Pott's disease of the cervico-occipital junction in an AIDS patient

Hearing loss unusually caused by tubercular retropharyngeal abscess

A 25-year-old man with complaints of neck pain for approximately 6 months and hearing loss accompanied by a feeling of obstruction of the left ear was presented. Findings from the oral cavity examination showed a retropharyngeal fluctuant, mildly tender mass. A conductive hearing loss of approximately 45 dB and a flat-shaped (type B) tympanogram were detected on the left ear. A magnetic resonance image of the neck demonstrated an abscess occupying the retropharyngeal space. Retropharyngeal space abscess was drained and sent both for pathologic and microbiologic analyses. Myringotomy and grommet ventilation tube insertion were performed in the left eardrum. The tube was removed 6 months later, but perforation on the insertion location did not close spontaneously. Therefore, we had to do myringoplasty 3 months later. Antitubercular drugs were given for a period of 9 months. There has been no previous report of a retropharyngeal tuberculous abscess with conductive hearing loss.

Spontaneous descending retropharyngeal abscess

Retropharyngeal abscesses are rare but can occur spontaneously in adults and are potentially life threatening. Such a diagnosis should be considered so that aggressive treatment can be initiated as soon as possible to avoid life threatening mediastinal complications.

Abcès rétropharyngés révélant un mal de Pott cervical

INTRODUCTION

Retropharyngeal abscesses are exceptional in adults. The etiologies are numerous, cervical spine tuberculosis is one of them.

OBSERVATION

We report two cases of cervical Pott's disease revealed by a retropharyngeal abscess. The clinical presentation was non-specific, dominated by oropharyngeal obstruction. Radiological findings suggested the diagnosis, showing a retropharyngeal collection with vertebral osteolysis. The bacteriological and histological assessment confirmed the diagnosis. The evolution was favorable after treatment by antituberculosis drugs.

DISCUSSION

Vertebral tuberculosis is rare. Cervical involvement is exceptional, and retropharyngeal abscesses can be the revealing feature of this condition. Symptoms are not specific. The diagnosis is based on radiological and bacteriological assessment. Treatment with antituberculosis drugs leads to a good outcome.

Spinal tuberculosis: CT and MRI feature

BACKGROUND

Spinal tuberculosis (TB) is perhaps the most clinically important extrapulmonary form of the disease. Early recognition is therefore necessary to minimize residual spinal deformity and/or permanent neurological deficit. We defined the CT and MRI image morphology of spinal TB and correlated the imaging features of these two modalities.

METHODS

CT (29 patients) and MRI (11 patients) images were retrospectively analyzed in 30 patients with proved spinal TB. CT and MRI findings were compared in cases with both imaging tests (10 cases). The parameters assessed were the type and extent of bone and soft tissue involvement.

RESULTS

The majority of the 30 patients were males (n=18) in the 30-49 year age group (43%). The most common clinical presentation was backache (73.3%) followed by fever (63.3%) and malaise (36.6%). The lumbar spine was the commonest site of the disease (43.3%) followed by the thoracic region (36.6%). A fragmentary type of bone destruction was the most frequent CT feature of the disease (48.2%) followed by the lytic type (24.1%). Intervertebral disc destruction (72%) and paravertebral mass/abscess (65.5%) were other features. Of the 11 patients who had an MRI, contiguous vertebral disease with disc destruction was seen in 10 cases. In 4 patients, there was distant vertebral disease in addition to the disease at the symptomatic site.

CONCLUSIONS

MRI offers excellent visualization of the bone and soft tissue components of spinal tuberculosis and helps to identify disease at distant asymptomatic sites. CT is useful in assessing bone destruction, but is less accurate in defining the epidural extension of the disease and therefore its effect on neural structures. MR imaging clearly demonstrated the extent of soft tissue disease and its effect on the theca/cord and foramen in cases with doubtful CT findings.

Outcome in neurologically impaired patients with craniovertebral junction tuberculosis: results of combined anteroposterior surgery

Object. The authors studied the immediate and long-term outcome after transoral decompression, occipitocervical fusion, and antituberculous therapy (ATT) in patients who had neurological deficits due to craniovertebral junction (CVJ) tuberculosis.

Methods. In this retrospective study, the authors reviewed the management and outcome in nine consecutive patients in whom features of spinal cord compression were observed and CVJ tuberculosis was diagnosed between 1993 and 1999. They ranged in age from 9 to 55 years. Onset of symptoms was acute or subacute and rapidly progressive (median 4 months, range 1–12 months). Patients presented with neck pain (89%), progressive limb weakness (89%), sensory symptoms (22%), and urinary dysfunction (33%). The mean preoperative functional grade based on the Nurick Scale was 3.4 (range 1–5). The disease caused reducible atlantoaxial dislocation (AAD) in three patients (33%), irreducible AAD in two (22%), basilar impression (BI) in one (11%), AAD with BI in one (11%), and C-2 vertebral body (VB) destruction without dislocation in two (22%). Surgery was performed in all cases. Five patients (56%) underwent transoral odontoidectomy, two (22%) transoral decompression of retropharyngeal abscess and granulation tissue, and two (22%) transoral decompression of abscess and diseased parts of the C-2 VB. All patients then underwent occipitocervical (occiput—C3) fusion in which a contoured Steinmann pin and iliac bone grafts were used.

Postoperatively, ATT was prescribed for 18 months. In the immediate postoperative period, function in these patients improved from a mean Nurick grade of 3.4 to 2.3 (p < 0.01). At long-term follow-up examination (median 18.8 months, range 7–46 months) function improved from a mean Nurick grade of 3.4 to 0.3 (range 0–2) (p < 0.001).

Conclusions. Patients with CVJ tuberculosis with features of cervical myelopathy are ideally managed with transoral decompressive procedures followed by occipitocervical fusion because this therapy provides immediate neurological improvement, stability, and allows early mobilization. The long-term prognosis in patients with this disease is excellent provided it is treated with appropriate surgical intervention(s) and with adequate duration of ATT.

Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis: a study of 29 cases

FNAC is a simple diagnostic tool for the initial evaluation of various deep seated pathological lesions. This study describes the applicability and practical aspects of the technique in establishing the diagnosis of spinal tuberculosis (TB) with the aid of radiographic guidance. The study was conducted in a major teaching hospital in Kuwait between the years 1985 and 1994. Twenty-nine patients (M:F = 18:11 and age range 8-72 years) with clinically and/or radiologically suspected spinal TB were seen in the Department of Cytology, Mubarak Al Kabeer Hospital. The patients were re-examined by either computed tomography (CT) scanning (n = 19) or fluoroscopy (n = 10) to localize the lesion for FNAC. FNAC smears were routinely stained with Papanicolaou and Diff Quik stains and one smear of each case was stained with Ziehl-Neelsen (Z-N) stain for acid-fast bacilli (AFB). Aspirated purulent material or syringe washings of dry aspirates were also submitted for microbiological cultures including AFB. Radiological and cytological findings were recorded in each case. Radiological findings included: bony rarefaction and destruction (93.1%), narrowed disc space (89.7%), soft tissue calcification (65.5%) and para-vertebral abscess formation (51.7%). Cytological findings included: epithelioid cell granulomas (89.7%), granular necrotic background (82.8%) and lymphocytic infiltration (75.9%). Smears were positive for AFB in 51.7% of cases. A positive AFB culture was obtained in 82.8% of cases, including all cases with positive AFB on smear by Z-N stain. Radiologically guided FNAC with AFB culture is a simple, reliable and practical approach to diagnosing spinal TB lesions. With a high diagnostic yield, it allows immediate initiation of specific treatment, helps to avoid invasive diagnostic procedures, and decreases hospitalization time.

Musculoskeletal complications of the patient with acquired immunodeficiency syndrome (AIDS): CT evaluation

Musculoskeletal disorders are infrequent complications of HIV infection in this country. However, AIDS patients are susceptible to a wide range of musculoskeletal complications, from the common to the otherwise uncommon. The following is a summary of some of the more frequently encountered musculoskeletal manifestations of these disorders within the HIV-positive community and their associated imaging characteristics.

Osteoarticular bacterial infections are rare in HIV-infected patients. 14 cases found among 4,023 HIV-infected patients

Among 4,023 HIV-infected patients admitted to a large Italian university hospital in the period 1985-1996, 14 had concomitant HIV and bacterial osteoarticular infections. Staphylococcus aureus infections were commonest and were diagnosed in 8 patients. Intravenous drug addiction was the only risk factor significantly associated with the development of osteoarticular infection (p = 0.04). In contrast, no statistical correlations were found with age, sex, absolute number of circulating T-CD4+ lymphocytes, neutrophils and stage of HIV infection. In conclusion, osteoarticular infections are uncommon in HIV-infected patients and are more directly related to parenteral drug abuse than to HIV.