A 78 year old woman with acute abdominal pain
The patient was admitted with a 12 hour history of severe upper abdominal pain. She had been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for back pain for two to three months. She had a low grade pyrexia of 37.8C and a raised white cell count and C reactive protein. Contrast enhanced computed tomography (CT) of the abdomen and pelvis demonstrated a large amount of free intraperitoneal gas and a moderate amount of free fluid in keeping with a perforated viscus. A suspected site of perforation in the distal stomach was later confirmed at laparotomy as a perforated benign prepyloric ulcer, presumed secondary to NSAID use. In addition, CT showed bone destruction adjacent to the inferior endplate of the L1 vertebra with associated epidural and psoas collections. Peripheral amorphous calcification was seen in association with the psoas abscess, highly suggestive of a tuberculous aetiology.
Although it accounts for fewer than 1% of all infections due to mycobacterium tuberculosis, tuberculous spondylitis represents the commonest site of osseous tuberculous infection. Patients usually complain of back pain of insidious onset with or without constitutional symptoms. At least half will have no radiological evidence of past or present pulmonary tuberculous infection. The vertebrae around the thoracolumbar junction are most commonly affected. Vertebral infection is a result of haematogenous seeding of the organism and infection usually begins in the anterior portion of the vertebra adjacent to the superior or inferior endplates corresponding to the presence of low flow vascular arcades at these sites. Subsequent spread may then occur to the remainder of the vertebra, through subchondral endplate into the adjacent intervertebral disc, beneath anterior or posterior longtitudinal ligaments for variable distances, or into paraspinal soft tissues, often with extensive abscess formation more dramatic than the osseous abnormalities. Complications include spinal cord compression, vertebral body collapse leading to angular kyphosis (gibbus) in adults or vertebra plana in children, and haematogenous spread of infection to other sites. Mortality may be as high as 30%. The classical description of tuberculous spondylitis by Pott involves destruction of two or more contiguous vertebral bodies and the intervening intervertebral discs. Many cases such as this one have an atypical picture, however, with involvement of only one vertebra, sparing of the intervertebral disc, and early extension into paraspinal soft tissues. Conventional radiography is insensitive in the earlier stages of infection. CT performs well in demonstrating vertebral body endplate destruction and the amorphous rim calcification often seen in association with tuberculous paraspinal abscesses but only rarely seen in pyogenic abscesses. Magnetic resonance imaging is the imaging modality of choice, however, with its superior soft tissue contrast allowing delineation of effects on neural structures and discrimination between enhancing inflammatory tissue and true abscess formation which may require drainage. The principal differential diagnosis is pyogenic spondylitis. Although it may be impossible to distinguish between pyogenic and tuberculous spondylitis on imaging criteria alone, features favouring a tuberculous aetiology are: relative sparing of the intervertebral disc; large paraspinal abscesses, especially with a thick enhancing rim or peripheral calcification; relatively little new bone formation; and a fragmentary pattern of bone destruction. This case emphasises the importance of reviewing the bones on abdominal CT even when they are not the primary reason for performing the study.
Tuberculous spondylitis. NSAID-induced perforated prepyloric peptic ulcer.
According to the provided abdominal CT images, the following observations are noted:
1. A localized area of bone destruction at the thoracolumbar junction (approximately the 12th thoracic vertebra or an adjacent vertebra), particularly along the anterior margin of the vertebral body or near the endplate region.
2. Some images reveal obvious swelling or low-density lesions in the anterior aspect of the vertebral body and the paravertebral soft tissues, continuous with the vertebral lesion, suggesting the formation of a paravertebral abscess (as indicated by the arrows and the regions they point to).
3. The adjacent intervertebral disc space appears relatively preserved or only mildly affected, with no clear evidence of severe disc space destruction.
4. Preliminary observation indicates a relatively thickened rim of the abscess wall; in certain cases, ring-like calcification can be observed (vaguely visible in this case), which may suggest the typical calcification found in tuberculous abscesses.
5. This scan is primarily an abdominal CT rather than a dedicated spinal study. Nonetheless, viewing the bone window reveals vertebral changes, emphasizing the necessity of checking spinal bony structures when reviewing abdominal CT images.
Considering the patient is 78 years old with acute abdominal pain and based on the imaging findings, the following possibilities should be considered:
Based on the above analysis and the patient’s clinical presentation, the following classic indicators are noted:
1. Relatively preserved intervertebral discs.
2. Large paravertebral abscesses with thick walls or possible calcification.
3. Initial vertebral involvement at the anterior margin of the endplate with focal bone destruction.
Therefore, the most likely diagnosis in this case is: Tuberculous spondylitis (Pott’s disease). If conditions permit, further investigation via paravertebral abscess aspiration or vertebral biopsy can be performed to confirm the pathogen and determine drug susceptibility.
1. Medication and Conservative Treatment:
- Initiate a standard anti-tuberculosis regimen (commonly a four-drug regimen such as isoniazid, rifampin, ethambutol, and pyrazinamide) for at least 6-9 months. Medication type and duration should be adjusted based on pathogen testing.
- Use of a brace or supportive corset if necessary, to reduce spinal load and lower the risk of further vertebral collapse.
2. Surgical Intervention:
- If severe spinal cord compression occurs, if there is significant vertebral destruction leading to instability, or if a large paravertebral abscess presents a high risk of rupture, surgical decompression and debridement should be considered.
- In complex cases, intraoperative spinal stabilization with internal fixation may be required, followed by continued anti-tuberculosis treatment postoperatively.
3. Rehabilitation and Exercise Prescription (FITT-VP Principle):
Given the patient’s advanced age, bone quality, and potential cardiopulmonary considerations, exercise prescriptions should be both gradual and individualized:
For confirmed spinal tuberculosis, anti-tuberculosis treatment remains the mainstay, supplemented by proper nutrition and rehabilitation to control infection and preserve or restore normal spinal function as much as possible.
This report is a reference analysis based on the current imaging and clinical information available, and should not be considered the final basis for diagnosis or treatment. Specific treatment plans should be determined according to the patient’s actual condition, in conjunction with specialist medical advice and further examinations, and through in-person consultation.
Tuberculous spondylitis. NSAID-induced perforated prepyloric peptic ulcer.
