Cervical Pott’s disease

Abstract

An 88-year-old woman with a history of Alzheimer disease presented to the emergency department with a 12-month history of progressive generalized weakness. Physical examination revealed slight bilateral leg weakness. Chest computed tomography revealed incidental nonspecific nodules in right lower lobes; she had a history of exposure to pulmonary tuberculosis from her husband and was diagnosed with pulmonary tuberculosis. Sputum culture was positive for isoniazid-resistant Mycobacterium tuberculosis, similar to that isolated from her husband. One month later, despite anti-tuberculous treatment including rifampin (10 mg/kg), ethambutol (15 mg/kg), pyrazinamide (30 mg/kg), and levofloxacin (500 mg), her symptoms worsened, resulting in flexion contracture of left lower extremity with tendon hyperreflexia. Bilateral Hoffman and Babinski signs were present. Magnetic resonance imaging of the cervical spine revealed atlantoaxial subluxation and infiltration of paravertebral soft tissues, consistent with complication of cervical Pott’s disease (Fig. 1). She refused surgical intervention and continued antituberculous therapy. Her neurological symptoms have been stable for one year. Musculoskeletal tuberculosis accounts for ~10% of all extrapulmonary tuberculosis cases. Spinal tuberculosis, i.e., Pott’s disease, is the most common form, accounting for about half of all musculoskeletal tuberculosis cases, with its incidence increasing in both developing and developed countries. Spinal tuberculosis most commonly involves the thoracic and lumbar regions, whereas cervical involvement is extremely rare, representing approximately 2–3% of all spinal tuberculosis cases. The diagnosis of spinal tuberculosis is often delayed due to an insidious disease onset and low clinical suspicion. However, especially in cervical spinal tuberculosis, diagnostic delay can lead to retropharyngeal abscess and severe neurological defects; therefore, a high index of suspicion and early intervention, including imaging studies, needle aspiration, and biopsy, is necessary for diagnosis. Along with adequate anti-tuberculous therapy, surgical intervention is necessary in patients with severe neurological dysfunction and failure of conservative treatment.