Case Presentation:
An 18‐month old Hispanic female was brought to the emergency department of El Paso Children’s by her mother with a chief complaint of inability to bear weight. A detailed history revealed the child had no significant past medical history but had developed an abnormal right‐sided limp 6 weeks prior. The limp had started 2 days following the administration of vaccines and was accompanied by 1 week of fevers, chills and constipation. Pertinent negatives included absence of urinary/bowel incontinence, anorexia, weight loss or any history of recent infections. Physical examination was significant for 4/5 power in bilateral limbs, no sensory deficits, no cerebellar signs, unable to stand for more than 1 minute with support, unable to cruise or walk and normal anal wink/tone. The child had previously been seen by her pediatrician and orthopedic specialists, which resulted in a finding of an elevated ESR level and a normal hip x‐ray. A hip ultrasound was negative for any hip effusion. Hip/pelvis x‐rays showed normal alignment with no osseous, articular or soft tissue abnormality. MRI pelvis was normal. MRI lumbar spine mildly enlarged lymph nodes. MRI thorax showed destructive tumor of the T7 vertebral body resulting in significant cord compression, most severe at T8‐T9. level. Suspected infiltration of the adjacent T6 and T8 vertebral bodies. Patient underwent thoracic laminectomy and removal of epidural mass. BM aspiration and biopsy showed fibrohistiocytic/chronic granulomatous reactivity with multinucleated giant cells and active benign inflammation consistent with Mycobacterial agent type infectious disease. Multiple repeated AFB stains resulted in negative results. Mycobacterium Tuberculosis DNA PCR was positive on mass biopsy. Patient completed a 14 day course of steroids for spinal cord inflammation and was treated for TB by the Department of Public Health.
Discussion:
The approach to a child with an abnormal gait is to first attempt to find the lesion causing th pathology which may be of soft‐tissue, muscle, bone, joint or nerve origins and be secondary to numerous varying causes. The young child presented had Pott’s disease which is a compression type injury onto the spinal cord secondary to a tuberculosis infection. Pott’s disease has a reported average duration of symptoms at diagnosis of 4 months but can be considerably longer due to the nonspecific presentation. The thoracic spine is frequently reported as the most common site of involvement. Back pain is the earliest and most common symptom with other potential constitutional symptoms including fever, weight loss and neurologic abnormalities. The approach towards making the diagnosis is through laboratory work and different imaging modalities. With regards to the management, studies performed by the British Medical Research Council indicate that tuberculosis spondylitis of the should be treated with combination chemotherapy for 6‐9 months with certain indications for surgical intervention.
Conclusions:
Limp, abnormal gait and back pain is pathologic in the pediatric patient until proven otherwise. Developed countries are not immune from spinal tuberculosis. A thorough history and physical examination is quintessential to making the diagnosis of Pott’s disease.
