Pott's Disease: A Case Report

INTRODUCTION
Pott’s disease is a presentation of extrapulmonary tuberculosis that affects
the spine, a kind of tuberculous arthritis of the intervertebral joints. Scientifically,
it is called tuberculous spondylitis. Pott’s disease is the most common site of bone
infection in TB; hips and knees are also often affected. The lower thoracic and
upper lumbar vertebrae are the areas of the spine most often affected.

Pott's disease, which is also known as Pott’s caries, David's disease, and
Pott's curvature, is a medical condition of the spine. Individuals suffering from
Pott's disease typically experience back pain, night sweats, fever, weight loss, and
anorexia. They may also develop a spinal mass, which results in tingling,
numbness, or a general feeling of weakness in the leg muscles. Often, the pain
associated with Pott's disease causes the sufferer to walk in an upright and stiff
position.

Pott’s disease is caused when the vertebrae become soft and collapse as
the result of caries or osteitis. Typically, this is caused by mycobacterium
tuberculosis. As a result, a person with Pott's disease often develops kyphosis,
which results in a hunchback. This is often referred to as Pott’s curvature. In some
cases, a person with Pott's disease may also develop paralysis, referred to as
Pott’s paraplegia, when the spinal nerves become affected by the curvature.

The disease progresses slowly. Signs and symptoms include: back pain,
fever, night sweats, anorexia, weight loss, and easy fatigability. Diagnosis is based
on: blood tests - elevated ESR , skin tests ,radiographs of the spine , bone scan
,CT of the spine , and bone biopsy. Gibbus formation is the pathognomonic sign of
this disease. Gibbus formation refers to a sharply angled curvature of the
backbone, resulting from collapse of a vertebra or simply a hunchback.

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 Pott's Disease: A Case Report

Approximately 1-2% of total tuberculosis cases are attributable to Pott

disease. The incidence rate here in the Philippines is approximately 20-30% of all
the patient diagnosed to have Tuberculosis. Most of the cases of the Pott's disease
in the Philippines is caused by the non-compliance of the treatment regimen of
TB. Internationally, between 1993 and 2001, tuberculosis of the bone and joints
accounted for 3.5% of all tuberculosis cases (0.2-1.1% in patients of European
origin and 2.3-6.3% in patients of non-European origin) .

“21 nursing problems” according to Faye Glenn Abdellah could be best

adapted on this kind of case. She defined nursing as broadly grouped into the 21
nursing problem areas to guide care and promote the use of nursing judgement.
She also said that nursing is a service that is based on the art and science and
aims to help people, sick or well, cope with their health needs. The said disease
could lead to different problems that the patient can experince. It is the
responsibility of the nurse to meet the different needs of the client to achive the
optimum level of functioning. The researcher chose to discuss Pott's disease as
one of the requirement in the rotation. This study will help the researcher to
analyze and dig deeper and see a clearer picture, in response to our roles as
future registered nurses.

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 Pott's Disease: A Case Report

OBJECTIVES OF THE STUDY

GENERAL OBJECTIVES:
To be able to develop a comprehensive case study that would focus on the chosen
case with regards to the pathology of the disease, its corresponding medical
actions and the associative function of client-based interventions which will be
used to facilitate the client’s health status which is aimed towards achieving
optimum level of functioning.

SPECIFIC OBJECTIVES:
• To know the patho-physiologic mechanism of the disease process of Pott's
disease, placing emphasis on how the complications and the disease
etiology relate and sync with each other.
• To accurately explain the various laboratory examinations that require for
the detection of the disease and how the significant remarks or findings
relate to his disease.
• Cite various drugs required for the treatment of the disease in giving a
client based analysis on the said pharmacologic treatment.
• To be able to give health teachings regarding the prevention and cure of the
disease.
• To evaluate the presenting clinical manifestations based on the overall

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 Pott's Disease: A Case Report

condition with emphasis placed on the alterations.

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 Pott's Disease: A Case Report

ANATOMY AND PHYSIOLOGY

The spinal cord is the largest nerve in the body, and it is comprised of the
nerves which act as the communication system for the body. The nerve fibers
within the spinal cord carry messages to and from the brain to other parts of the
body. The spinal cord is surrounded by protective bone segments, called the
vertebral column. The vertebral column is comprised of seven cervical vertebrae,
twelve thoracic vertebrae, five lumbar vertebrae and five sacral vertebrae. The
vertebral column also provides attachment points for muscles of the back and
ribs. The vertebral disks serve as shock absorbers during activities such as

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 Pott's Disease: A Case Report

walking, running and jumping, they also allow the spine to flex and extend.

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 Pott's Disease: A Case Report

DIAGNOSTIC PROCEDURES
1. Tuberculin skin test (purified protein derivative [PPD])

results are positive in 84-95% of patients with Pott disease who are not infected
with HIV. A standard dose of 5 Tuberculin units (0.1 mL)(The standard Mantoux
test in the UK consists of an intradermal injection of 2TU of Statens Serum
Institute (SSI) tuberculin RT23 in 0.1ml solution for injection.) Injected
intradermally (between the layers of dermis) and read 48 to 72 hours later. This
intradermal injection is termed the mantoux technique. A person who has been
exposed to the bacteria is expected to mount an immune response in the skin
containing the bacterial proteins. The reaction is read by measuring the diameter
of induration (palpable raised hardened area) across the forearm (perpendicular
to the long axis) in millimeters. If there is no induration, the result should be
recorded as "0 mm". Erythema (redness) should not be measured. If a person has
had a history of a positive tuberculin skin test, or has not had a recent tuberculin
skin test (within one year), another skin test may be needed.

2. The erythrocyte sedimentation rate (ESR) may be markedly elevated

(>100 mm/h).

ESR stands for erythrocyte sedimentation rate. It is a test that indirectly measures
how much inflammation is in the body. However, it rarely leads directly to a
specific diagnosis. This test can be used to monitor inflammatory or cancerous
diseases. It is a screening test, which means it cannot be used to diagnose a
specific disorder. However, it is useful in detecting and monitoring tuberculosis,
tissue death, certain forms of arthritis, autoimmune disorders, and inflammatory
diseases that cause vague symptoms.

3. Radiography

Radiographic changes associated with Pott disease present relatively late. The

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 Pott's Disease: A Case Report

following are radiographic changes characteristic of spinal tuberculosis on plain

radiography: visibly seen curvature of the spine or visible bone lesions on different
levels.

4. CT scanning

CT scanning provides much better bony detail of irregular lytic lesions, sclerosis,
disk collapse, and disruption of bone circumference. Low-contrast resolution
provides a better assessment of soft tissue, particularly in epidural and paraspinal
areas. CT scanning reveals early lesions and is more effective for defining the
shape and calcification of soft-tissue abscesses. In contrast to pyogenic disease,
calcification is common in tuberculous lesions.

5. MRI

MRI is the criterion standard for evaluating disk-space infection and osteomyelitis
of the spine and is most effective for demonstrating the extension of disease into
soft tissues and the spread of tuberculous debris under the anterior and posterior
longitudinal ligaments. MRI is also the most effective imaging study for
demonstrating neural compression.

MRI findings useful to differentiate tuberculous spondylitis from pyogenic

spondylitis include thin and smooth enhancement of the abscess wall and well-
defined paraspinal abnormal signal, whereas thick and irregular enhancement of
abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic
spondylitis. Thus, contrast-enhanced MRI appears to be important in the
differentiation of these two types of spondylitis.

6. Bone biopsy

A bone biopsy is a procedure in which a small sample of bone is taken from the
body and looked at under a microscope for cancer, infection, or other bone
disorders.

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 Pott's Disease: A Case Report

Confirm the diagnosis of a bone disorder that was found by another test, such as
an X-ray, CT scan, bone scan, or a MRI. Tell the difference between a
noncancerous (benign) bone mass, such as a bone cyst, and bone cancer, such as
multiple myeloma. See what is causing a bone infection (osteomyelitis) or if an
infection is present. Find the cause of ongoing bone pain. Check bone problems
seen on an X-ray.

PATHOPHYSIOLOGY
PRECIPITATING FACTORS
PREDISPOSING FACTORS
- Non-compliance to medicines - PTB diagnosed
- Continuous exposure to M.Tubeculosis
- Malnutrition
- Socio-economic status

Exposure to Mycobacterium Tubeculosis

MEDICATIONS:
HRZE

Primary Pulmonary Tuberculosis Intermittent fever,

upper back pain, night
sweats, poor appetite,
weight loss.

Spread of M. Tuberculosis

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 Pott's Disease: A Case Report

Extrapulmonary Tuberculosis

Infection spreads to the intervertebral disc

in the T7-T9 of the spine

Progressive bone destruction Persistent back

pain

Intervertebral Collapse Caseation takes place

Gibbus formation between T4-T7 or T7-T9

Spinal cord depression

Neurological effects and lower motor defficits Pott's parplegia

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 Pott's Disease: A Case Report

MEDICAL-SURGICAL-NURSING
MANAGEMENT
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.
MEDICAL MANAGEMENT

• Before the advent of effective antituberculosis chemotherapy, Pott disease

was treated with immobilization using prolonged bed rest or a body cast.

• Studies performed by the British Medical Research Council indicate that

tuberculous spondylitis of the thoracolumbar spine should be treated with
combination chemotherapy for 6-9 months.
• According to the most recent recommendations issued in 2003 by the US
Centers for Disease Control and Prevention, the Infectious Diseases Society
of America, and the American Thoracic Society, a 4-drug regimen should be

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 Pott's Disease: A Case Report

used empirically to treat Pott disease.

• Isoniazid and rifampin should be administered during the whole course of
therapy. Additional drugs are administered during the first 2 months of
therapy. These are generally chosen among the first-line drugs, which
include pyrazinamide, ethambutol, and streptomycin. The use of second-line
drugs is indicated in cases of drug resistance.
• Opinions differ regarding whether the treatment of choice should be
conservative chemotherapy or a combination of chemotherapy and surgery.
The treatment decision should be individualized for each patient.

SURGICAL MANAGEMENT

• Indications for surgical treatment of Pott disease generally include the

following:

o Neurologic deficit (acute neurologic deterioration, paraparesis,

paraplegia)
o Spinal deformity with instability or pain
o No response to medical therapy (continuing progression of kyphosis or
instability)
o Large paraspinal abscess
o Nondiagnostic percutaneous needle biopsy sample
• Resources and experience are key factors in the decision to use a surgical
approach.
• The lesion site, extent of vertebral destruction, and presence of cord
compression or spinal deformity determine the specific operative approach
(kyphosis, paraplegia, tuberculous abscess).

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 Pott's Disease: A Case Report

• In Pott disease that involves the cervical spine, the following factors justify
early surgical intervention:
o High frequency and severity of neurologic deficits
o Severe abscess compression that may induce dysphagia or asphyxia
o Instability of the cervical spine
Nursing Diagnosis

• Acute pain related to inflammatory process

• Disturbed body image related to trauma/injury to spinal cord

• Self – bathing hygiene deficit related to musculoskeletal impairment

• Impaired physical mobility related to therapeutic restriction of movement

• Imbalance nutrition related to inadequate food intake

Nursing Responsibilities

• Drug treatment is generally sufficient for Pott’s disease, with spinal

immobilization if required.
• Surgery is required if there is spinal deformity or neurological signs of spinal
cord compression.
• Standard antituberculosis treatment is required. Duration of antituberculosis
treatment: If debridement and fusion with bone grafting are performed,
treatment can be for six months. If debridement and fusion with bone
grafting are NOT performed a minimum of 12 months’ treatment is required.
• It may also be necessary to immobilize the area of the spine affected by the
disease, or the person may need to undergo surgery in order to drain any
abscesses that may have formed or to stabilize the spine.
• Other interventions include application of knight/ taylor brace, head halter
traction.

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 Pott's Disease: A Case Report

PATIENT HEALTH TEACHING

P- atient should be reminded to attend check-ups at the nearest….

O- rthopedic center

T- reatment should be taken in a…..

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 Pott's Disease: A Case Report

T- imely manner

S- ight any symptoms other than the usual and report it to the
physician

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 Pott's Disease: A Case Report

Global City Innovative College

Bonifacio Global City, Taguig City
Philippines

In Partial Fulfilment of the Requirements in

Nursing Care Management 105

CASE STUDY
POTT'S DISEASE

Clinical Agency : Philippine Orthopedic Hospital

Submitted By:

FUERTES, Rheegell E.
N413 Group B Cluster 2

December 2010

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 Pott's Disease: A Case Report

Fuertes, Rheegell E. N413 POC