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Q. My mother had TB meningitis and is now suspected to have tubercular spine. Help.

Answered by
Dr. Ashaq Hussain Parrey
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Oct 08, 2017 and last reviewed on: Jun 19, 2019

Respected doctor,

My 63 year old mother was diagnosed with tuberculosis meningitis (TBM) 10 months ago when she complained of a severe headache. She has undergone CSF study and the report of the study is attached. She has been taking ATT medicines since then. The list of all the medicines she is taking is also attached. The medicines had come down to only one tablet (R-Cinex) in the last 10 months. But, now for the last two months, she started having back pain in the spine area and is now suspected to have a TB infection in the spine. She has a history of L3-L4 collapse four years ago, but that was due to osteoporosis. Her BMD score was -3.2. The spine has been severely infected from L1 to L5.  The MRI revealed an abscess with a pus collection in it (report attached). The doctor says it could be Pott's spine and may be because of a drug resistance (MDR), and they wanted to perform a USG aspiration for Xpert plus SRL, culture and sensitivity of pus. But, the test did not happen because the location of the pus was very deep in the muscle and could not be extracted. So, they extracted some tissues near by the infection area and sent for a small biopsy. The report of the histopathology (small biopsy) is also attached. It says mild nonspecific chronic inflammation. Since no strong evidence of drug resistance could be found in the small biopsy, the doctor has restarted the medicine of AKT-4 plus STM 0.75, and they want to see whether this reduces the problem or not. They said we cannot start DR/MDR treatment without any strong evidence of drug resistance. The current OPD card is also attached in which the medicine has been restarted. Now please guide us about what should be the treatment plan of the disease based on the information submitted. Can anything can be done to get a strong evidence of drug resistance since the ATT medicine is very heavy and the doctor has restarted this medicine only on the basis of his opinion? How can we assess the recovery from the disease apart from relying only on the reduction of pain? Does she require any further MRI or any test after some time?

#

Hello,

Welcome to icliniq.com.

I went through your post which has nicely described the events. Also, I reviewed her reports (attachment removed to protect patient identity).

  • If she has received ATT (antitubercular therapy) for tubercular meningitis 10 months ago, it is highly unlikely that she has Pott's spine.
  • But, if it is tubercular spine like he suspects, the possibility of MDR (multiple drug resistance) is very high.
  • As there is evidence of pus in the spine, I would always start anti pyogenic treatment simultaneously for about two weeks.
  • CT-guided aspiration of pus is very important and will have a gross impact on the treatment and prognosis of the patient.
  • I would suggest you hospitalize her in a good center where a proper diagnosis can be made and she can be treated based on evidence.

For more information consult an internal medicine physician online --> https://icliniq.com./ask-a-doctor-online/internal-medicine-physician

Hello doctor,

Many thanks for your answer. I also feel that medicines should be given after a strong evidence of MDR. But, as I mentioned, they tried to perform CT-guided aspiration, but the pus was unapproachable. So, they extracted a few tissues and performed a small biopsy which lead to nothing specific. Do you suggest she get hospitalized somewhere? In that case, I will try to consult some hospitals about the situation of the test. Also, if the test does not succeed again, then are the medicines AKT-4 and STM to be continued?

#

Hello,

Welcome back to icliniq.com.

  • With advanced technical help, one can extract even a deep-seated brain tumor. Hence, we cannot say the pus is inaccessible. We need to open the pus anywhere in the body and drain it ideally.
  • I would not treat her with first-line ATT. As I said, I would give her two weeks of anti pyogenic treatment which consists of Vancomycin and Ceftriaxone and treat her as MDR for the suspicion of tuberculosis.

For more information consult an internal medicine physician online --> https://icliniq.com./ask-a-doctor-online/internal-medicine-physician


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