INTRODUCTION OF POTTS DISEASE Pott's disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis

of the intervertebral joints. It is named after Percivall Pott (1714 1788), a London surgeon who trained at St Bartholomew's Hospital, London. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. Potts disease results from haematogenous spread of tuberculosis from other sites, often pulmonary. The infection then spreads from two adjacent vertebrae into the adjoining intervertebral disc space. If only one vertebra is affected, the disc is normal, but if two are involved, the 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. (http://en.wikipedia.org/wiki/Pott_disease) Pott's disease, which is also known as Potts 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. Potts 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 Potts curvature. In some cases, a person with Pott's disease may also develop paralysis, referred to as Potts paraplegia, when the spinal nerves become affected by the curvature. (Kietzman, 2011) Gibbus formation is the pathognomonic sign of the diseae. Gibbus formation refers to a sharply angled curvature of the backbone, resulting from collapse of the vertebra or simply a hunchback. (http://www.scribd.com/doc/45165559/Pott-s-Disease)

Physical exam: The exam may show localized tenderness over the spine; pain may precede x-ray changes by weeks to months. As the disease progresses, abnormal curvature in the spine may develop. Deformities may include a humpback (kyphoscoliosis) or a side-to-side curvature (scoliosis). Abscesses may be present in adjacent tissues. Collapse of the spinal vertebrae may cause spinal cord and nerve compression. An individual's neurological exam may be positive for paralysis of the extremities and cranial nerve palsies. (Hidalgo, 2004) If there is neural involvement there will be neurological signs. A psoas abscess may present as a lump in the groin and resemble a hernia. A psoas abscess most often originates from a tuberculous abscess of the lumbar vertebra that tracks from the spine inside the sheath of the psoas muscle.

The Causative organism is Mycobacterium tuberculosis and spreads by blood (Haematogenous). It is commonly associated with Debilitating diseases, AIDS, Drug addiction, Alcoholism. ( http://health.hpathy.com/potts-disease-symptoms-treatment-cure.asp) According to Dr. Draper, there are several risk factors for Pott's disease in children and adults. One of the primary risk factors is being HIV positive or having developed AIDS. Both of these conditions are susceptible to infections such as tuberculosis. Another risk factor is poor socioeconomic conditions. As stated, being an immigrant from one of the countries mentioned or living in cramped environments can make tuberculosis a rampant infection and may result in Pott's disease in children living in such conditions and become infected.(www.ehow.com) Silicosis, also known as Potter's rot, a form of occupational lung disease caused by inhalation of crystalline silica dust is also one of the risk factors, and is marked by inflammation and scarring in forms of nodular lesions in the upper lobes of the lungs. (http://www.trueknowledge.com)

Studies done in New York and Los Angeles have revealed that TB of the muscles and skeleton is more prevalent in black, Asian, and Hispanic Americans. Adults are more likely to be affected, and men are 1.5 to 2.0 times more likely than women to contract the infection. (Hidalgo, 2004)

In the developed world, the disease is more common in certain sections of society such as alcoholics, the undernourished, ethnic minority communities and the elderly. The disease is also more common in patients after gastrectomy for peptic ulcer. The commonest area affected is T10 to L1. The lower thoracic region is the most common area of involvement at 40 to 50%, with the lumbar spine in a close second place at 35 to 45%. The cervical spine accounts for about 10%. (http://www.patient.co.uk/doctor/Pott%27s-Disease-%28Spine%29.htm) A person with Pott's disease may experience additional complications as a result of the curvature. For example, an infection can more easily spread from the paravertebral tissue, which can cause abscesses to occur. Regardless of the complications that may occur, Pott's disease is typically slow spreading and can last for several months or years. Since Pott's disease is caused by a bacterial infection, prevention is possible through proper control. The best method for preventing the disease is to 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. (Kietzman, 2011) Since the advent of antituberculous drugs and improved public health measures, spinal tuberculosis has become rare in developed countries, although it is still a significant cause of disease in developing countries. Tuberculous involvement of the spine has the potential to cause serious morbidity, including permanent neurologic deficits and severe deformities. Medical treatment or combined medical and surgical strategies can control the disease in most patients. In the United States, although the incidence of tuberculosis increased in the late 1980s to early 1990s, the total number of cases has decreased in recent years. The frequency of extrapulmonary tuberculosis has remained stable. Bone and soft-tissue tuberculosis accounts for approximately 10% of extrapulmonary tuberculosis cases and between 1% and 2% of total cases. Tuberculous spondylitis is the most common manifestation of musculoskeletal tuberculosis, accounting for approximately 40-50% of cases. Internationally, approximately 1-2% of total tuberculosis cases are attributable to Potts disease. In the Netherlands 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). Potts disease is the most dangerous form of musculoskeletal tuberculosis because it can cause bone destruction, deformity, and paraplegia. Potts disease most commonly involves the thoracic and lumbosacral spine. However, published series have showed some variation. Lower thoracic vertebrae is the most common area of involvement (40-50%), followed closely by the lumbar spine (35-45%). In other series, proportions are similar but favor lumbar spine involvement. Approximately 10% of Potts disease cases involve the cervical spine. Although some series have found that Potts disease does not have a sexual predilection, the disease is more common in males (male-to-female ratio of 1.5-2:1).

In the United States and other developed countries, Potts disease occurs primarily in adults. In countries with higher rates of Potts disease, involvement in young adults and older children predominates. (Taylor GM, Murphy E, Hopkins R, et al; 2007,153:1243-9)

Pott's disease is rare in the UK but in developing countries it represents about 2% of cases of tuberculosis and 40 to 50% of musculoskeletal tuberculosis. Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of tuberculosis occurs in poorer countries, but a global resurgence is affecting richer ones. India, China, Indonesia, Pakistan and Bangladesh have the largest number of cases but there has been a marked increase in the number of cases in the former Soviet Union and in sub-Saharan Africa in parallel with the spread of HIV. About two thirds of affected patients in developed countries are immigrants, as shown from both London and Paris and spinal tuberculosis may be quite a common presentation. (http://www.patient.co.uk/doctor/Pott%27s-Disease-%28Spine%29.htm) With the emergence of AIDS, extrapulmonary tuberculosis has increased from 10% of the total tuberculosis cases to 18-20% of the total cases. The most frequent site of extrapulmonary involvement is skeletal tuberculosis, and 50% of these are spinal tuberculosis. (www.medscape.com)

About 140 000 new cases of tuberculosis (all types) were reported in 2005. Most patients with TB receive treatment under the directly observed treatment, short-course (DOTS) strategy. In 2003, in order to capture all cases, the National TB Program (NTP) officially adopted the Public-Private Mix DOTS strategy in an effort to engage all private practitioners in DOTS. In 2004, the Philippines was the second high-TB-burden country (after Vietnam) to reach the global targets of 70% case detection and 85% treatment success rates, which has been maintained since. In addition, the NTP has been expanding the management of multidrug-resistant-TB cases from the private project site into the public sector in Metro Manila. (http://www.wpro.who.int/countries/2007/phl/health_situation.htm) Approximately 1-2% of total tuberculosis cases are attributable to P o t t s 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). (http://www.scribd.com/doc/45165559/Pott-sDisease) Investigations are Elevated ESR, Strongly positive Mantoux skin test, Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for changes to be visible on Xray. If the disease is on early stage, X-ray spine shows narrowed joint space, diffuse vertebral osteoporosis adjacent to joint, erosion of bone, and fusiform paraspinal shadow of abscess in soft tissue. On the late stage of the disease, X-ray spine shows destruction of bone, wedge-shaped deformity (collapse of vertebrae anteriorly), and bony ankylosis. Plain X-ray can show vertebral destruction and narrowed disc space. MRI scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy. CT scans can demonstrate the degree of soft tissue infection surrounding the spinal cord. But MRI is best to assess risk to the spinal cord, extent of nerve damage and infection can be seen on MRI . A needle biopsy of bone or synovial tissue is usual. If it shows tubercle bacilli this is diagnostic but usually culture is required. Culture should include mycology. A chest x-ray or sputum smear and culture may show evidence of lung infection with M. tuberculosis. A protein-purified derivative (PPD) or tuberculin skin test can be placed on the arm; it becomes raised if the person has been exposed to TB. (http://www.patient.co.uk/doctor/Pott%27s-Disease-%28Spine%29.htm) Histology shows granulomatous tubercle. Aspirate from joint space or abscess: transparency is

turbid. Color is creamy, consistency is cheesy, fibrin clot is large, mucin clot is poor, and WBC is 25000/cc.mm. (www.http://health.hpathy.com)

Management includes immobilization of the spine is usually for 2 or 3 months. Surgery plays an important part in the management. It confirms the diagnosis, relieves compression if it occurs, permits evacuation of pus, and reduces the degree of deformation and the duration of treatment. However, a Cochrane review found that routine surgery in addition to chemotherapy had not been shown to improve outcome but the problem was that the evidence was poor. A study from India suggested that surgery is not mandatory. (http://www.patient.co.uk/doctor/Pott%27s-Disease-%28Spine%29.htm) Pott's disease is treated with multiple antibiotics. Because of the recent increase in antibiotic-resistant organisms, the recommended treatment includes the use of a four-drug regimen. Treatment must be maintained for at least 6 to 9 months, and some doctors advise individuals to take medication for as long as 9 to 12 months. Immunodeficient individuals may require lifelong drug therapy to keep the infection from recurring. In the past, immobilizing the patient with a cast or a splint may have been recommended, but now external bracing only is the intervention of choice, allowing the individual to participate in rehabilitation and self care. Surgery (spinal fusion, rod placement) may ultimately be needed to relive spinal cord pressure, correct abnormal curvature of the spine, or resolve spinal instability secondary to loss of bone mass. Although brief bed rest may be indicated, rehabilitation to promote independent transfers and ambulation should be attempted as soon as tolerated. (http://www.mdguidelines.com)

Progressive bone destruction leads to vertebral collapse and kyphosis: The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion. This leads to spinal cord compression and neurological signs (Pott's paralysis). Kyphosis occurs because of collapse in the anterior spine and can be severe. Lesions in the thoracic spine have a greater risk of kyphosis than those in the lumbar spine. Neurological problems can be prevented by early diagnosis and prompt treatment. It can reverse paralysis and minimize disability. A combination of conservative management and surgical decompression gives success in most patients. Late onset paraplegia is best avoided by prevention of the development of severe kyphosis. Patients with tuberculosis of the spine who are likely to have severe kyphosis should have surgery in the active stage of disease. The degree of kyphosis, the area of affected vertebrae and the lack of sphincter control all correlate with the chance of recovery from paraplegia. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin and form sinuses. Prognosis is variable. Some individuals will recover completely, particularly if the infection is treated promptly and aggressively. Advanced disease may leave the individual with long-term disability even after the bacterial infection has been cured. Those requiring long-term suppressive therapy may develop recurrences if drug therapy is not maintained. Spinal fusion may be effective in relieving discomfort, depending on the severity of symptoms. Surgery will not, however, treat the underlying disease. In the past, prior to the discovery of drugs for TB that helped treat the disease, 20% of patients died and 30% had recurrences of their symptoms. (Hidalgo,2004) A study from London showed that diagnosis can be difficult and is often late. (http://www.patient.co.uk/doctor/Pott%27s-Disease-%28Spine%29.htm) Although progress and treatment can be slow---taking several weeks to months to years---once the tuberculosis is

resolved, then Pott's disease will also resolve. The key to a good prognosis is early intervention. With prescription chemotherapy, the prognosis for most individuals is good. However, according to Dr. Draper the later the patient receives a diagnosis and treatment, the longer the recovery time required. (ehow.com)

Prevention includes BCG vaccination as for all tuberculosis, improvement of socioeconomic conditions and prevention of HIV and AIDS. (http://www.patient.co.uk/doctor/Pott%27s-Disease-%28Spine%29.htm)