Pott's Disease

CASE PRESENTATION
NAME OF THE PATIENT :- Kamal AGE / SEX :- 21 yrs./male ADDRESS :- 8/5, J.N.U, Ber sarai. D.O.A :- 31/12/07 OCCUPATION :- waiter
PRESENTING COMPLAINTS
1. Painful eruption on left lumbar region since 3-4 months. 2. Low backache since 2 months.
HISTORY OF PRESENTING COMPLAINTS

Patient was apparently well 3-4 months back when he noticed a painful eruption on left lumbar region. ONSET :- gradual. Patient noticed a small fixed mass while bathing. It enlarged gradually and started discharging pus and became painful. LOCATION :- left lumbar region. SIZE :- 2-3 cm. CHARACTER OF DISCHARGE :- thick pus like, bloody discharge. CHARACTER OF PAIN :- severe drawing pain which makes him unable to walk. MODALITIES :- < night, walking, lying on right side. > N.S. ASSOCIATED COMPLAINT :- bed-sore on dorsal region of back.
2. Low backache since 2 months.
ONSET :- gradual. LOCATION :- right and left lumbar region. CHARACTER OF PAIN :- severe drawing pain. EXTENSION :- nil. MODALITIES :- < night, lying on right side > hot fomentation. He is unable to walk due to his complaints and has become bedridden, has to take support to carry out his daily activities, trembles while walking and feels as if he would fall.
PAST HISTORY
History of T.B spine 2-21/2 yrs. back ( taken A.T.T for 6 months) No history of any other major illness, accidents or operation. X- Ray exposure :- done Allergies :- nil.
FAMILY HISTORY
Father and mother , alive and apparently well. Has 1 brother and 1 sister , both alive and apparently well. No family history of any major illness like T.B , hypertension, diabetes etc.
PERSONAL HISTORY
DEVELOPMENTAL LANDMARKS :- delayed. teething ( 1 yr. ), walking (3 yrs.), talking (4-5 yrs.) MARITAL STATUS :- unmarried. HABITS / ADDICTIONS :- nil. DIET :- non-veg. EDUCATION :- till 6th class. OCCUPATION :- waiter. ENVIRONMENT AT HOME & WORKPLACE :- congenial.
PHYSICAL GENERALS
THERMAL REACTION :- chilly (2+) APPETITE :- normal, 3 meals / day. THIRST :- 11/2-2L / day, yet has dryness of mouth and tongue. URINE :- D3-4N1-2, no associated complaints. STOOL :- constipated, dry hard stools, once in 2 days. SLEEP :- refreshing DREAMS :- N.S DESIRES :- spicy things, meat / chicken. AVERSIONS :- N.S. PERSPIRATION :- normal, non-staining, non-offensive.
MENTAL GENERALS
Desires company, always wants somebody to be with him. An average student. Irritable ( was very calm before his illness but now has become irritable ). Weeps only when scolded. Anxious about his illness / disease. Wants to get healthy soon. Averse to narrow and closed places. Becomes anxious in crowd. Averse to loud noises. Gets headache. Very concerned about his family. Gets angry if he sees someone drinking alcohol. Wants to beat him but does not do so.
SYSTEMIC EXAMINATION
LOCAL SKIN EXAMINATION :INSPECTION :- skin is very dry and rough with scaling. pustular eruption on left lumbar region with bloody pus- like discharge. eruption on dorsal region of back ( bedsore ). size :- 2-3cm (approx.) PALPATION :- eruptions are tender and painful on touch.
CHEST EXAMINATION
INSPECTION :- shape of chest :- bilaterally symmetrical. markedly emaciated, ribs unduly prominent. R.R :- 20 /min. Type of breathing :- abdomino-thoracic. PALPATION :- position of trachea :- central. vocal fremitus :- equivocal. chest expansion :- B/L symmetrical. PERCUSSION :- dull note on percussion all over the chest. AUSCULTATION :- breath sounds :- increased. no added sounds. vocal resonance :- equivocal.
RUBRICS FOR REPERTORISATION (KENTS REPERTORY)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. MIND, ANGER, VIOLENT. MIND, COMPANY, DESIRE FOR. MIND, ANXIETY, CROWD IN. HEAD, PAIN, NOISE FROM. MOUTH, DRYNESS, TONGUE. STOMACH, THIRST, LARGE QUANTITY. STOMACH, DESIRE, MEAT. STOMACH, DESIRE, HIGHLY SEASONED FOOD. BACK, ERUPTIONS, PUSTULES, LUMBAR REGION. BACK, PAIN, DRAWING, LUMBAR REGION. BACK, PAIN, DRAWING, LUMBAR REGION, NIGHT. STOOL, HARD. STOOL, DRY. GENERALITIES, HEAT VITAL LACK OF.
RESULT OF REPERTORISATION
ARSENIC ALB. SULPHUR PHOSPHORUS NUX-VOM CALC-CARB BRYONIA LYCOPODIUM NAT-MUR NITRIC-ACID 22/10 21/10 23/9 22/9 21/9 20/9 19/9 17/8 19/7
PRESCRIPTION TILL DATE

Silicea 30/ tds / 1 day on 31-12-07.
PROVISIONAL DIAGNOSIS
ABSCESS DUE TO T.B SPINE ( POTTS SPINE )
POTTS DISEASE
Pott's disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. More precisely it is called tuberculous spondylitis and the original name was formed after Percivall Pott (1714-1788), a London surgeon. It is most commonly localized in the thoracic portion of the spine.
Pathogenesis Of Potts Disease

Potts disease results from haematogenous spread of tuberculosis from other sites, often pulmonary. The infection then spreads from two adjacent vertebrae into the adjoining disc space. If only one vertebra is affected, the disc is normal, but if two are involved the intervertebral disc, which is avascular, cannot receive nutrients and collapses. The disc tissue dies and is broken down by caseation, leading to vertebral narrowing and eventually to vertebral collapse and spinal damage). A dry soft tissue mass often forms and superinfection is rare.
SKELETAL TUBERCULOSIS
Bone and joint tuberculosis may account for up to 35 percent of cases of extrapulmonary tuberculosis. Skeletal tuberculosis most often involves the spine, followed by tuberculous arthritis in weight-bearing joints and extraspinal tuberculous osteomyelitis.
Spinal tuberculosis (Pott's disease) most commonly involves the thoracic spine. Infection begins in the anteroinferior aspect of the vertebral body with destruction of the intervertebral disc and adjacent vertebrae. The resulting anterior wedging and angulation of adjacent vertebral bodies with disc space obliteration are responsible for the palpable spinal prominence (gibbus) and a classic radiographic appearance. Paraspinal and psoas abscesses can develop, with extensions to the surface or adjacent tissues. Patients present with local pain, constitutional symptoms, or paraplegia secondary to cord compression.
Articular tuberculosis is a slowly progressive mono-arthritis of the hip or knee. Presentation is indolent with pain, joint swelling, and decreased range of motion. Draining sinuses and abscesses are seen in chronic cases. Systemic symptoms usually are absent. Radiographic changes are nonspecific and include soft tissue swelling, juxta-articular osteopenia, joint space narrowing, and subchondral erosions .
Extraspinal tuberculous osteomyelitis often presents with local pain and can involve any bone. Involvement of adjacent structures may result in complications such as carpal tunnel syndrome, tenosynovitis, and facial palsy.
Chest radiography shows pulmonary disease in one half of patients with osteoarticular tuberculosis, but active pulmonary disease is uncommon. Magnetic resonance imaging may be helpful to assess the degree of bony destruction and to identify soft tissue extension and encroachment on adjacent structures such as the spinal cord.
COLD ABSCESS
Cold abscess, an abscess of slow formation, unattended with the pain and heat characteristic of ordinary abscesses, and lasting for years without exhibiting any tendency towards healing; a chronic abscess. It commonly accompanies tuberculosis. It develops so slowly that there is little inflammation and it becomes painful only when there is pressure on the surrounding area. This type of abscess may appear anywhere on the body, but it is most commonly found on the spine, hips, lymph nodes or in the genital region.
SIGNS AND SYMPTOMS

back pain fever night sweating anorexia weight loss Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of the legs
DIAGNOSIS
blood tests - elevated erythrocyte sedimentation rate tuberculin skin test radiographs of the spine bone scan CT of the spine bone biopsy MRI
COMPLICATIONS
Vertebral collapse resulting in kyphosis Spinal cord compression sinus formation paraplegia (so called Pott's paraplegia)
PREVENTION
Since Pott's disease is caused by a bacterial infection, prevention is possible through proper control. The best method for preventing the disease is reduce or eliminate the spread of tuberculosis. In addition, testing for tuberculosis is an important preventative measure, as those who are positive for purified protein derivative (PPD) can take medication to prevent tuberculosis from forming. A tuberculin skin test is the most common method used to screen for tuberculosis, though blood tests, bone scans, bone biopsies, and radiographs may also be used to confirm the disease.

Pott's Disease

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Pott's Disease

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CASE PRESENTATION

HISTORY OF PRESENTING COMPLAINTS

2. Low backache since 2 months.

RUBRICS FOR REPERTORISATION (KENTS REPERTORY)

PRESCRIPTION TILL DATE

ABSCESS DUE TO T.B SPINE ( POTTS SPINE )

Pathogenesis Of Potts Disease

SIGNS AND SYMPTOMS

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