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Spondylitis TBDarmawan B Setyanto

Respirology DivisionDepartment of Child Health FMUI - CM Hospital Jakarta

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lymphadenitis

lymphangitis

primary focus

TB pathogenesisTB pathogenesis ......

Ghon focus

Simon focus

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M. tuberculosis inhalation

phagocytosis by PAM

live bacilli

multiplies

primary focus formationlymphogenic spread

hematogenic spread1)

Primary complex2)

Cell mediated immunity (+)TST (+)

incubation period(2-12 weeks)

Pri

mary

TB

3)primary complex complication

hematogenic spread complicationlymphogenic complication

TB disease

Dead

Optimal CMI

TB infection

Cured TB disease4)

CMI reactivation/reinfection

bacilli deadTB pathogenesi

s

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TB hematogenous spread

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Tuberculosis

primary • usually in children• initial infection• primary complex• most : lung (>95%)• other : GI tract,

skin• disease : within 1

year after infection

post primary• usually in adult /

older children• reinfection :

usually exogenous• reactivation of

the remote foci• years after

infection

04/17/23 6Miller FJW. Tuberculosis in children, 1982

A minority of childrenexperience :1. Febrile illness2. Erythema Nodosum3. Phlyctenular Conjunctivitis

Complications of focus1. Effusion2. Cavitation3. Coin shadow

Complications of nodes1. Extension to bronchus2. Consolidation3. Hyperinflation

MENINGITIS OR MILIARYin 4% of children infected

under 5 years of ageLATE COMPLICATIONS

Renal & SkinMost after 5 years

1 2 3 4 5 6

BONE LESIONMost within

3 years

24 months

Resistance reduced :1. Early infection (esp. in first year)2. Malnutrition3. Repeated infections :measles, whooping coughstreptococcal infections4. Steroid therapy

infection

BRONCHIAL EROSION

Most childrenbecome tuberculin

sensitive

12 months

DIMINISHING RISK

But still possible90% in first 2 yearsGREATEST RISK OF LOCAL & DISEMINATED LESIONS

Development Of Complex

4-8 weeks 3-4 weeks fever of onset

PRIMARY COMPLEXProgressive HealingMost cases

Uncommon under 5 years of age25% of cases within 3 months75% of cases within 6 months

3-9 monthsIncidence decreasesAs age increased

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Remote foci, reactivation• lung, Simon foci at the apex adult type KP

• lymph nodes • meninges• skeletal : any bones & joints

– bones : spine, rib, phalanx (dactylitis)– joints : hip, knee, ankle, shoulder, elbow, wrist

• kidney• liver

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Spondylitis TB

•spinal tuberculosis•tuberculosis of the spine•Pott’s disease•Pott’s paraplegia

most commonmost dangerous

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Typical clinical presentation• pain• weakness• rigidity• deformity : loss of lordosis

angular kyphosis gibbus

• cold abscess• paraplegia

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Imaging • plain radiographic :

– narrowing intervertebral space– erosion adjacent surface– destruction– collapse vertebral bodies

• CT scan• MRI• Bone scintigraphy

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Diagnosis

• Typical clinical presentation• Systemic constitutional

manifestation• Prove of TB infection, TST (+)• Imaging diagnostic

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Treatment

Uncomplicated, without neurologic complication

• conservatively, anti TB drugs• ambulatory, out patient setting• orthotic support

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Treatment - 2

Complicated, with neurologic complication

• warrants immediate attention• team: orthopedic surgeon &

pediatrician• anti TB drugs ASAP• surgical intervention, depends on

severity

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Surgical interventionAbsolute indications• marked neurological deficit• severe kyphosis • large abscess respiratory

obstruction• worsened neurological, despite

adequate therapy• progression of kyphosis or instability

JBJS, 1996

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TB tracking

Child TBpatient

Adult TB patient

centri-petal

centri-fugal

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The case : clinical manifestation

pain weakness rigidity

deformity : loss of lordosis angular kyphosis gibbus

cold abscess paraplegia lost of control: urinary, defecation

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Thank you

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Surgical intervention

Relative indications• Inability to obtain culture material • Neurological deficit in prolong

bedrest contra indication

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case findingcentripetal

• trace the source

• adult people• close contact• by chest X ray

centrifugal• trace other

‘victims’• children• close contact• by tuberculin

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Presented at:

• Lina Haryanti case presentation• 06 Aug 2009