Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 3140 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 

Table of Contents   
LETTER TO THE EDITOR  
Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 1015-1017
Backache in patients on maintenance hemodialysis: Beware of spinal tuberculosis


1 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Click here for correspondence address and email

Date of Web Publication7-Sep-2015
 

How to cite this article:
Yadla M, Sriramnaveen P, Kishore C K, Sivakumar V, Reddy Y S, Sridhar A, Vijayalakshmi B, Lakshmi A Y. Backache in patients on maintenance hemodialysis: Beware of spinal tuberculosis. Saudi J Kidney Dis Transpl 2015;26:1015-7

How to cite this URL:
Yadla M, Sriramnaveen P, Kishore C K, Sivakumar V, Reddy Y S, Sridhar A, Vijayalakshmi B, Lakshmi A Y. Backache in patients on maintenance hemodialysis: Beware of spinal tuberculosis. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2020 Feb 28];26:1015-7. Available from: http://www.sjkdt.org/text.asp?2015/26/5/1015/164595
To the Editor,

The incidence of tuberculosis is sixto 16fold higher in uremic patients, and extrapulmonary tuberculosis (EPTB) is more frequent than pulmonary TB in patients on maintenance hemodialysis as compared with the general population. There is often a delay in the diagnosis of EPTB because of non-specific clinical presentation, difficulty in localization of EPTB and latency in laboratory techniques. The mortality was reported to be as high as 75% if the diagnosis is delayed.

Of the various causes of EPTB, lymph nodal TB is the most common cause. The incidence of skeletal TB is reported to be <5%. Of skeletal TB, spinal TB accounts for >50% of the incidences. Other sites of skeletal TB were reported in long bones, skull and clavicles.

Although spinal TB (STB) is the most common cause of skeletal TB, it is sparsely reported in patients on dialysis. The literature search revealed one case report of STB in patients on dialysis.

Herein, we report four cases of Potts spine in patients on dialysis, and they were managed with antituberculous treatment. All the four cases died. They presented with backache of variable duration. There was no neurologic deficit in any of them. The routine evaluation was normal, except raised erythrocyte sedimentation rate. In view of the persistence of backache, detailed radiological evaluation was performed, which revealed features suggestive of Potts spine along with paravertebral abscess [Figure 1] , [Figure 2] and [Figure 3].
Figure 1: MRI of the thoracic spine showing compression at the D 5-6 and pre-vertebral abscess.

Click here to view
Figure 2: MRI of the lumbar spine showing compression of thecal sac at L2-3 due to pre-vertebral collection.

Click here to view
Figure 3: MRI of the cervical spine showing destruction of the C5, C6 vertebra.

Click here to view


The STB manifests as low backache, fever and constitutional symptoms. In patients on dialysis, the clinical picture is often confused with uremia and mineral bone disease. Other clinical presentations include bilateral paraparesis, bilateral thigh pains and sudden onset of fever with severe low backache.

The STB is hematogenous in origin. Because of the common arterial supply of two vertebral bodies, involvement in the antero-inferior part of one vertebra involves the other, along with the involvement of the intervertebral disc. Associated paravertebral abscess is common. On imaging, involvement of the disc and the paravertebral soft tissue is reported to be specific for STB. [1]

We had four patients of STB (102 patients on hemodialysis); thus, the incidence is 0.039%. In our patients, backache was present in two patients, one patient had backache along with painful flexion of the right hip. Another patient had pain in the lower cervical region. All the four patients did not have constitutional symptoms. The mean duration of symptoms was 12 days. None of them had focal neurological deficit. The tuberculin skin test was negative in all of them. Chest X-ray did not show features of old pulmonary Kochs. Two patients were found to be hepatitis C positive.

The site of involvement of the STB was dorsal, cervical and lumbar in each and dorsal + lumbar in one patient. Paravertebral abscess was present in all of them. The aspiration of the abscess in the patient with psoas abscess was found to be positive for acid fast bacilli on Ziehl-Nielsen stain.

Based on the typical radiological appearance of destruction of the intervertebral disc along with paravertebral component, the diagnosis of STB was made. Although all the patients were initiated on anti-tuberculous treatment immediately after the diagnosis, the mortality rates were high. The mean survival in all these patients after the diagnosis of STB was 2.5 months + 0.5 months.

The incidence of mortality due to TB in patients on maintenance hemodialysis (MHD) was reported to be between 17% and 75%. [2] The one-year mortality of TB in dialysis patients was reported to be 3.3-times higher compared with the dialysis population without TB. [3] The literature search reveals no mortality directly related to the STB. The factors associated with unfavorable outcome were reported to be older age, limb weakness, spinal kyphotic deformity, incontinence and spinal cord compression. In our group, the mean age was 57 ± 1.6 years, and all of them had spinal compression. Although the mortality cannot be directly related to the STB, the possible etiologies of death include delay in diagnosis, coronary ischemia, pulmonary thromboembolism and malnutrition. Although there was no evidence of pulmonary thromboembolism in any of them, it needs to be considered due to prolonged bedridden status. The mean serum albumin was 2.7 + 0.25 g/dL. Whether malnutrition reflected by hypoalbuminemia was associated with poor outcome could not be assessed.

El-Shawney et al reported recovery in two patients of MHD with Potts spine. Both of them were symptomatic with neurological deficit. Both showed a good recovery without residual focal neurological deficit. [4] The presence of focal deficit may be one of the reasons for early presentation and thus the diagnosis. In our patients, the absence of focal deficit would have caused a delay in diagnosis.

We conclude that spinal tuberculosis in patients on maintenance hemodialysis may have a non-specific clinical presentation. We need a high index of clinical suspicion in patients who present with severe low backache. Delay in the diagnosis due to absence of focal deficit may be fatal.

Conflict of Interest: None declared.

 
   References Top

1.
Agrawal V, Patgaonkar PR, Nagariya SP. Tuberculosis of spine. J Craniovertebr Junction Spine 2010;1:74-85.  Back to cited text no. 1
    
2.
Hussein MM, Mooij JM, Roujouleh H. Tuberculosis and chronic renal disease. Semin Dial 2003;16:38-44.  Back to cited text no. 2
    
3.
Chou KJ, Fang HC, Bai KJ, Hwang SJ, Yang WC, Chung HM. Tuberculosis in maintenance dialysis patients. Nephron 2001;88:138-43.  Back to cited text no. 3
    
4.
El-Shawney MA, Gadallah MF, Campese VM. Tuberculosis of spine (Potts Disease) in patients with end stage renal disease. Am J Nephrol 1994;14:55-9.  Back to cited text no. 4
    

Top
Correspondence Address:
Dr. Manjusha Yadla
Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh
India
Login to access the Email id


DOI: 10.4103/1319-2442.164595

PMID: 26354582

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    References
    Article Figures
 

 Article Access Statistics
    Viewed1650    
    Printed14    
    Emailed0    
    PDF Downloaded221    
    Comments [Add]    

Recommend this journal