Early Detection and Analysis of Children with Multidrug-Resistant Tuberculosis of the Spine

Abstract

Study design: Retrospective case series.

Purpose: The aim of the study is to report the clinical characteristics, early diagnosis, management, and outcome of children with multidrug-resistant (MDR) tubercular spondylodiscitis and to assess the early detection of rifampicin resistance using the Xpert MTB/ RIF assay.

Overview of literature: MDR tuberculosis is on the rise, especially in developing countries. The incidence rate of MDR has been reported as 8.9% in children.

Methods: A retrospective study of children aged <15 years of age who were diagnosed and treated for MDR tuberculosis of the spine was conducted. Confirmed cases of MDR tuberculosis and patients who had completed at least 18 months of second-line antituberculous treatment (ATT) were included. Children were treated with ATT for 24 months according to drug-susceptibility-test results. Outcome measures included both clinical and radiological measures. Clinical measures included pain, neurological status, and return to school. Radiological measures included kyphosis correction and healing status.

Results: Six children with a mean age of 10 years were enrolled. The mean follow-up period was 12 months. All the children had previous history of treatment with first-line ATT, with an average of 13.6 months before presentation. Clinically, 50% (3/6 children) had psoas abscesses and 50% had spinal deformities. Radiologically, 50% (three of six children) had multicentric involvement. Three children underwent surgical decompression; two needed posterior stabilization with pedicle screws posteriorly followed by anterior column reconstruction. Early diagnosis of MDR was achieved in 83.3% (five of six children) with Xpert MTB/RIF assay. A total of 83.3% of the children were cured of the disease.

Conclusions: Xpert MTB/RIF assay confers the advantage of early detection, with initiation of MDR drugs within an average of 10.5 days from presentation. The cost of second-line ATT drugs was 30 times higher than that of first-line ATT.

Keywords: Diagnosis; Multiple drug resistance; Treatment; Tuberculosis; Xpert MTB/RIF assay.

Fig. 1.

(A) Plain radiograph lateral view of the spine showing involvement of the T1–T4 and T9–T11 spine with 57° and 26° of kyphosis, respectively. (B) T2 weighted sagittal MRI showing significant prevertebral abscess extending up to the T4 vertebra and significant cord compression at T2–T4. (C) T1 weighted sagittal MRI demonstrating involvement of T9–T11 vertebrae with pathological subluxation of the vertebra. MRI, magnetic resonance imaging; TB, tuberculosis; ASIA, American Spinal Injury Association.

Fig. 2.

(A) Immediate postoperative plain radiograph lateral view showing with pedicle screws and fusion with anterior cage and cancellous bone graft. (B) Two-year follow-up plain radiograph lateral view with significant improvement in kyphosis angle of 20° and 10° at T1–T4 and T9–T11 spine, respectively. (C) T2-weighted sagittal MRI image at 2-year follow-up with near-total resolution of the prevertebral and epidural abscess. MRI, magnetic reso- MRI, magnetic reso magnetic resonance imaging; ASIA, American Spinal Injury Association.