eMedicine Specialties > Infectious Diseases > Bone and Joint Infections

Pott Disease (Tuberculous Spondylitis): Differential Diagnoses & Workup

Author: Jose A Hidalgo, MD, Assistant Professor, Universidad de San Marcos Medical School; Attending Physician, Department of Internal Medicine, Division of Infectious Diseases, Guillermo Almenara Hospital
Coauthor(s): George Alangaden, MD, Staff Physician, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Detroit Medical Center, Wayne State University School of Medicine
Contributor Information and Disclosures

Updated: Aug 29, 2008

Differential Diagnoses

Actinomycosis
Multiple Myeloma
Blastomycosis
Mycobacterium Avium-Intracellulare
Brucellosis
Mycobacterium Kansasii
Candidiasis
Nocardiosis
Cryptococcosis
Paracoccidioidomycosis
Histoplasmosis
Septic Arthritis
Metastatic Cancer, Unknown Primary Site
Spinal Cord Abscess
Miliary Tuberculosis
Tuberculosis

Other Problems to Be Considered

Spinal tumors

Workup

Laboratory Studies

  • Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-95% of patients with Pott disease who are not infected with HIV.
  • The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h).
  • Microbiology studies are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. These study findings are positive in only about 50% of the cases.

Imaging Studies

  • Radiography
    • Radiographic changes associated with Pott disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain radiography:13
      • Lytic destruction of anterior portion of vertebral body
      • Increased anterior wedging
      • Collapse of vertebral body
      • Reactive sclerosis on a progressive lytic process
      • Enlarged psoas shadow with or without calcification
    • Additional radiographic findings may include the following:
      • Vertebral end plates are osteoporotic.
      • Intervertebral disks may be shrunk or destroyed.
      • Vertebral bodies show variable degrees of destruction.
      • Fusiform paravertebral shadows suggest abscess formation.
      • Bone lesions may occur at more than one level.
  • CT scanning14
    • 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.
  • 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.15,16
    • 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.17

Other Tests

  • Radionuclide scanning findings are not specific for Pott disease.
  • Gallium and Tc-bone scans yield high false-negative rates (70% and up to 35%, respectively).18

Procedures

  • Use a percutaneous CT-guided needle biopsy of bone lesions to obtain tissue samples.
    • This is a safe procedure that also allows therapeutic drainage of large paraspinal abscesses.
    • Obtain a tissue sample for microbiology and pathology studies to confirm diagnosis and to isolate organisms for culture and susceptibility.
  • Some cases of Pott disease are diagnosed following an open drainage procedure (eg, following presentation with acute neurologic deterioration).

Histologic Findings

Because microbiologic studies may be nondiagnostic of Pott disease, anatomic pathology can be significant. Gross pathologic findings include exudative granulation tissue with interspersed abscesses. Coalescence of abscesses results in areas of caseating necrosis.

More on Pott Disease (Tuberculous Spondylitis)

Overview: Pott Disease (Tuberculous Spondylitis)
Differential Diagnoses & Workup: Pott Disease (Tuberculous Spondylitis)
Treatment & Medication: Pott Disease (Tuberculous Spondylitis)
Follow-up: Pott Disease (Tuberculous Spondylitis)
Multimedia: Pott Disease (Tuberculous Spondylitis)
References
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References

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Further Reading

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Keywords

Pott’s disease, Pott disease, tuberculous spondylitis, spinal tuberculosis, spinal TB, TB, disk disease, vertebral collapse, kyphosis, kyphotic deformity, musculoskeletal tuberculosis, cold abscess, bone tuberculosis, soft-tissue tuberculosis, tuberculosis of the spine, osteomyelitis, arthritis, spinal deformity

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Contributor Information and Disclosures

Author

Jose A Hidalgo, MD, Assistant Professor, Universidad de San Marcos Medical School; Attending Physician, Department of Internal Medicine, Division of Infectious Diseases, Guillermo Almenara Hospital
Jose A Hidalgo, MD is a member of the following medical societies: HIV Medicine Association of America and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

George Alangaden, MD, Staff Physician, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Detroit Medical Center, Wayne State University School of Medicine
George Alangaden, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Medical Editor

Thomas Herchline, MD, Professor of Medicine, Wright State University Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio
Thomas Herchline, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center
Disclosure: BioMerieux Honoraria Review panel membership; Cubist Honoraria Review panel membership; Pfizer Honoraria Speaking and teaching; Merck Stock dividends stock holdings

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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