12-02-2008, 08:05 PM
AAA
This patient most likely has Mycobacterium tuberculosis infection of the lumbar spine and requires a CT-guided needle biopsy of the lesion to establish the diagnosis and guide therapy. The clinical scenario is compatible with various entities, but some type of spinal infection seems most likely because of the time frame. Distinguishing mycobacterial from bacterial infections of the spine is difficult without tissue for histopathologic examination and culture, as there is some overlap between the presentations of more common bacterial infections and less common mycobacterial infections. Local pain, muscle spasm, and rigidity are the most common presenting symptoms for both types of infection. Fever and other constitutional symptoms are reported by less than 50% of patients.
Almost all immunocompetent patients with spinal tuberculosis have a positive intermediate-strength tuberculin skin test, whereas false-negative test results are more common in immunosuppressed patients. However, a negative tuberculin skin test can never exclude the diagnosis of tuberculosis in any clinical setting. In immunosuppressed transplant recipients and other persons at high risk for developing active tuberculosis (e.g., patients with HIV infection or persons having recent close contact with someone with tuberculosis), a tuberculin skin test result of >5 mm of induration is now considered positive and is a key finding in the patient described in this clinical scenario. Although there is no report of prior tuberculin skin testing in this patient, transplant candidates are routinely tested before transplantation, and therapy is initiated for any candidates with positive test results. This preventive therapy does not need to delay the transplant procedure.
This patient most likely has Mycobacterium tuberculosis infection of the lumbar spine and requires a CT-guided needle biopsy of the lesion to establish the diagnosis and guide therapy. The clinical scenario is compatible with various entities, but some type of spinal infection seems most likely because of the time frame. Distinguishing mycobacterial from bacterial infections of the spine is difficult without tissue for histopathologic examination and culture, as there is some overlap between the presentations of more common bacterial infections and less common mycobacterial infections. Local pain, muscle spasm, and rigidity are the most common presenting symptoms for both types of infection. Fever and other constitutional symptoms are reported by less than 50% of patients.
Almost all immunocompetent patients with spinal tuberculosis have a positive intermediate-strength tuberculin skin test, whereas false-negative test results are more common in immunosuppressed patients. However, a negative tuberculin skin test can never exclude the diagnosis of tuberculosis in any clinical setting. In immunosuppressed transplant recipients and other persons at high risk for developing active tuberculosis (e.g., patients with HIV infection or persons having recent close contact with someone with tuberculosis), a tuberculin skin test result of >5 mm of induration is now considered positive and is a key finding in the patient described in this clinical scenario. Although there is no report of prior tuberculin skin testing in this patient, transplant candidates are routinely tested before transplantation, and therapy is initiated for any candidates with positive test results. This preventive therapy does not need to delay the transplant procedure.