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A 19-year-old male with HIV presents with increasing neck pain, lower extremity weakness, and constitutional symptoms over the past 4 weeks. Radiograph and MRI is shown in Figures A and B, respectively. Figure C shows a histologic specimen with Ziehl-Neelsen staining. In addition to surgical management, which of the following pharmacologic regimens is most appropriate?
Cyclophosphamide, hydroxydanurubicin, oncovin, and prednisone
Nafcillin and rifampin
Isoniazid, rifampin, pyrazinamide, and streptomycin
Denosumab, ritonavir, and efavirenz
Vincristine, actinomycin D, and cyclophosphamide
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The clinical scenario is consistent with tuberculoid infestation in the spine (Pott’s disease) with resulting compressive cervical myelopathy. Tuberculous infection often shows vertebral destruction with relative preservation of the disk spaces. As the infection progresses, the disk is also destroyed and a kyphotic deformity may be present. The Ziehl-Neelsen stain displays the mycobacterium as "red snappers" against a blue background. Culture for acid-fast bacilli on Lowenstein-Jensen medium is diagnostic. Because this patient has a progressive neurologic deficit with radiographic evidence of cord compression, surgical decompression followed by pharmacologic therapy is indicated. Isoniazid, rifampin, pyrazinamide, and streptomycin is the first line of medical therapy.
Khoo et al note that since “HIV-related tuberculosis demonstrates exceptionally high rates of spinal involvement, the prevalence of Pott disease will continue to increase rapidly across the globe over the next decade.” They also note that medical treatment alone remains the cornerstone of therapy for the majority of Pott's disease cases, and surgical intervention should be limited primarily to cases of severe or progressive deformity and/or neurological deficit.
Khoo LT, Mikawa K, Fessler RG
Spine J. 2003 Mar-Apr;3(2):130-45. PMID: 14589227 (Link to Abstract)
Khoo, SPINEJ 2003
HPI - Insidious onset gradually progressive spasticity of lower limbs since 6 years. associated weakness on lt lower limb. decreased sensation below xiphisternum.
How would you treat this patient as a FIRST LINE of treatment?
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HPI - Patient under Anti Tubercular drugs for last 14 months.
After 6 months of Category 1 treatment for New Pulmonary TB, he again had sputum positive. This was drug resistance. So he was on DR TB treatment for last 8 months.
He developed weakness of limbs for last 2 months.
But weakness is more on upper limbs than lower limbs.
How would you treat this TB patient with progressive weakness?