tuberculosa
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Se evidencia una espondilodiscitis C7-T1 (flecha) con abscesificaciones prevertebrales (asterisco) y en el canal vertebral, ocasionando una mielopatía compresiva (punta de flecha). B) RM medular cervical en secuencia STIR, corte axial. 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(B) STIR MRI sequence of the cervical spine in the axial plane showing multiple paravertebral abscesses (arrowheads) and an epidural collection protruding through the spinal canal through the left intervertebral foramen at the C7-T1 level (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tuberculosis is the second most common infectious disease worldwide and the leading cause of osteomyelitis in certain regions. Pulmonary involvement is the most common type, but there are also other variants such as spinal tuberculosis, which accounts for 1% of all cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this paper we present the case of a 50-year-old man from Equatorial Guinea who has been living in Spain since 2002 and has a history of liver cirrhosis secondary to hepatitis B and a chronic kidney disease of unknown etiology for which he undergoes hemodialysis. He presented to another hospital for a ten-day episode of cervical pain, paresthesia in his upper limbs, and progressive weakness in his lower limbs. Three days later, he lost his ability to walk and consequently visited our clinic. A physical examination revealed a positive Lhermitte's sign, a muscle balance of 4/5 in the upper limbs and of 2/5 in the lower limbs, patellar hyperreflexia, a T8 medullary sensory level, and no Babinski reflex bilaterally.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A basic blood count revealed no relevant findings. A chest X-ray showed no signs of tuberculosis stigmas. A spinal magnetic resonance imaging (MRI) scan was requested, observing images of C7-T1 spondylodiscitis, voluminous paravertebral collections, and a 2.4-cm epidural abscess with significant spinal cord involvement and protrusion through the intervertebral foramina, all of which were compatible with a diagnosis of tuberculous myeloradiculopathy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was also assessed in the Neurology Department, where immediate spinal decompression surgery was ruled out and surgical drainage of the prevertebral collection was performed. Although a sputum smear microscopy screening for acid-fast bacilli and a mycobacteria culture were both negative, a polymerase chain reaction (PCR) test was positive for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>. A QuantiFERON-TB Gold test supported this finding. A sputum microbiology study was also negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Based on the above, tuberculostatic therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol was administered for two months, followed by isoniazid and rifampicin for another four months. A cervicothoracic computed tomography (CT) scan performed after one month of treatment revealed a C7-T1 vertebral collapse and a persistent epidural abscess, which were treated by means of a corpectomy, intervertebral fusion, and aspiration of the collection. The patient’s subsequent clinical evolution was torpid, with persistent paraplegia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Tuberculous spondylodiscitis, also known as Pott's disease, is a common cause of spinal infection in developing countries and endemic areas. However, its incidence has increased in our setting over the last decade as a result of immigration and immunosuppression in subjects with the human immunodeficiency virus (HIV), chronic kidney disease, cancer, or those receiving chemotherapy or next-generation biologics.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The predominant causative agent is <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>. Hematogenous dissemination of the bacillus occurs after the primary pulmonary infection, with colonization of the anterior region of the vertebral body, where a granulomatous inflammatory reaction characterized by osteolysis develops. This process preferentially affects the thoracic and thoracolumbar portions of the spine in more than 50% of cases, followed by the lumbar portion and, rarely, the cervical or cervicothoracic portions.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The disease follows an insidious course, lasting between two and seven months, and manifesting with dorsal pain, kyphosis, constitutional syndrome, and fever. Almost half of the patients that suffer from this disease develop neurological complications due to the spinal cord compression or its direct invasion, developing myeloradiculopathy with secondary paraparesis or tetraparesis in 10–27% of cases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The progression of the condition was faster in our patient.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A high degree of clinical suspicion is crucial, although the definitive diagnosis is usually reached through a combination of microbiological and histological analyses of a biopsy sample or an excisional surgery specimen, with a yield of 70–80%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Imaging tests, particularly MRI, play a fundamental role in the diagnostic approach and follow-up. The typical pattern of this condition consists in scarce vertebral involvement associated with extensive infiltration of the contiguous soft tissues, as in the present case, contrary to what occurs in spondylodiscitis caused by <span class="elsevierStyleItalic">Staphylococcus aureus.</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The combination of treatment with four tuberculostatic drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) for six months, which was the regimen prescribed to our patient, represents the generally accepted therapeutic approach. Some experts propose prolonging this treatment to up to nine or 12 months based on the condition’s clinical or radiological evolution.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Several authors also defend the need for surgery as a complement to the standard medical treatment in the case of acute spinal cord compromise or structural instability of the spine.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In short, because the continuous migratory flows and the immunosuppression of many patients have led to an increase in cases of tuberculous spondylodiscitis in our setting, it is essential to consider this condition in the differential diagnosis of acute spinal cord syndrome, as the diagnostic-therapeutic delay can be catastrophic.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors of this paper declare that they have not received funding from any public or private entity in the process of writing this manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Molina-Gil J, Meijide Rodríguez L, Amorín-Díaz M. Mielopatía compresiva cérvico-torácica por una espondilodiscitis tuberculosa. Med Clin (Barc). 2021;157:e285–e286.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1250 "Ancho" => 2500 "Tamanyo" => 185962 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) T2-weighted MRI sequence of the cervical spine in the sagittal plane showing evidence of C7-T1 spondylodiscitis (arrow) with prevertebral (asterisk) and vertebral canal abscesses causing a compressive myelopathy (arrowhead). (B) STIR MRI sequence of the cervical spine in the axial plane showing multiple paravertebral abscesses (arrowheads) and an epidural collection protruding through the spinal canal through the left intervertebral foramen at the C7-T1 level (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spinal tuberculosis: current concepts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Ajasekaran" 1 => "D.C.R. Soundararajan" 2 => "A.P. Shetty" 3 => "R.M. 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Somvanshi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1179/2045772311Y.0000000023" "Revista" => array:6 [ "tituloSerie" => "J Spinal Cord Med" "fecha" => "2011" "volumen" => "34" "paginaInicial" => "440" "paginaFinal" => "454" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22118251" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000006/v2_202201010922/S2387020621004423/v2_202201010922/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000006/v2_202201010922/S2387020621004423/v2_202201010922/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621004423?idApp=UINPBA00004N" ]
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