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Back pain: An old cause in a young adult
EJINME-02868; No of Pages 2 European Journal of Internal Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Back pain: An old cause in a young adult Barbara Ferrari ⁎, Raffaella Rossio, Flora Peyvandi Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
a r t i c l e
i n f o
Article history: Received 7 November 2014 Received in revised form 29 December 2014 Accepted 3 February 2015 Available online xxxx
1. Indication A 23-year-old man from the Philippines was admitted to our emergency department for a three-weeks-lasting thoracic back pain, followed by an onset of postural instability; he also complained about repeated alternation of constipation and diarrhoea, associated with burning abdominal pain. On physical examination, the patient showed
ataxic gait, a T10 spinal sensory level and symmetric hyperreflexia at lower limbs. A magnetic resonance imaging (MRI) scan of the spine was performed and revealed the collapse of the ninth thoracic vertebral body and a pathologic mass invading the spinal canal with spinal cord compression (Fig. 1). What is the diagnosis?
Fig. 1. Spine mass with collapse of the ninth thoracic vertebral body and presence of pathologic mass invading the spinal canal with spinal cord compression, by magnetic resonance imaging (MRI) scan of the spine (Panel A and B).
⁎ Corresponding author at: Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy. Via Pace 9, 20122 Milan, Italy. Tel.: +39 02 5503 5414, fax; +39 02 54 100 125. E-mail address: [email protected] (B. Ferrari).
http://dx.doi.org/10.1016/j.ejim.2015.02.002 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Ferrari B, et al, Back pain: An old cause in a young adult, Eur J Intern Med (2015), http://dx.doi.org/10.1016/ j.ejim.2015.02.002
2
B. Ferrari et al. / European Journal of Internal Medicine xxx (2015) xxx–xxx
2. Diagnosis The patient underwent surgery for decompression and dorsal arthrodesis to stabilize the spine. The extemporaneous histologic examination of the mass revealed a giant-cell granulomatous chronic inflammation, focally necrotizing. After rapid detection of Mycobacterium tuberculosis complex DNA on the biopsy tissue by polymerase chain reaction, anti-tuberculous therapy was started. Culture tests confirmed the diagnosis. At the last follow-up, two months after discharge, patient's conditions are good and neurological examination normal. Despite socio-economic improvement in western countries and availability of effective drugs, the impact of acquired immunodeficiency syndrome and immigration has increased the rate of tuberculosis. Spinal tuberculosis (Pott's disease) is the most common extra-pulmonary manifestation of tuberculosis. The thoracic segment is the most frequently affected spinal segment, followed by the lumbar spine [1]. Imaging tests such as MRI and computed tomography help in diagnosing the disease but microbiological diagnosis based on culture and/or histology techniques is indicated for definitive diagnosis [2]. Spinal tuberculosis is a great challenge to physicians due to the wide non-specific spectrum of clinical presentations, which result in delay of
diagnosis and the risk of significant potential morbidity and mortality due to several complications (i.e. paraplegia). Early diagnosis and treatment are the keys to avoid this long-term disability [3]. Therefore, spinal tuberculosis should be considered as a differential diagnosis in patients with chronic back pain and neurological symptoms, especially if coming from endemic areas.
Conflict of interest None.
References [1] Fuentes Ferrer M, Gutiérrez Torres L, Ayala Ramírez O, Rumayor Zarzuelo M, del Prado González N. Tuberculosis of the spine. A systematic review of case series. Int Orthop 2012;36:221–31. [2] Trecarichi EM, Di Meco E, Mazzotta V, Fantoni M. Tuberculous spondylodiscitis: epidemiology, clinical features, treatment and outcome. Eur Rev Med Pharmacol Sci 2012;16:58–72. [3] Ansari S, Amanullah MF, Ahmad K, Rauniyar RK. Pott's spine: diagnostic imaging modalities and technology advancements. N Am J Med Sci 2013;5:404–11.
Please cite this article as: Ferrari B, et al, Back pain: An old cause in a young adult, Eur J Intern Med (2015), http://dx.doi.org/10.1016/ j.ejim.2015.02.002
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Back pain: An old cause in a young adult Barbara Ferrari ⁎, Raffaella Rossio, Flora Peyvandi Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy
a r t i c l e
i n f o
Article history: Received 7 November 2014 Received in revised form 29 December 2014 Accepted 3 February 2015 Available online xxxx
1. Indication A 23-year-old man from the Philippines was admitted to our emergency department for a three-weeks-lasting thoracic back pain, followed by an onset of postural instability; he also complained about repeated alternation of constipation and diarrhoea, associated with burning abdominal pain. On physical examination, the patient showed
ataxic gait, a T10 spinal sensory level and symmetric hyperreflexia at lower limbs. A magnetic resonance imaging (MRI) scan of the spine was performed and revealed the collapse of the ninth thoracic vertebral body and a pathologic mass invading the spinal canal with spinal cord compression (Fig. 1). What is the diagnosis?
Fig. 1. Spine mass with collapse of the ninth thoracic vertebral body and presence of pathologic mass invading the spinal canal with spinal cord compression, by magnetic resonance imaging (MRI) scan of the spine (Panel A and B).
⁎ Corresponding author at: Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan, Italy. Via Pace 9, 20122 Milan, Italy. Tel.: +39 02 5503 5414, fax; +39 02 54 100 125. E-mail address: [email protected] (B. Ferrari).
http://dx.doi.org/10.1016/j.ejim.2015.02.002 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Ferrari B, et al, Back pain: An old cause in a young adult, Eur J Intern Med (2015), http://dx.doi.org/10.1016/ j.ejim.2015.02.002
2
B. Ferrari et al. / European Journal of Internal Medicine xxx (2015) xxx–xxx
2. Diagnosis The patient underwent surgery for decompression and dorsal arthrodesis to stabilize the spine. The extemporaneous histologic examination of the mass revealed a giant-cell granulomatous chronic inflammation, focally necrotizing. After rapid detection of Mycobacterium tuberculosis complex DNA on the biopsy tissue by polymerase chain reaction, anti-tuberculous therapy was started. Culture tests confirmed the diagnosis. At the last follow-up, two months after discharge, patient's conditions are good and neurological examination normal. Despite socio-economic improvement in western countries and availability of effective drugs, the impact of acquired immunodeficiency syndrome and immigration has increased the rate of tuberculosis. Spinal tuberculosis (Pott's disease) is the most common extra-pulmonary manifestation of tuberculosis. The thoracic segment is the most frequently affected spinal segment, followed by the lumbar spine [1]. Imaging tests such as MRI and computed tomography help in diagnosing the disease but microbiological diagnosis based on culture and/or histology techniques is indicated for definitive diagnosis [2]. Spinal tuberculosis is a great challenge to physicians due to the wide non-specific spectrum of clinical presentations, which result in delay of
diagnosis and the risk of significant potential morbidity and mortality due to several complications (i.e. paraplegia). Early diagnosis and treatment are the keys to avoid this long-term disability [3]. Therefore, spinal tuberculosis should be considered as a differential diagnosis in patients with chronic back pain and neurological symptoms, especially if coming from endemic areas.
Conflict of interest None.
References [1] Fuentes Ferrer M, Gutiérrez Torres L, Ayala Ramírez O, Rumayor Zarzuelo M, del Prado González N. Tuberculosis of the spine. A systematic review of case series. Int Orthop 2012;36:221–31. [2] Trecarichi EM, Di Meco E, Mazzotta V, Fantoni M. Tuberculous spondylodiscitis: epidemiology, clinical features, treatment and outcome. Eur Rev Med Pharmacol Sci 2012;16:58–72. [3] Ansari S, Amanullah MF, Ahmad K, Rauniyar RK. Pott's spine: diagnostic imaging modalities and technology advancements. N Am J Med Sci 2013;5:404–11.
Please cite this article as: Ferrari B, et al, Back pain: An old cause in a young adult, Eur J Intern Med (2015), http://dx.doi.org/10.1016/ j.ejim.2015.02.002