Sue Greenhalgh Consultant Physiotherapist March 18th

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Joanna Evans
6 years ago
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1 Sue Greenhalgh Consultant Physiotherapist March 18th

2 Caused by the Myobacterium Tuberculosis well known to Hippocrates Sir Percival Pott gave a very good description of the disease in 1779 Consumption Historically characterised, by a fever, haemoptysis, and long relentless wasting with sufferers appearing markedly pale

3 TB is a disease of poverty Worlds most prevalent and lethal infectious disease (Khoo, Mikawa, & Fessler 2003) One third (2 billion people) of the world's population have TB Many die with it rather than from it (WHO 2007) Categorised as pulmonary or extrapulmonary (or non-pulmonary)

4 All forms of the disease are initially contracted by the same air borne route through the lungs When people suffering from active pulmonary TB cough, sneeze, speak, kiss, or spit, they expel minute infectious droplets A person with active but untreated pulmonary tuberculosis can infect other people per year (WHO 2007).

5 Can affect any organ of the human body Bacillus can be carried through the blood stream and lymph Skeletal system is affected in 1% to 2% of cases if HIV negative This rises to 60% if HIV positive (Khoo, Mikawa, & Fessler 2003).

6 UK between 2004 and 2005 there was a larger percentage increase in the number of extra-pulmonary cases of TB reported (17%) compared to pulmonary cases (7%) (Health Protection Agency 2006).

7 The most common extra-pulmonary site for TB is the spine (Potts Disease), with the commonest zone affected being T10 to L1

8 During a 7 year period in Blackburn there were 1072 cases of TB 7% (n=79) of which were extra-pulmonary bone and joint TB. The spine was the most commonly affected site with 44% of cases 3 Cervical, 32 Thoracolumbar and 1 Sacroilliac

9 Griffith (2002) states that the majority of patients have 2 or more affected vertebrae by the time they are diagnosed

10 Most affected is the anterior part of the vertebral body adjacent to the sub-chondral plate It can then spread under the anterior longitudinal ligament.

11 X-ray MRI

12 On Plain x-ray anterior destruction of the vertebral body with preservation of the disc space distinguishes TB from pyogenic infection (Miller 2004). TB can cause destruction of several adjacent vertebral levels or in 10% of cases it can skip levels (Khoo, Mikawa, & Fessler 2003).

14 In the UK most cases occur in young adults; 61% aged In 2005 rates of disease in all age groups were higher among the non-uk born population compared to the UK born

15 The highest rates in the non-uk born were among those aged years Among the UK born population the highest rates occurred in the elderly (9.3 per 100,000 among those aged 80 years and over)

16 In most of the world TB affects more men than women. In the UK infection rates are males 16.6 per 100,000 and females 12.9 per 100,000.

17 In Africa, TB primarily affects adolescents and young adults. In developed countries where TB has gone from high to low incidence, TB is mainly a disease of older people (WHO 2007).

18 HIV/AIDS Immuno-compromised Prolonged corticosteroid therapy and rheumatoid arthritis drugs (block tumour necrosis factor alpha)

19 Low body weight / undernourished / anorexia Alcoholism Diabetes Mellitis Penetration of the body e.g. needles, catheters or surgical procedures

20 Poor socio-economic conditions Drug Abuse Homeless Migrants Health care workers In the UK in 2005, 43% of all cases reported were in London

21 Screening was required if respondents answered yes to the following questions; Was your child born in a country outside of the UK with a rate of TB of at least 40 cases per 100,000 people (a list of countries was included) Your child s parents or grandparents were born in a country with a rate of TB of at least 40 cases per 100,000 people Your child is to visit or live in a country with a rate of TB of at least 40 cases per 100,000 people for a period of one month or more

22 SouthAfrica 600 Zambia 600 India 168 Thailand 142 Russian Federation 119 China 100 Brazil 60 Saudi Saudi Arabia 41 Portugal Portugal 33 Japan Japan 28 Iran Iran 23 United United Kingdom 14 Finland Finland 6.2 Australia Australia 5.8 United United States 4.5

23 Sandher et al (2007) report in their series of 79 cases of extra-pulmonary TB eight patients were Caucasian, and seventy one non-white; only four of the non-white patients were born in the UK. Ask where was place of birth

24 Gradual onset of back pain Local pain is often described as severe stabbing In cervical cases pain may be referred to the occiput In thoracic cases pain may manifest as intercostal neuralgia

25 In the lumbar spine pain may be referred to hips and legs Lethargy Fever Weight loss

26 Evening rise in temperature Night sweats Night crying

27 Bogduk and McGuirk (2002) report that the cardinal indicator for an infection is fever Why should, or why could this patient have an infection?

28 When a patient walks into the physiotherapy department for the first time complaining of back pain, what 3 questions would you ask in order to exclude/include extra-pulmonary TB as a diagnostic possibility?

29 Q. How did the pain start? A. Insidious onset Q. Since starting with back pain has your general health changed? A. Malaise, fever, night sweats, loss of appetite Q. What are the conditions (environment) like; at home, in the workplace or places you frequently visit? A. Over crowding, squalid, regular close contact with high risk groups

30 Local spinal pain May be a kyphosis Paravertebral swelling may be seen Antalgic posture of protective upright, stiff position. - Boarding, result of muscular rigidity can be one of the earliest clinical signs to appear

31 Decreased range of motion If there is neural involvement there are likely to be neurological signs (maybe widespread) Abscess sites should be examined, triangles of the neck, iliac fossae, groin, gluteal and ischial regions. Skin overlying the abscess may redden but not feel warm on palpation leading to the term Cold Abscess.

32 A psoas abscess may present as a lump in the groin and resemble a hernia or as a tender swelling below the inguinal ligament

33 A psoas abscess can be confused with a hernia or enlarged inguinal lymph nodes Spinal x-ray may be normal in early disease as 50% of the bone mass must be lost for changes to be visible on x-ray Pallor associated with iron deficient anaemia. This is usually caused by inadequate iron for haemoglobin synthesis. TB causes a decreased release of iron from the bone marrow. Iron deficient anaemia is usually responsive to traditional treatment such as improved diet and iron supplements (Kumar & Clark 2005).

34 Pyogenic infection Spinal tumours Infective discitis Acute bacterial osteomyelitis Septic arthritis

35 If an infective process is suspected the absence of BCG vaccination should raise the index of suspicion for TB (Sandher et al 2007).

36 A needle biopsy from lymph nodes or pus aspirated from lymph nodes, pleura or any other surgical or radiological sampleculture may be required Chest x-ray to check for coexisting respiratory TB. (NICE 2006)

37 Elevated ESR. Laboratory investigations normally include a full blood count ESR and CRP. The ESR is generally elevated in TB sufferers but the leukocyte count may be normal (Perra & Winter 1996) MRI (in suspected spinal cases)

38 TB is not actually that easy to catch Estimated that 8 hours of cumulative close contact is required Progression from TB infection to TB disease occurs when the TB bacilli overcome the immune system defenses and begin to multiply. In primary TB disease 1 to 5% of cases, this occurs soon after infection

39 In the majority of cases, a latent infection occurs that has no obvious symptoms. These dormant bacilli can produce tuberculosis in 2 to 23% of these latent cases, often many years after infection (WHO 2007).

40 As abscesses develop they coalesce, resulting in regions of necrosis which contain a characteristic opaque yellow cheesy substance Abscesses can follow tissue planes and at their margins they can form adhesions with visceral and vascular structures which may become primary sources of symptoms including pain

41 TB can remain dormant for years Once appropriate combination chemotherapy has been instigated a cure is the most likely outcome

42 Short course (6 months) combination chemotherapy. (NICE 2006) A combination of drugs helps overcome problems associated with drug resistance

43 Look at this case history in groups and stop at the appropriate points to reflect

46 Magnetic Resonance Scan (MRI) of the spine identified signs of vertebral body osteomyelitis from T4-T12 with signs of discitis at T10 and T11, there was anterior paraspinal mass under the anterior longitudinal ligament which contrast enhancement identified as an abscess. There was an acute kyphosis at T10/11 with slight cord impingement but no soft tissue mass within the canal. In addition, Alice had a Psoas abcess!

47 12/40 In a study conducted in Egypt, of forty consecutive patients complaining of LBP, attending a Rheumatology service for their initial primary medical management, twelve were found to have extra-pulmonary TB as the cause of back pain TB remains a significant cause of back pain in many parts of the world.

48 TB is a leading killer among HIV infected people with weakened immune systems HIV infection is also the most potent risk factor for converting latent TB into active TB

49 In recent years a lack of prevalence in the Western world due to successful medical management has led to a low index of suspicion generally in relation to TB (Abou- Raya & Abou-Raya 2006). Be vigilant

New Entrant Screening and Latent TB Get screened and find out if you have TB infection before you develop TB disease!

New Entrant Screening and Latent TB Get screened and find out if you have TB infection before you develop TB disease! Screening and treatment for TB are free. What does this leaflet cover? What is Tuberculosis