P O T T ‘S
DISEASE
Pembuat : TONDO BAYU (11-2011-048) MERCY SYLVIA (11-2012-009) Pembimbing : dr. Suhana, SpOT
POTT’s DISEASE • Definition – Pott’s disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. – It is named after Percivall Pott (1714-1788), a London surgeon who trained at Barts. – Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. – AKA: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's disease
POTT’s DISEASE • Etiology – Pott’s disease is caused when the vertebrae become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott'sdisease often develops kyphosis, which results in a hunchback.
Pathophysiology Of Tuberculous Spondylitis
Tuberculous spondylitis “Cold Abscesses” • Not as hot, warm or painful as other abscesses
• Hidden deep inside the body • May burst out leaving behind a track, or sinus, which discharges pus
POTT’s DISEASE • Epidemiology – Approximately 1-2% of total tuberculosis cases are attributable to Pott’s disease. The incidence rate here in the Philippines is approximately 20-30% of the entire patient diagnosed to have Tuberculosis. Most of the cases of the Pott's disease in the Philippines are caused by the non-compliance of the treatment regimen of TB. – Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of TB occurs in poorer countries, but a global resurgence is affecting richer ones. – The disease affects males more than females in a ratio of between 1.5 and 2:1. – In the USA it affects mostly adults but in the countries where it is commonest it affects mostly children.
POTT’s DISEASE • Risk Factors – Tuberculosis/Endemic TB – Poor socioeconomic conditions – Diabetes – Steroid Use – Chronic Disease – Immunosuppression – IV drug Abuse – Rheumatoid Arthritis
POTT’s DISEASE • Signs and Symptoms – – – – –
Localized back pain Paravertebral swelling Systematic signs and symptoms of TB Neurological signs may occur leading to paraplegia Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of the leg
POTT’S DISEASE
POTT’S DISEASE
POTT’S DISEASE
PHYSICAL ASSESSMENT
Body Parts
Actual Findings
Height
Change of shape of back
kyphosis
Weight
Weight loss
Anorexia
Vital signs Temperature
Analysis
Normal Findings
Actual Findings
Analysis
36.5-37.5 degrees Celsius
Increase in temperature
Febrile
General Survey Body built Overall hygiene and grooming
Normal Findings mesomorph
Actual Findings Ectomorph
clean and neat
Self bathing hygiene deficit
POTT’S DISEASE
Analysis Deviation from Normal Deviation from Normal
PHYSICAL ASSESSMENT Assessment of the Skin Normal Findings
Skin color
Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive
Actual Findings
Analysis
redness
erythema
-Fundamentals of Nursing 8th edition Kozier and Erb’s page 579
No edema Presence of edema
-Fundamentals of Nursing 8th edition Kozier and Erb’s page 579
with edema
Uniform: within normal range Skin temperature
-Fundamentals of Nursing 8th edition Kozier and Erb’s page 579
edema
Febrile Warm skin temperature Deviation from Normal
PHYSICAL ASSESSMENT Assessment of the Nose
Palpate the maxiliary and frontal sinuses for tenderness
Not tender
Tenderness in one or more sinuses
Deviation from normal
Assessment of the Thorax Posterior Thorax
Inspect the spinal alignment for deformities.
Palpate the posterior thorax
Normal Findings Spine is vertically aligned. Spinal column is straight, right and left shoulder and hips are at the same height. - Fundamentals of Nursing 8th edition Kozier and Erb’s page 614 No tenderness, no masses
Actual Findings
Analysis
Exaggerated spinal curvatures
Kyphosis due to gibbous formation
Pain with palpation over the spine
Deviation from normal
PHYSICAL ASSESSMENT Assessment of the Musculoskeletal System Normal Findings
Actual Findings
Analysis
Muscle atrophy
Deviation from Normal
Weakness
Deviation from Normal
Equal in size on both body parts. Inspect the muscle for size.
- Fundamentals of Nursing 8th edition Kozier and Erb’s page 640 Equal strength on each body sides
Test muscle strength.
( sternocleidomastoid, trapezius, deltoid, biceps, triceps, wrist and finger, grip strength, hip and hamstring. - Fundamentals of Nursing 8th edition Kozier and Erb’s page 640
Assess range of motion
Varries in accordance to a person genetic make-up Fundamentals of Decrease range of motion. Pain in movement Nursing 8th edition Kozier and Erb’s page 641
Deviation from Normal
Bones Inspect the skeleton for structure
No deformities
Palpate the bones to locate any No tenderness or swelling areas of edema or tenderness
Bones misaligned
Deviation from normal
Presence of tenderness or swelling
Deviation from normal
Swelling joints
Deviation from Normal
Decreased range of motion
Deviation from normal
Joints Inspect the swelling. Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and presence of nodules.
Assess joint range of motion
No swelling No tenderness, crepitation or nodules Joints move smoothly Varies to some degree in accordance with person’s genetic make-up and degree of physical activity
DIAGNOSTICS
Diagnosis Blood cp( ESR) Range of motion in the spine. A series of neurological tests complete medical history blood immunoglobin profile X-rays magnetic resonance images (MRIs)
CT scan guided biopsy Bone scans
DIAGNOSTIC PROCEDURE – – – – – –
Blood Test- elevated ESR Tuberculine Test Radiographs of the spine Bone Scan CT of the Spine Bone biopsy
• MICROBIOLOGY – Needle biopsy – Acid-fast strain and culture
DIAGNOSTIC PROCEDURE • Imaging Studies – CT scanning • CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference. • Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal areas.
– MRI • MRI is the criterion standard for evaluating disk-space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression.
LABORATORY RESULTS: • Laboratory Studies – Tuberculin skin test (purified protein derivative [PPD])• Results are positive in 84- 95% of patients with Pott disease who are not infected with HIV
– The erythrocyte sedimentation rate (ESR) • May be markedly elevated (>100mm/h).
– Microbiology studies • Are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. These study findings are positive in only about 50% of the cases.
LABORATORY RESULTS • Aspirate from joint space & abscess • Transparency: turbid. • Colour: creamy. • Consistency: cheesy. • Fibrin clot: large. • Mucin clot: poor. • WBC: 25000/cc.mm.
LABORATORY RESULTS • Imaging Studies – Radiography • •Radiographic changes associated with Pott disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain radiography: • •Lytic destruction of anterior portion of vertebral body • •Increased anterior wedging • •Collapse of vertebral body • •Reactive sclerosis on a progressive lytic process • •Enlarged psoas shadow with or without calcification
– •Additional radiographic findings may include the following: • • • • •
•Vertebral end plates are osteoporotic. •Intervertebral disks may be shrunk or destroyed. •Vertebral bodies show variable degrees of destruction. •Fusiform paravertebral shadows suggest abscess formation. •Bone lesions may occur at more than one level.
LABORATORY RESULTS • Imaging Studies – X-Ray spine • Early:• Narrowed joint space. • Diffuse vertebral osteoporosis adjacent to joint. • Erosion of bone. • Fusiform paraspinal shadow of abscess in soft tissue. • Late:• Destruction of bone. • Wedge-shaped deformity (collapse of vertebrae anteriorly). • Bony ankylosis.
LABORATORY RESULTS • Imaging Studies – CT SCAN • CT scanning reveals early lesions and is more effective for defining the shape and calcification of soft-tissue abscesses. • In contrast to pyogenic disease, calcification is common in tuberculous lesions.
– MRI • MRI findings useful to differentiate tuberculous spondylitis from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.
DIFFERENTIAL DIAGNOSIS – Osteitis Piogen – Poliomielitis – Skoliosis idiopatik – Metastasis spinal cord – Pulmo infection after empiema
– Kifosis senilis
Complication • Spinal cord injury • Empyema tuberculosis
Treatment • Drug treatment • Bed rest • Spinal braces • Surgery
