Pott's Disease

Pott's Disease: A Case Report

INTRODUCTION

Pott’s disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of

tuberculous arthritis of the intervertebral joints. Scientifically, it is called tuberculous spondylitis. Pott’s

disease is the most common site of bone infection in TB; hips and knees are also often affected. The

lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected.

Pott's disease, which is also known as Pott’s caries, David's disease, and Pott's curvature, is a

medical condition of the spine. Individuals suffering from Pott's disease typically experience back pain,

night sweats, fever, weight loss, and anorexia. They may also develop a spinal mass, which results in

tingling, numbness, or a general feeling of weakness in the leg muscles. Often, the pain associated

with Pott's disease causes the sufferer to walk in an upright and stiff position.

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's

disease often develops kyphosis, which results in a hunchback. This is often referred to as Pott’s

curvature. In some cases, a person with Pott's disease may also develop paralysis, referred to as Pott’s

paraplegia, when the spinal nerves become affected by the curvature.

The disease progresses slowly. Signs and symptoms include: back pain, fever, night sweats,

anorexia, weight loss, and easy fatigability. Diagnosis is based on: blood tests - elevated ESR , skin tests

,radiographs of the spine , bone scan ,CT of the spine , and bone biopsy. Gibbus formation is the

pathognomonic sign of this disease. Gibbus formation refers to a sharply angled curvature of the

backbone, resulting from collapse of a vertebra or simply a hunchback.

Approximately 1-2% of total tuberculosis cases are attributable to Pott disease. The incidence

rate here in the Philippines is approximately 20-30% of all the patient diagnosed to have Tuberculosis.

Most of the cases of the Pott's disease in the Philippines is caused by the non-compliance of the

treatment regimen of TB. Internationally, between 1993 and 2001, tuberculosis of the bone and joints

Fuertes, Rheegell E. N413 POC


accounted for 3.5% of all tuberculosis cases (0.2-1.1% in patients of European origin and 2.3-6.3% in

patients of non-European origin) .

“21 nursing problems” according to Faye Glenn Abdellah could be best adapted on this kind of

case. She defined nursing as broadly grouped into the 21 nursing problem areas to guide care and

promote the use of nursing judgement. She also said that nursing is a service that is based on the art

and science and aims to help people, sick or well, cope with their health needs. The said disease could

lead to different problems that the patient can experince. It is the responsibility of the nurse to meet

the different needs of the client to achive the optimum level of functioning. The researcher chose to

discuss Pott's disease as one of the requirement in the rotation. This study will help the researcher to

analyze and dig deeper and see a clearer picture, in response to our roles as future registered nurses.



OBJECTIVES OF THE STUDY

GENERAL OBJECTIVES:

To be able to develop a comprehensive case study that would focus on the chosen case with regards

to the pathology of the disease, its corresponding medical actions and the associative function of

client-based interventions which will be used to facilitate the client’s health status which is aimed

towards achieving optimum level of functioning.

SPECIFIC OBJECTIVES:

To know the patho-physiologic mechanism of the disease process of Pott's disease, placing

emphasis on how the complications and the disease etiology relate and sync with each other.

To accurately explain the various laboratory examinations that require for the detection of the

disease and how the significant remarks or findings relate to his disease.

Cite various drugs required for the treatment of the disease in giving a client based analysis on

the said pharmacologic treatment.

To be able to give health teachings regarding the prevention and cure of the disease.

To evaluate the presenting clinical manifestations based on the overall condition with emphasis

placed on the alterations.



ANATOMY AND PHYSIOLOGY

The spinal cord is the largest nerve in the body, and it is comprised of the nerves which act as

the communication system for the body. The nerve fibers within the spinal cord carry messages to and

from the brain to other parts of the body. The spinal cord is surrounded by protective bone segments,

called the vertebral column. The vertebral column is comprised of seven cervical vertebrae, twelve

thoracic vertebrae, five lumbar vertebrae and five sacral vertebrae. The vertebral column also provides

attachment points for muscles of the back and ribs. The vertebral disks serve as shock absorbers



during activities such as walking, running and jumping, they also allow the spine to flex and extend.



DIAGNOSTIC PROCEDURES

1. Tuberculin skin test (purified protein derivative [PPD])

results are positive in 84-95% of patients with Pott disease who are not infected with HIV. A standard

dose of 5 Tuberculin units (0.1 mL)(The standard Mantoux test in the UK consists of an intradermal

injection of 2TU of Statens Serum Institute (SSI) tuberculin RT23 in 0.1ml solution for injection.)

Injected intradermally (between the layers of dermis) and read 48 to 72 hours later. This intradermal

injection is termed the mantoux technique. A person who has been exposed to the bacteria is

expected to mount an immune response in the skin containing the bacterial proteins. The reaction is

read by measuring the diameter of induration (palpable raised hardened area) across the forearm

(perpendicular to the long axis) in millimeters. If there is no induration, the result should be recorded

as "0 mm". Erythema (redness) should not be measured. If a person has had a history of a positive

tuberculin skin test, or has not had a recent tuberculin skin test (within one year), another skin test

may be needed.

2. The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h).

ESR stands for erythrocyte sedimentation rate. It is a test that indirectly measures how much

inflammation is in the body. However, it rarely leads directly to a specific diagnosis. This test can be

used to monitor inflammatory or cancerous diseases. It is a screening test, which means it cannot be

used to diagnose a specific disorder. However, it is useful in detecting and monitoring tuberculosis,

tissue death, certain forms of arthritis, autoimmune disorders, and inflammatory diseases that cause

vague symptoms.

3. Radiography

Radiographic changes associated with Pott disease present relatively late. The following are

radiographic changes characteristic of spinal tuberculosis on plain radiography: visibly seen curvature

of the spine or visible bone lesions on different levels.


http://en.wikipedia.org/wiki/Erythema

http://en.wikipedia.org/wiki/Induration


4. 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. 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.

5. 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.

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.

6. Bone biopsy

A bone biopsy is a procedure in which a small sample of bone is taken from the body and looked at

under a microscope for cancer, infection, or other bone disorders.

Confirm the diagnosis of a bone disorder that was found by another test, such as an X-ray, CT scan,

bone scan, or a MRI. Tell the difference between a noncancerous (benign) bone mass, such as a bone

cyst, and bone cancer, such as multiple myeloma. See what is causing a bone infection (osteomyelitis)

or if an infection is present. Find the cause of ongoing bone pain. Check bone problems seen on an X-

ray.


http://www.webmd.com/hw-popup/osteomyelitis

http://www.webmd.com/hw-popup/multiple-myeloma


PATHOPHYSIOLOGY

PRECIPITATING FACTORS PREDISPOSING FACTORS

- Non-compliance to medicines - PTB diagnosed

- Continuous exposure to M.Tubeculosis

- Malnutrition

- Socio-economic status

Exposure to Mycobacterium Tubeculosis

Primary Pulmonary Tuberculosis

Spread of M. Tuberculosis

Extrapulmonary Tuberculosis

Infection spreads to the intervertebral disc

in the T7-T9 of the spine


MEDICATIONS: HRZE

Intermittent fever, upper back pain, night sweats, poor appetite, weight loss.


Progressive bone destruction

Intervertebral Collapse Caseation takes place

Gibbus formation between T4-T7 or T7-T9

Spinal cord depression

Neurological effects and lower motor defficits Pott's parplegia


Persistent back pain


MEDICAL-SURGICAL-NURSING MANAGEMENT

Since Pott's disease is caused by a bacterial infection, prevention is possible through proper control.

The best method for preventing the disease is reduce or eliminate the spread of tuberculosis. In

addition, testing for tuberculosis is an important preventative measure, as those who are positive for

purified protein derivative (PPD) can take medication to prevent tuberculosis from forming. A

tuberculin skin test is the most common method used to screen for tuberculosis, though blood tests ,

bone scans, bone biopsies, and radiographs may also be used to confirm the disease.

MEDICAL MANAGEMENT

Before the advent of effective antituberculosis chemotherapy, Pott disease was treated with

immobilization using prolonged bed rest or a body cast.

Studies performed by the British Medical Research Council indicate that tuberculous

spondylitis of the thoracolumbar spine should be treated with combination chemotherapy for

6-9 months.

According to the most recent recommendations issued in 2003 by the US Centers for Disease

Control and Prevention, the Infectious Diseases Society of America, and the American Thoracic

Society, a 4-drug regimen should be used empirically to treat Pott disease.

Isoniazid and rifampin should be administered during the whole course of therapy. Additional

drugs are administered during the first 2 months of therapy. These are generally chosen among

the first-line drugs, which include pyrazinamide, ethambutol, and streptomycin. The use of

second-line drugs is indicated in cases of drug resistance.

Opinions differ regarding whether the treatment of choice should be conservative

chemotherapy or a combination of chemotherapy and surgery. The treatment decision should

be individualized for each patient.



SURGICAL MANAGEMENT

Indications for surgical treatment of Pott disease generally include the following:

o Neurologic deficit (acute neurologic deterioration, paraparesis, paraplegia)

o Spinal deformity with instability or pain

o No response to medical therapy (continuing progression of kyphosis or instability)

o Large paraspinal abscess

o Nondiagnostic percutaneous needle biopsy sample

Resources and experience are key factors in the decision to use a surgical approach.

The lesion site, extent of vertebral destruction, and presence of cord compression or spinal

deformity determine the specific operative approach (kyphosis, paraplegia, tuberculous

abscess).

In Pott disease that involves the cervical spine, the following factors justify early surgical

intervention:

o High frequency and severity of neurologic deficits

o Severe abscess compression that may induce dysphagia or asphyxia

o Instability of the cervical spine

Nursing Diagnosis

Acute pain related to inflammatory process

Disturbed body image related to trauma/injury to spinal cord

Self – bathing hygiene deficit related to musculoskeletal impairment

Impaired physical mobility related to therapeutic restriction of movement

Imbalance nutrition related to inadequate food intake

Nursing Responsibilities

Drug treatment is generally sufficient for Pott’s disease, with spinal immobilization if required. Surgery is required if there is spinal deformity or neurological signs of spinal cord compression. Standard antituberculosis treatment is required. Duration of antituberculosis treatment: If



debridement and fusion with bone grafting are performed, treatment can be for six months. If debridement and fusion with bone grafting are NOT performed a minimum of 12 months’ treatment is required.

It may also be necessary to immobilize the area of the spine affected by the disease, or the person may need to undergo surgery in order to drain any abscesses that may have formed or to stabilize the spine.

Other interventions include application of knight/ taylor brace, head halter traction.



PATIENT HEALTH TEACHING

P- atient should be reminded to attend check-ups at the nearest….

O- rthopedic center

T- reatment should be taken in a…..

T- imely manner

S- ight any symptoms other than the usual and report it to the physician



Global City Innovative CollegeBonifacio Global City, Taguig City

Philippines

In Partial Fulfilment of the Requirements inNursing Care Management 105

CASE STUDY

POTT'S DISEASE

Clinical Agency : Philippine Orthopedic Hospital

Submitted By:

FUERTES, Rheegell E.N413 Group B Cluster 2



December 2010


Pott's Disease

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