Pott's disease in pregnancy - The University of Chicago Department ...

MKSAP
An 18-year-old woman is evaluated in the emergency department
because of a 3-day history of lower abdominal pain. She does not
have urinary frequency, dysuria, flank pain, nausea, or vomiting.
Her only medication is an oral contraceptive agent.
On physical examination, temperature is 38.3 °C (101.0 °F), blood
pressure is 118/68 mm Hg, pulse rate is 104/min, and respiration
rate is 16/min. Abdominal examination is normal. There is no flank
tenderness. Pelvic examination shows cervical motion tenderness,
fundal tenderness, and bilateral adnexal tenderness on bimanual
examination.
The leukocyte count and urinalysis are normal. Urine and serum
pregnancy tests are negative.

Which of the following is the most appropriate treatment?
A. Ampicillin and gentamicin, intravenously
B. Azithromycin, orally
C. Cefoxitin, intramuscularly
D. Ceftriaxone, intramuscularly, and doxycycline, orally
E. Metronidazole, orally

Which of the following is the most appropriate
treatment?
A. Ampicillin and gentamicin,
intravenously
B. Azithromycin, orally
C. Cefoxitin, intramuscularly
D. Ceftriaxone IM &
doxycycline PO
E. Metronidazole, orally
20% 20% 20% 20% 20%
A. B. C. D. E.

This patient’s clinical findings are compatible with pelvic inflammatory disease (PID), and
she should receive intramuscularly delivered ceftriaxone and oral doxycycline.
PID is a polymicrobial infection of the endometrium, fallopian tubes, and ovaries;
diagnosis is based on the presence of abdominal discomfort, uterine or adnexal
tenderness, or cervical motion tenderness.
Other diagnostic criteria include temperature higher than 38.3 °C (101.0 °F), cervical or
vaginal mucopurulent discharge, leukocytes in vaginal secretions, and documentation of
gonorrheal or chlamydial infection.
PID is most likely to occur within 7 days of the onset of menses. All women with
suspected PID should be tested for infection with gonorrhea and chlamydia and undergo
pregnancy testing. In severe cases, imaging should be performed to exclude a tuboovarian
abscess. Ambulatory patients are treated with ceftriaxone and doxycycline with
or without metronidazole.
Duration of treatment is 14 days. Patients with PID should be hospitalized if there is (1)
no clinical improvement after 48 to 72 hours of antibiotics; (2) an inability to tolerate oral
antibiotics; (3) severe illness with nausea, vomiting, or high fever; (4) suspected intraabdominal
abscess; (4) pregnancy; or (5) noncompliance with outpatient therapy.

27 F G4P2 @ 12 weeks p/w chest/back pain

27 F G4P2 @ 12 weeks p/w chest/back pain
3 week h/o worsening mid-thoracic pain
Seen 1 week ago at OSH ER and DC’d with Tylenol
30 lb weight loss since start of pregnancy
Mild SOB with pain

27 F G4P2 @ 12 weeks p/w chest/back pain
PMH
Stillbirth @ 32 weeks
PSH
None
Social
1 ppd x 10 years (now 1 cig
per day during pregnancy)
Occasional marijuana use
No EtOH or IVDA
Unemployed
Family
Mother – HTN, DM
Father – HTN, DM
Meds
Prenatal vitamins
Tylenol prn

Differential Diagnosis?

Physical Exam
VS T 35.8 HR 96 BP 122/81 RR 20 98% RA
Gen: Gravid AAF in NAD
HEENT: PERRLA, EOMI, anicteric, o/p clear
Neck: No LAD
CV: RRR, s1/s2, no m/r/g, no JVD
Lungs: CTAB
Abd: Gravid uterus, size c/w date, NT, +bowel sounds
Msk: TTP @ mid thoracic spine, mild b/l calf TTP
Neuro: A&Ox3, 3/5 L hand grip strength otherwise 5/5 throughout.
CN II-XII intact.
Derm: No rashes

Bratton RL. Am Fam Physician 1999.
Back Pain Differential

Bratton RL. Am Fam Physician 1999.
Spinal Nerve Roots

Labs/Studies?

10.3
6.4 662
32.1
N 60% L 25% M 14% E 0%
7.9 3.3
0.3 0.1/0.2
16 15
199
Studies
CK 25
CKMB 2.0
Trop T 120
UA
pH 8.0
LE neg
Nitrites neg
Protein neg
Blood trace
WBC 5-10

EKG: NSR, no ischemic changes
BLE Dopplers: No DVT
Studies

Radiation during Pregnancy
Toppenberg KS, Hill A, Miller DP. Am Fam Physician 1999.

Toppenberg KS, Hill A, Miller DP. Am Fam Physician 1999.
Radiation during Pregnancy

CT Chest
Studies

Studies
CT Chest:
Impression:
1. No evidence of acute PE.
2. Destructive soft tissue mass involving the lower cervical and
upper thoracic spine with pathologic fracture of T3. The mass
displaces the trachea and esophagus anteriorly and encroaches
upon the areas of exiting nerve roots of the upper thoracic spine.
3. Multiple calcified mediastinal and hilar lymph nodes are also
noted.

Abscess
Pyogenic osteomyelitis
Differential of vertebral lesion
S. aureus, brucellosis, melioidosis
Invasive fungal disease
Histoplasmosis, actinomycosis, candidiasis
Atypical infection
Mycobacterium
Lymphoma
Multiple myeloma
Metastatic lesion
Trophoblastic disease

ESR 126
CRP 113
Blood Cx: Neg
HIV: Nonreactive
Histo: Neg
Blasto: Neg
Hep B S Ag: Neg
HCV Ab: Neg
Additional Studies
PPD Refused: Additional history- pt had PPD placed 1 month ago at
OSH and developed painful swelling at site.

1. Extensive marrow signal replacement of vertebral bodies of C5 – T5 with
large perispinal soft tissue mass.
2. Compression fracture of T3.
3. Significant extension of soft tissues into the ventral epidural space with tight
spinal stenosis at T3.
4. Normal signal intensity of the cord.
5. Significant bulge of the disk material and hypertrophied changes along the
ventral aspect of the canal at C5 and C6 with central spinal stenosis.

Additional Studies
CT-guided needle biopsy: Successful aspiration of 5 cc of green
purulent fluid from paraspinal fluid collection.
Smear: 3+ AFB

Incidence per
100,000
90
80
70
60
50
40
30
20
10
0
Spinal TB
1950 1960 1970 1980 1990 2000 2010
Percivall Pott 1776
• Incidence of TB in the US has
declined for most of the 20th Century
• 20% have extrapulmonary TB
• Of these, 10% have skeletal
involvement
• Initial radiographs are often unrevealing
• May spare the disc space entirely while causing central rarefaction of the
vertebral body3 • MRI is diagnostic study of choice
• Abscess formation in the anterior soft tissues and collection of
granulation tissue adjacent to vertebral body
McLain RF, Isada C. Cleveland Clinic Journal of Medicine 2004; 71(7): 537-549.

Pott’s Disease
McLain RF, Isada C. Cleveland Clinic Journal of Medicine 2004; 71(7): 537-549.

Complications
Pregnancy minimally impacts disease progression but often obscures
initial diagnosis leading to greater risk of complications 1
Psoas abscess
Cauda equina compression resulting in paraplegia or quadriplegia
Meningitis
Premature labor resulting in stillbirth
Autonomic dysreflexia causing dysregulation of sympathetic spinal
reflexes and severe hypertension when lesion is above T62, 5
Rarely infects the fetus, but has been reported to spread
lymphohematogenously via the infected placenta at time of delivery 1
1. Hamadeh MA, Glassroth J. Chest 1992; 101: 1114-1120.
2. Luewan S, Bunmaprasert T, Chiengthong K, Tongsong T. Int J Gynaecol Obstet 2008; 102(3): 298-300.
3. Rosenfeld JV, Torey EI, Michael MS, Johnson MM. J Clin Neuroscience 1998; 5(2): 212-215.

Myers TH. J Bone Joint Surg Am 1891; s1-4: 124-131.
Treatment

Treatment
Pregnant women diagnosed with TB should be treated without delay1, 3, 5
Drug therapy is cornerstone of successful management
Unlike the management of many infected fluid collections, drainage and
surgery in Pott’s disease are adjunctive, rather than primary,
interventions
Adjunctive post-parturition surgery – abscess drainage, debridement of
necrotic bone and disc, and reconstruction of local spinal column
Agent Pregnancy
Category
Isoniazid C
Rifampin C
Pyrazinamide C
Ethambutol B
Streptomycin D
1. Hamadeh MA, Glassroth J. Chest 1992; 101: 1114-1120.
2. McLain RF, Isada C. Cleveland Clinic Journal of Medicine 2004; 71(7): 537-549.
3. Rosenfeld JV, Torey EI, Michael MS, Johnson MM. J Clin Neuroscience 1998; 5(2): 212-215.

Case Conclusion
4-drug therapy with INH, pyrazinamide, ethambutol, rifampin, and
vitamin B6 initiated
Uncomplicated NSVD at 36 weeks
Completed 9 month course
No surgical intervention required

References
1. Hamadeh MA, Glassroth J. Tuberculosis and Pregnancy. Chest 1992; 101: 1114-1120.
2. Luewan S, Bunmaprasert T, Chiengthong K, Tongsong T. Spinal Tuberculosis in Pregnancy. Int J
Gynaecol Obstet 2008; 102(3): 298-300.
3. McLain RF, Isada C. Spinal Tuberculosis Deserves a Place on the Radar Screen. Cleveland
Clinic Journal of Medicine 2004; 71(7): 537-549.
4. Myers TH. Pott’s Disease and Pregnancy. J Bone Joint Surg Am 1891; s1-4: 124-131.
5. Rosenfeld JV, Torey EI, Michael MS, Johnson MM. Tuberculous Spinal Cord Compression in
Pregnancy. J Clin Neuroscience 1998; 5(2): 212-215.
6. Toppenberg KS, Hill A, Miller DP. Safety of Radiographic Imaging During Pregnancy. Am Fam
Physician 1999.
7. Arce D, Sass P, Abdul-Khoudoud H. Recognizing Spinal Cord Emergencies. Am Fam Physician
2001; 64(4):631-639.
8. Bratton RL. Assessment and Management of Acute Low Back Pain. Am Fam Physician 1999.