The patient was admitted with symptoms of left sided renal colic and haematuria. A routine unenhanced helical CT abdomen was performed which yielded an unsuspecting find.
The patient presented with symptoms of renal colic on the left side. This was accompanied by microscopic haematuria. No other physical findings were present. A routine unenhanced helical CT abdomen was performed as per departmental protocol. The CT revealed a 2mm calculus at the left vesicouereteric junction, with mild hydroureter above this and very mild left sided hydronephrosis. No renal calculi was identified on the right side. Of greater importance however was the presence of bilateral psoas abscesses which originated from an infective discitis / vertebral body osteomyelitis centered on the L2/3 disc and involving the inferior portion of L2 and most of the L3 vertebral body. The L3 vertebral body was comminuted with posterior displacement towards the spinal canal. A subsequent spinal MRI revealed diffuse high signal of the L2 and L3 vertebrae on STIR imaging with expansion and some enroachment into the spinal canal. The bilateral psoas abscesses were drained and microbiological specimens confirmed the presence of tuberculosis.
Tuberculous spondylitis also known by its eponymous name, Pott disease, is destruction of the vertebral body and intervertebral disk by mycobacterium tuberculosis. The clinical onset is insidious and it presents as back pain, stiffness and local tenderness, fever and malaise. The commonest site of involvement appears to be the thoracic and lumbar vertebrae with a predilection for the anterior part adjacent to the superior and inferior endplates. Since the anterior parts of the vertebrae are most affected, a gibbus deformity will appear. The bony destruction of the vertebral body tends to be of the fragmentary type followed by lytic destruction. Other manifestations include paraspinal masses, epidural abscesses, psoas abscesses and collapse of the intervertebral disk spaces. The abscesses may track widely and become calcified which differentiates it from a non-tuberculous which rarely clacifies. Differentiating between tuberculous and pyogenic infections is difficult with both sharing many similar imaging characteristics. However, tuberculous infections may be suggested by the presence of associated lesions elsewhere in other organs e.g lung, urinary tract, tendency of tuberculosis to be multifocal in the spine and tendency to result in a gibbus deformity. Recent MRI work suggest that tuberculous infections cause a local and heterogeneous enhancement of the vertebral body compared with diffuse and homogeneous enhancement in pyogenic spondylitis. Treatment of the psoas collections would involve a combination of medical therapy and drainage of the abscess. As demonstrated in this case, percutaneous drainage represents an efficient and attractive alternative to surgical drainage as a supplement to medical therapy in the management of patients with large tuberculous psoas abscesses.
Tuberculous spondylitis with psoas abscesses.
1. On the plain CT scan of the abdomen, partial destruction is observed in the anterior edge of the lumbar vertebral bodies, and the adjacent intervertebral disk space may be narrowed.
2. Prominent soft tissue swelling is seen around the lumbar spine, and abnormal density can be observed in the psoas muscle region, suggesting abscess formation. In some images, a cyst-like mass adjacent to the psoas muscle can be seen.
3. MRI images show abnormal signals in the affected vertebrae with irregular enhancement, destruction of the vertebral bodies and intervertebral disks, accompanied by paravertebral and peridural soft tissue lesions. A considerable fluid signal is visible within the psoas muscle, consistent with pus or exudates.
4. There is no evident fracture line, but there is a significant risk of anterior collapse of the vertebral bodies, which could lead to gibbus deformity.
1. Tuberculosis of the spine (Pott disease)
• Mycobacterium tuberculosis invades the vertebral bodies and intervertebral spaces, often accompanied by paravertebral abscesses or psoas abscesses.
• Imaging typically shows destruction of vertebral bone, disk collapse, and formation of adjacent soft tissue abscesses.
• In this case, the clearly affected anterior portion of the vertebral bodies and the psoas abscess strongly suggest a high association with tuberculosis infection.
2. Pyogenic spondylitis
• Often caused by pyogenic bacteria such as Staphylococcus aureus. It can cause destruction of vertebrae and intervertebral disks, as well as paravertebral abscesses.
• However, the lesions usually present with more acute features, often with pronounced systemic inflammatory symptoms such as high fever and significantly elevated white blood cell counts.
• Imaging often shows homogeneous enhancement, and the condition is more acute, requiring correlation with clinical and laboratory tests for differential diagnosis.
3. Other less common causes of spinal destruction (tumors, metastases, etc.)
• Lytic destruction of vertebrae can be seen in tumor infiltration, but paravertebral soft tissue manifestations are often different, and psoas abscesses are less common.
• The present case is more suggestive of an infectious lesion.
Taking into account the young patient’s clinical symptoms (lumbar and dorsal pain with fever, hematuria possibly incidental or due to inflammatory irritation), the imaging findings of anterior vertebral body destruction, paravertebral and psoas abscesses, and the chronic, destructive imaging features typical of tuberculosis infection, the most likely diagnosis is:
Lumbar tuberculosis (Pott disease) with the formation of a psoas abscess
If further confirmation is required, a diagnostic biopsy by paravertebral or abscess puncture is recommended, along with etiological tests (acid-fast staining, Mycobacterium tuberculosis culture, PCR, etc.).
1. Pharmacological Treatment
• First-line combination anti-tuberculosis therapy (commonly HREZ: isoniazid, rifampicin, ethambutol, pyrazinamide) following the standard course of treatment. The specific regimen should be individualized and aligned with local tuberculosis guidelines.
• Monitor liver and kidney function and be attentive to potential drug side effects.
2. Puncture or Drainage
• In cases with large psoas abscesses, CT or ultrasound-guided puncture or catheter drainage can be performed to relieve pressure from the pus and enhance treatment efficacy.
• When necessary, local irrigation may be added to boost the local concentration of anti-tuberculosis drugs.
3. Indications for Surgery
• If severe vertebral destruction results in significant instability or if there is notable spinal cord or nerve compression, surgical intervention should be considered. If no severe complications are present, conservative management or minimally invasive drainage is preferred.
4. Rehabilitation and Exercise Prescription
(Following the FITT-VP principle: Frequency, Intensity, Time, Type, Volume, Progression)
• Early stage (acute phase): Primarily bed rest and local immobilization to avoid aggravating vertebral damage. Gentle bed exercises, such as leg lifts and gentle turning over, several times a day for a few minutes each time. The intensity is minimal, aimed at causing no pain.
• Middle stage (symptom relief phase): After some control is achieved with abscess drainage and anti-tuberculosis treatment, low-intensity lumbar and back muscle exercises can be carried out under brace protection, such as low-load flexion-extension exercises of the lumbar region. The frequency can gradually increase to 3–5 times per week, 10–15 minutes each time, with mild sore sensations but no significant pain.
• Late stage (recovery phase): Depending on bone healing and improvement of clinical symptoms, core muscle training and low-impact aerobic exercises (such as slow walking on flat surfaces, swimming, etc.) can be started under professional rehabilitation guidance. The frequency may be increased to 4–5 times per week, about 30 minutes each time, with a gradual increase in exercise intensity.
• Throughout the rehabilitation process, close monitoring of pain, fever, or other discomfort is required. Should any unusual symptoms appear, a prompt follow-up consultation is recommended.
Disclaimer:
This report is a reference analysis based on current imaging and clinical history. It cannot replace an in-person consultation or professional medical advice. Treatment and rehabilitation programs must be conducted under the guidance of a specialist. Specific prescriptions and procedures should be determined according to actual clinical circumstances.
Tuberculous spondylitis with psoas abscesses.
