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    Gibbus deformity representing wedged vertebrae as a result of vertebral body collapse.

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    Anteroposterior chest x-ray demonstrating a mediastinal mass.

  • 1.

    World Health Organization, 2012. Global Tuberculosis Report 2012. Available at: http://www.who.int/tb/publications/global_report/en/. Accessed May 1, 2013.

    • Search Google Scholar
    • Export Citation
  • 2.

    Cheung WY, Luk KD, 2012. Clinical and radiological outcomes after conservative treatment of TB spondylitis: is the 15 years' follow-up in the MRC study long enough? Eur Spine J 22: 594602.

    • Search Google Scholar
    • Export Citation
  • 3.

    De Backer AI, Mortele KJ, Vanschoubroeck IJ, Deeren D, Vanhoenacker FM, De Keulenaer BL, Bomans P, Kockx M, 2005. Tuberculosis of the spine: CT and MR imaging features. JBR-BTR 88: 9297.

    • Search Google Scholar
    • Export Citation
  • 4.

    Nhu NT, Ha DT, Anh ND, Thu do DA, Duong TN, Quang ND, Lan NT, Quyet TV, Tuyen NT, Ha VT, Giang do C, Dung NH, Wolbers M, Farrar J, Caws M, 2013. Evaluation of Xpert MTB/RIF and MODS Assay for the Diagnosis of Pediatric Tuberculosis. Available at: http://www.biomedcentral.com/1471-2334/13/31. Accessed July 11, 2013.

    • Search Google Scholar
    • Export Citation
  • 5.

    Chandra SP, Singh A, Goyal N, Laythalling RK, Singh M, Kale SS, Sharma MS, Suri A, Singh P, Garg A, Sarkar C, Sharma BS, Mahapatra AK, 2013. Analysis of Changing Paradigms of Management in 179 Patients with Spinal Tuberculosis over a 12-Year Period and Proposal of a New Management Algorithm. Available at: http://dx.doi.org/10.1016/j.wneu.2012.12.019. Accessed May 1, 2013.

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Mediastinal Mass Causing Spinal Cord Compression

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  • Department of Pediatrics, MassGeneral Hospital for Children, Boston, Massachusetts; Department of Pediatrics, Angkor Hospital for Children, Siem Reap, Cambodia

A 4-year-old Cambodian male presented to the emergency room with 2 weeks of gradually increasing leg weakness until he could no longer stand. He was also reported to have a deformity on his back, intermittent fevers and cough. His physical exam was notable for a 2 cm × 1 cm bony protrusion at his T4 vertebrae, and 2/5 strength and positive Babinski reflexes in his lower extremities. A chest x-ray showed a 3.2 cm × 2.9 cm mass in the middle mediastinum extending to the posterior mediastinum. A purified protein derivative test was positive. A computed tomography scan showed findings consistent with pulmonary tuberculosis and a paravertebral mass with amorphous calcifications, which involved destruction of the T4-T5 vertebrae and evidence of cord compression. These findings were all consistent with tuberculous spondylitis (Pott's disease).

A 4-year-old male presented to a Cambodian emergency department with gradually increasing leg weakness for 2 weeks until he could no longer stand. He was also reported to have a deformity on his back for the past 2 months, and intermittent fevers and cough for several months. He retained control of his bowel and bladder function. On physical exam he was mildly tachypneic. His skin exam revealed a 2 cm × 1 cm bony protrusion at his T4 vertebrae (Figure 1). His neurological exam was significant for 2/5 strength, and positive Babinski reflexes in his lower extremities. He had normal sensation.

Figure 1.
Figure 1.

Gibbus deformity representing wedged vertebrae as a result of vertebral body collapse.

Citation: The American Society of Tropical Medicine and Hygiene 90, 3; 10.4269/ajtmh.13-0381

Workup included anteroposterior (Figure 2) and lateral chest x-rays, which showed a 3.2 cm × 2.9 cm mass in the middle mediastinum extending to the posterior mediastinum. The patient was promptly started on anti-tuberculosis (TB) treatment. A purified protein derivative test was positive. Three sputum samples were analyzed with the Xpert Mycobacterium tuberculosis/rifampin resistance (MTB/RIF) test and were all negative. A computed tomography scan done at an outside facility showed findings consistent with pulmonary tuberculosis as well as a paravertebral mass with amorphous calcifications, which involved destruction of the T4-T5 vertebrae and evidence of cord compression. These findings were all consistent with tuberculous spondylitis (Pott's disease). After 1 month of treatment with anti-tuberculosis medication in conjunction with physical therapy, the patient had significantly improved. He remained afebrile, his cough had decreased in frequency, and he was able to stand with support.

Figure 2.
Figure 2.

Anteroposterior chest x-ray demonstrating a mediastinal mass.

Citation: The American Society of Tropical Medicine and Hygiene 90, 3; 10.4269/ajtmh.13-0381

Despite significant progress to reverse the TB epidemic, it was estimated that there were 500,000 cases of TB in the pediatric population and 64,000 deaths in 2011.1 Tuberculosis can spread hematogenously to vertebral bodies, causing pain and eventual bony destruction.2 A Gibbus deformity is a late finding in Pott's disease3 and clinicians should keep TB high on the differential when presented with this finding in any TB-endemic area. Although microbiological confirmation is preferred, TB can be very difficult to isolate in children in the developing world due to lack of effective diagnostic tools, paucibacillary samples, and the difficulty of obtaining high-quality specimens from children. Even the new Xpert MTB/RIF test has only been shown to have 79.5% sensitivity for detection of confirmed TB from sputum, gastric, cerebrospinal fluid, and pleural fluid samples in a pediatric population from Vietnam.4

Current management always includes medical management and can also include surgical management for patients with acute neurological deterioration.5 In a resource-limited setting without a neurosurgeon, it is important to promptly initiate TB treatment without waiting for the results of diagnostic studies, advanced imaging, or biopsy.

  • 1.

    World Health Organization, 2012. Global Tuberculosis Report 2012. Available at: http://www.who.int/tb/publications/global_report/en/. Accessed May 1, 2013.

    • Search Google Scholar
    • Export Citation
  • 2.

    Cheung WY, Luk KD, 2012. Clinical and radiological outcomes after conservative treatment of TB spondylitis: is the 15 years' follow-up in the MRC study long enough? Eur Spine J 22: 594602.

    • Search Google Scholar
    • Export Citation
  • 3.

    De Backer AI, Mortele KJ, Vanschoubroeck IJ, Deeren D, Vanhoenacker FM, De Keulenaer BL, Bomans P, Kockx M, 2005. Tuberculosis of the spine: CT and MR imaging features. JBR-BTR 88: 9297.

    • Search Google Scholar
    • Export Citation
  • 4.

    Nhu NT, Ha DT, Anh ND, Thu do DA, Duong TN, Quang ND, Lan NT, Quyet TV, Tuyen NT, Ha VT, Giang do C, Dung NH, Wolbers M, Farrar J, Caws M, 2013. Evaluation of Xpert MTB/RIF and MODS Assay for the Diagnosis of Pediatric Tuberculosis. Available at: http://www.biomedcentral.com/1471-2334/13/31. Accessed July 11, 2013.

    • Search Google Scholar
    • Export Citation
  • 5.

    Chandra SP, Singh A, Goyal N, Laythalling RK, Singh M, Kale SS, Sharma MS, Suri A, Singh P, Garg A, Sarkar C, Sharma BS, Mahapatra AK, 2013. Analysis of Changing Paradigms of Management in 179 Patients with Spinal Tuberculosis over a 12-Year Period and Proposal of a New Management Algorithm. Available at: http://dx.doi.org/10.1016/j.wneu.2012.12.019. Accessed May 1, 2013.

    • Search Google Scholar
    • Export Citation

Author Notes

* Address correspondence to Hasan S. Merali, MassGeneral Hospital for Children, 175 Cambridge Street, CPZS-501C, Boston, MA 02114. E-mail: Hasan_Merali@post.harvard.edu

Authors' addresses: Hasan S. Merali, MassGeneral Hospital for Children, Boston, MA, E-mail: Hasan_Merali@post.harvard.edu. Heng Sing, Angkor Hospital for Children, Siem Reap, Cambodia, E-mail: hengsing2003@yahoo.com.

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