MRI diagnosis of tuberculous vertebral osteomyelitis

Two patients with suspected tuberculous spondylitis and one patient with previous Pott's disease were evaluated preoperatively with magnetic resonance imaging (MRI). The MRI provided more exact anatomic localization of vertebral and paravertebral tuberculous abscesses in multiple planes not previously available with more conventional diagnostic methods in the patients with suspected tuberculous spondylitis. This was helpful for localization in planning of surgical approaches. In the patient with previous Pott's disease, spinal cord compression was detected using MRI, which showed no evidence of active tuberculosis. Two case reports are offered to show the benefit of using MRI as a diagnostic technique in preoperative evaluation and as a method of monitoring treatment response of tuberculous spondylitis. The third case shows the benefit of using MRI to rule out active infection and to detect other forms of spinal pathology.     

Pleuropneumonectomy for pulmonary tuberculosis and chronic tuberculous empyema

Surgical intervention is often necessary to treat either the active pulmonary tuberculosis or its sequelae such as destroyed lung, tuberculous empyema, and bronchial stenosis. Pleuropneumonectomy, which has been reported to be associated with high mortality and morbidity, is performed when the pleural space is completely obliterated due to previous inflammation or when preoperative empyema is complicated. In this article we report 3 patients receiving pleuropneumonectomy for pulmonary tuberculosis or chronic tuberculous empyema in recent 3 years. The mean operation time is 5 hours and 56 minutes, and the mean volume of intraoperative bleeding amounted to 1,417 ml. Autologous blood transfusion was prepared for all 3 patients and transfused them during the operation. No mortality, but postoperative complications were seen in 2 patients (67%) with a history of diabetes mellitus. They were sternum infection and bronchopleural fistula, which were successfully treated conservatively. Diabetes mellitus is thought to be a major risk factor for not only tuberculous disease itself, but also postoperative morbidity. As for surgical techniques, wide skin incision with multiple thoracotomy is necessary to keep a good operative field, and special care must be taken for great vessels and nerves at extrapleural dissection. We conclude that pleuropneumonectomy is relatively risky but effective surgical procedure for adequately selected patients with destroyed lung and tuberculous empyema.     

Intrapleural streptokinase in the management of empyema.

BACKGROUND--Significant morbidity and mortality result from the ineffective evacuation of empyema. Failure of conventional first line treatment with closed intercostal tube drainage and antibiotic therapy may result in fibrin deposition and loculated empyema. Enzymatic debridement using intrapleural instillation of streptokinase is a non-invasive therapeutic option which may obviate the need for surgical intervention. METHODS--Eleven adults with multiloculated post-pneumonic empyemas who had failed to respond satisfactorily to intercostal tube drainage and antibiotic therapy were treated with intrapleural streptokinase between November 1992 and January 1994. A small catheter was inserted under ultrasound guidance into a loculation within the pleural space. Aliquots of 250,000 units of streptokinase in 100 ml normal saline were instilled into the pleural cavity and the tube clamped for four hours. Response was assessed by clinical outcome, measurement of drain output after unclamping, and subsequent pleural ultrasound, chest radiography, or both. RESULTS--Streptokinase enhanced drainage in all patients. Complete resolution of the empyema with re-expansion of the underlying lung was effected in eight patients, all of whom remain well. Further resolution of minimal pleural thickening was shown on subsequent chest radiographs. Two patients with considerably thickened visceral pleura following empyema drainage underwent successful decortication. The other, with myocarditis and a pyopneumothorax, underwent surgery for non-resolution of the pneumothorax but died perioperatively from cardiac failure. The number of streptokinase instillations per patient ranged from two to six (median three), and the volume of empyema fluid drained per patient ranged from 100 ml to 4870 ml (median 900 ml). Streptokinase was well tolerated in all patients. CONCLUSIONS--Intrapleural streptokinase is an effective adjunct in the management of complicated empyema and may reduce the need for surgery.     

Evaluation of open window thoracostomy for chronic tuberculous empyema with broncho-pleural fistula; a retrospective analysis of 33 cases

We report here our 13-year experience treating chronic tuberculous empyema by open window thoracostomy. The subjects were 33 patients (28 males and 5 females) with a median age of 70 (range: 56-83) years who underwent surgery between January 1990 and December 2002. Patients with a history of pulmonary resection or thoracoplasty were excluded. All patients complained of cough and purulent sputum related to the presence of bronchopleural fistula. Previous illnesses included pulmonary tuberculosis (n = 20) and tuberculous pleurisy (n = 14) treated by artificial pneumothorax (n = 1) or chemotherapy (n = 22). Median duration from the initial episode of tuberculosis to surgery was 44 (range: 1-60) years. Mycobacterium tuberculosis (n = 9), Aspergillus fumigatus (n = 6), methicillin-resistant Staphylococcus aureus (MRSA) [n = 5], and Pseudomonas aeruginosa (n = 5) were representative microorganisms isolated from empyema. Preoperative mean %VC was 48 (range: 31-74)%. Mean follow-up was 34 (range: 1-131) months. Seven patients died of empyema-related disease within 6 months postoperatively. Nine patients underwent curative surgery to close the thoracostomy, including extrapleural pneumonectomy (n = 5), muscular transposition with thoracoplasty (n = 3), and lobectomy with muscular transposition and thoracoplasty (n = 1). In 17 patients, the thoracostomy was left open throughout the observation period because of severe impairment of pulmonary function. In elderly patients with severely impairment of pulmonary function, open window thoracostomy does not control empyema well and has a high rate of mortality.     

Tuberculous spondylitis: a retrospective study on a series of 12 patients operated on in a 25-year period.

BACKGROUND: The incidence of tuberculous spondylitis, which had declined steadily for over 40 years in our countries, started increasing again in the eighties, paralleling the resurgence of pulmonary tuberculosis. Therefore it has become a matter of discussion in contemporary literature, because it can be a diagnostic challenge and, in spite of its severe neurological complications, it is a potentially curable illness. METHODS: In this retrospective study the authors report their experience concerning 12 patients operated on in a 25-year period because of serious cord compression from thoracic (9 cases) and cervical (1 case) tuberculous spondylitis or from thoracic tubercular epidural lesion (2 cases). Surgical techniques were selected on the basis of the cause of cord compression. Fusion with autologous bone and metallic osteosynthesis was performed in the cervical case (1986); no other patient received spinal instrumentation, and this can be explained with the consideration that all but one cases of Pott's paraplegia were treated in the years 1968-1977. In all of these cases fusion was achieved by means of plaster jackets and prolonged bed rest. Prolonged chemotherapy was systematically administered. RESULTS: Follow-up data collected in 1995 show good and long-lasting results. CONCLUSIONS: They conclude that surgical treatment is required in case of cord compression and results can be excellent even in presence of severe neurological impairment; spinal instrumentation available in our era should be now considered in order to make rehabilitation earlier and morphologic results more satisfactory.     

Management of tuberculous empyema.

OBJECTIVE: In an attempt to establish a treatment protocol for tuberculous empyema, we retrospectively reviewed our experience over a 3-year period. METHODS: Between January 1996 and December 1998, 26 patients (23 male and three female) with an average age of 33.8 years (range 18-61 years) presented with tuberculous empyema. The empyema was right-sided in 13, left-sided in 12 and bilateral in one patient. Patients presented with respiratory symptoms for a mean duration of 4.43 months (range 1-48 months). All patients had a computerized scan of the chest and managed according to the stage of empyema. RESULTS: In patients with exudative empyema (n=4) the fluid was aspirated, but one patient required intercostal tube (ICT) drainage for 6 days. There were four patients with fibrinopurulent empyema treated with thoracoscopic drainage with a mean post-operative stay of 8 days (range 4-12 days). In the organizing stage (n=18), initial drainage with large ICT was performed. The pleura was less than 2 cm in thickness in eight patients, for which repeated installation of streptokinase was performed (three to seven times). Satisfactory results were achieved in six patients (75%) and the remaining two required decortication. Of the ten patients with thick cortex, one required a window and nine had decortication, two of which had additional lobectomy and two had pneumonectomy. All patients fully recovered with no mortality and with a mean duration of drainage of 18 days (range 3-61 days). CONCLUSION: Its stage and the state of the underlying lung should guide surgical treatment for tuberculous empyema. This protocol aims to achieve cure utilizing the least invasive approach and acceptable hospital stay.     

Tuberculous meningitis presenting as an obstructive myelopathy. Case report

Subacute paraplegia progressing over 3 months due to spinal cord compression was the presenting symptom of tuberculous meningitis in this patient with a normal chest x-ray film and no radiological or autopsy evidence of Pott's vertebral tuberculosis. The obstructive myelopathy was the result of proliferative granulomatous meningitis. A review of the literature indicates that this is a very unusual presentation of tuberculous meningitis.     

单孔胸腔镜胸膜纤维板剥脱术治疗慢性结核性脓胸

目的探讨单孔胸腔镜胸膜纤维板剥脱术治疗慢性结核性脓胸的手术方法和术后疗效。方法收集2019年3月至2019年12月期间在武汉市肺科医院外科行单孔胸腔镜纤维板剥脱术的53例慢性结核性脓胸患者的临床资料,其中男40例,女13例;年龄16~69岁,平均36岁。病变位于右侧36例,左侧17例;合并肺结核38例;术前抗结核药物治疗疗程2~24个月。所有患者术前胸腔积液或术后标本病原学和病理学检测确诊为结核性脓胸。阐述单孔胸腔镜纤维板剥脱术治疗慢性结核性脓胸的手术方法,评价其临床疗效。结果全组无围手术期死亡,治愈49例(92.45%)。术后发生并发症1例(1.89%),为术后胸腔出血致凝固性血胸,经延长胸腔引流时间,积血溶解排出后治愈。行单孔胸腔镜纤维板剥脱术49例(92.45%),中转开胸手术4例(7.55%)。手术100~370 min,平均(234.53±56.06)min。术中出血量50~1400 ml,中位出血量300(175.0,402.5)ml。胸腔引流管留置3~22天,中位时间8(6.00,11.25)天。结论在围手术期评估、治疗恰当和手术操作熟练的前提下,单孔胸腔镜胸膜纤维板剥脱术治疗慢性结核性脓胸可行、安全、有效。     

Chylothorax due to tuberculosis lymphadenopathy: Report of a case

While pulmonary tuberculosis is a very frequent infection, chylothorax is an unusual manifestation of tuberculous disease. A 71-year-old woman with chylothorax is herein presented. The ductus thoracicus was ligated and lymphadenomegaly, which was adjacent to diaphragm, was resected. Based on the findings of various tests, a diagnosis of tuberculosis lymphadenitis was made. The patient was administered antituberculosis chemotherapy and has since remained asymptomatic for 1 year after the operation. In conclusion, tuberculosis lymphadenomegaly may lead to the development of chylothorax. The combination of appropriate surgical and medical treatment is an effective therapeutic strategy for this pathology.     

Value of adenosine deaminase in the diagnosis of tuberculous pleural effusions in young patients in a region of high prevalence of tuberculosis.

BACKGROUND--Pleural biopsy is usually considered important for the diagnosis of pleural effusions, especially for distinguishing between tuberculosis and neoplasia, even though tuberculous pleural fluid contains sensitive biochemical markers. In regions with a high prevalence of tuberculosis, and in patient groups with a low risk of other causes of pleurisy, the positive predictive value of these markers is increased. The criteria for performing a pleural biopsy under these circumstances have been investigated, using adenosine deaminase (ADA) as a pleural fluid marker for tuberculosis. METHODS--One hundred and twenty nine patients with a pleural effusion aged < or = 35 years (mean (SD) 25.2 (4.9) years) were studied. Seventy three were men. Eighty one effusions (62.8%) were tuberculous, 12 (9.3%) parapneumonic, and 10 (7.7%) neoplastic, five were caused by pulmonary thromboembolism, four by systemic lupus erythematosus, seven by empyema, three following surgery, one was the result of asbestosis, and one of nephrotic syndrome. In five cases no definitive diagnosis was reached. ADA levels were determined by the method of Galanti and Giusti. RESULTS--The diagnostic yield of procedures not involving biopsy was 94.5% (122/129). Pleural biopsy provided a diagnosis in a further two cases, but not in the remaining five. All tuberculous cases had pleural fluid levels of ADA of > 47 U/l (mean (SD) 111.1 (36.6) U/l). The only other cases in which ADA exceeded this level were six of the seven patients with empyema. Cytological examination of the pleural fluid diagnosed eight of the 10 neoplastic cases, compared with six diagnosed by pleural biopsy. CONCLUSIONS--In a region with a high prevalence of tuberculosis procedures not involving pleural biopsy have a very high diagnostic yield in patients with a pleural effusion aged < or = 35 years, making biopsy necessary only in cases in which pleural levels of ADA are below 47 U/l, pleural fluid cytology is negative and, in the absence of a positive basis for some other diagnosis, neoplasia is suspected.     

Tuberculosis of the spine (Pott's disease) presenting as 'compression fractures'

STUDY DESIGN: Case reports and survey of literature. OBJECTIVE: Case reports of two women with tuberculosis (TB) of the spine (Pott's disease) presenting with severe back pain and diagnosed as compression fracture are described. Physicians should include Pott's disease in the differential diagnosis when patients present with severe back pain and evidence of vertebral collapse. SETTING: Ohio, USA METHODS: A review of the literature on the pathogenesis, pathophysiology, clinical presentation, diagnostic methods, treatment and prognosis of spinal TB was conducted. RESULTS: After initial delay, proper diagnosis of spinal TB was made in our patients. Microbiologic diagnosis confirmed M. tuberculosis, and appropriate medical treatment was initiated. CONCLUSIONS: Although uncommon, spinal TB still occurs in patients from developed countries, such as the US and Europe. Back pain is an important symptom. Vertebral collapse from TB may be misinterpreted as 'compression fractures' especially in elderly women. Magnetic resonance imaging scan (MRI) is an excellent procedure for the diagnosis of TB spine. However, microbiologic diagnosis is essential. Mycobacterium tuberculosis may be cultured from other sites. Otherwise, biopsy of the spine lesion should be done for pathologic diagnosis, culture and stain for M. tuberculosis. Clinicians should consider Pott's disease in the differential diagnosis of patients with back pain and destructive vertebral lesions. Proper diagnosis and anti-tuberculosis treatment with or without surgery will result in cure.     

Acute abdomen: an unusual case of ruptured tuberculous mesenteric abscess

BACKGROUND: Abdominal tuberculosis is an uncommon extra-pulmonary manifestation of tuberculosis. METHODS: Case report and literature review. RESULTS: Herein, we report an unusual case of ruptured tuberculous mesenteric cold abscess, which was managed by laparotomy for diagnosis and drainage, and post-operative chemotherapy. CONCLUSIONS: Peritoneal tuberculosis may present to surgeons as ascites, an abdominal mass, or peritonitis. Preoperative diagnosis of abdominal tuberculosis is notoriously difficult. Acute peritonitis provoked by rupture of tuberculosis mesenteric cold abscess is exceedingly rare. Surgical intervention is warranted for diagnosis and drainage.     

Whither short-course chemotherapy for tuberculous meningitis?

Short-course chemotherapy is well established for the treatment of pulmonary tuberculosis but not for extrapulmonary disease. We present a series of 35 cases in which chemotherapy for tuberculous meningitis was given for a period of less than 2 years. Short-term therapy was associated with recrudescence of tuberculous meningitis and, in some cases, with the development of deep cerebral infarcts and permanent neurological deficits. We think short-term chemotherapy for tuberculosis of the central nervous system is inadequate.     

Centro-somatic staged tuberculous vertebral osteitis: a case report

Centro-somatic tuberculous vertebral osteitis is defined as tuberculous infection of the vertebral body with preserved integrity of the adjacent intervertabral disk. Other types of vertebral tuberculosis include Pott's spondylodiscitis and exceptional lesions of the posterior arch. We report a case of centro-somatic tuberculous vertebral osteitis in a 14-year-old boy who developed staged lesions of the L2 to S1 bodies, associated with a posterior epidural collection but without any deterioration of the intervertebral disk on plain x-rays and computed tomography. This atypical aspect of the lesions required a surgical biopsy which yielded a yellow-whitish fibro-oleagenous, friable product more suggestive of neoplasm than infection, but histology rectified the diagnosis, showing typical caseo-follicular tuberculosis. A 6-month anti-tuberculosis regimen was rapidly followed by symptom improvement. We emphasize the importance of modern imaging techniques for the diagnosis of vertebral lesions and for guided biopsy or drainage.     

An open technique of pleural biopsy in the diagnosis of tuberculous effusions.

To assess an open technique of pleural biopsy as an aid to diagnosis in pleural disease 107 African patients with radiological evidence of pleural effusion underwent biopsy. In 87 there was radiological evidence of an effusion but not of underlying lung disease; 73 patients (84%) in this group were ultimately diagnosed as suffering from tuberculosis and of these 56 (77%) had a positive pleural biopsy. There was a heavy male predominance of tuberculous infection (male:female ratio approximately 5:1) and half of the patients were aged 21 to 30 years. In the 20 patients with radiological changes in the lung a diagnosis was established by biopsy in 13 cases. Four of these were tuberculous and a further two cases of tuberculosis were established on clinical grounds.     

Videothoracoscopy versus intrapleural streptokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases

BACKGROUND: Post traumatic retained haemothorax (PRH) may cause pulmonary restrictions or septic pleural complications. Currently, minimally invasive procedures such as videothoracoscopy or intrapleural fibrinolysis have replaced open surgery in an effort to avoid these complications. OBJECTIVE: We have reviewed retrospectively our use of videothoracoscopy versus intrapleural streptokinase for the management of PRH over the last 10 years. PATIENTS AND METHOD: There were 56 males and nine females in the study. Thirty-one cases had been managed by intrapleural streptokinase (group I), and videothoracoscopy was performed on 34 cases (group II). Therapeutic results for both groups were determined by chest radiographs. RESULTS: In the population from which we drew our study group, retained haemothoraces occurred in 10.9% of 596 cases with traumatic haemothorax. In group I, 22 patients had radiological improvement; the others underwent thoracotomy. In this group, mean hospitalisation time was 14.5(+/-4.2) days, and three cases were complicated by empyema. In group II, all patients except four had complete radiological improvement; two of them required a decortication. In this group, mean hospital stay was 9.8(+/-3.7) days. There were no deaths in either group. The differences between group I and group II for length of hospital stay and number of thoracotomies was statistically significant. CONCLUSION: Videothoracoscopy is therefore a more effective procedure than intrapleural streptokinase for the management of PRH.     

Pott's paraplegia in patients with severely deformed dorsal or dorsolumbar spines: treatment and prognosis

STUDY DESIGN: Pott's paraplegic patients with severe spinal deformity were reviewed retrospectively after being treated with chemotherapy and/or decompressive surgery. OBJECTIVES: To determine the most appropriate treatment protocol and to predict the prognosis for Pott's paraplegics with severe spinal deformity. SETTING: Catholic University of Korea Medical Center and Moon-Kim's Institute of Orthopedic Research, Seoul, Korea from 1971 to 1996. METHOD: In this study, there were 33 patients (eight children and 25 adults), ranging from 13 to 56 years of age. They developed spinal tuberculosis at the age of 9 years (range, 2-29 years), and remained neurologically symptom free from an average of 16 years (range, 4-27 years). Four adults who responded well to treatment initially suffered relapses of paraplegia. Only six patients had previously received a full course of triple chemotherapy. Seven (two children, five adults) had healed disease, and 26 (six children, 20 adults) had active disease. Eleven cases had frequent drainage from the sinuses. Kyphoscoliosis was found in 11 patients: four children and seven adults. The remaining patients had kyphosis only. Among the 26 patients with active tuberculosis, 10 had triple chemotherapy itself and the rest had additional decompression surgery (10 anterior and six posterior). All seven patients with healed tuberculosis were subjected only to surgery (two anterior and five posterior). RESULTS: In seven patients with healed tuberculosis, surgery did not improve neurologically except in one child patient. In four patients, the severity of paralysis remained unchanged and two patients, deteriorated neurologically after surgery. In six children with active tuberculosis, there were remarkable neurological recoveries by either conservative treatment or surgical decompression. Seven adults with active tuberculosis recovered slowly, improving by one or two Frankel grades (three Frankel C, three D, one E). In 11 out of 13 surgically treated adults with active disease, paralysis that had persisted for less than 3 months gradually improved by one or two Frankel grades. One Frankel A and one Frankel B paraplegic patients who had paralysis that had lasted through 6 months did not recover after surgery. CONCLUSION: The neurological recovery of Pott's paraplegics with severe spinal deformity resulted in three different outcomes: (1) severe deformity is different from moderate and mild deformities; (2) patients with healed tuberculosis had poorer prognosis than patients with active tuberculosis; (3) children had better prognosis than adults. Furthermore, patients with paralysis persisting over 6 months did not recover neurologically after surgery.     

Tuberculous encephalitis, Landouzy sepsis and Pott's disease: complications after surgery for spinal stenosis

Tuberculosis is an infectious disease with a decreasing incidence in Germany. In particular, the occurrence of reinfections and possible complications associated with this disease, such as tuberculous meningitis/encephalitis and Landouzy sepsis are rare in industrial countries. In this article the intensive care treatment of a patient who initially underwent surgery for spinal stenosis is reported. Due to recurrent appearance of neurological symptoms with increasing severity and abscess formation in the spine, further surgery was performed. Additionally, the patient developed sepsis and meningitis. At this time an infection with Mycobacterium tuberculosis could be detected in both cerebrospinal fluid and abscess material of the spine suggesting a Landouzy sepsis, tuberculous meningitis/encephalitis and the suspicion of an underlying Pott's disease.     

Infection of the pleura by Aspergillus fumigatus

Pleural aspergillosis occurs mostly in established cases of pleural empyema with a broncho-pleural fistula. Ten such patients are reported here: in all, Aspergillus fumigatus infection was related to tuberculosis. In three cases with an active, sputum-positive tuberculous process the pleural empyema was a complication of spontaneous pneumothorax in two, and of lung resection in one. In two cases the empyema occurred as a complication of tuberculous pleuritis, but A. fumigatus infection was noted only after the sputum had become negative for tubercle bacilli. In five patients with inactive tuberculosis, the empyema was a late complication of pneumothorax therapy. The diagnosis of pleural aspergillosis is made on the basis of microscopical examination and culture of A. fumigatus in the pleural pus. The cultures were positive in seven of the 10 cases presented. In two cases in which the culture was negative microscopical examination of the pus revealed the presence of numerous fungal hyphae which was evidence of fungal necrosis. In one case the diagnosis was not made until necropsy. Serum precipitin tests with filtrates of A. fumigatus are further valuable evidence of aspergillous infection. Of 10 presented patients, this test was positive in all seven cases in which it was done. The treatment of pleural aspergillosis by local instillation of nystatin or amphotericin B was effective in six out of seven cases in which it was used.     

One-stage surgical management for multilevel tuberculous spondylitis of the upper thoracic region by anterior decompression, strut autografting, posterior instrumentation, and fusion

STUDY DESIGN: A retrospective clinical study of 1-stage surgical management for multilevel tuberculous spondylitis of the upper thoracic region (MTSUTR). OBJECTIVE: MTSUTR has rarely been documented in the literature. We present a retrospective clinical study of 23 patients with MTSUTR treated by anterior decompression, strut autografting, posterior instrumentation, and fusion. The purpose was to determine the clinical efficacy of such surgical treatment for MTSUTR. SUMMARY OF BACKGROUND DATA: It is considered safe and effective to treat surgically tuberculous spondylitis with local spinal cord compression. Many reports have documented a good clinical efficacy of surgical management for spinal tuberculosis. However, how to deal with MTSUTR is rarely reported in the literature. METHODS: There were 14 men and 9 women, with average age of 35 years. All patients underwent 1 stage anterior debridement, strut autografting, and posterior instrumentation and received combined medication antituberculosis chemotherapy for 12 to 24 months (average 18 mo). The following data were followed up for an average period of 42 months (24 to 60 mo) in these patients: deformity angle, neurologic function, and spinal bony fusion. RESULTS: The average preoperative deformity angle was 44 degrees, correcting to 20-degree postoperatively and 24 degrees at final follow up. In the series, 19 patients with preoperative neurologic deficit restored by 1.3 grades according to Frankel. All patients got bony spinal fusion within 6 months postoperatively. There was no recurrent tuberculous infection. CONCLUSIONS: Single-stage anterior debridement, strut autografting, posterior instrumentation, and fusion proved safe and effective for MTSUTR, which can achieve goals of complete spinal cord decompression and good deformity correction.