pott spine/ spine tb

[pawanj]

my son nikhil jindal aged 20 years had neck pain and stiffness abt a month back followed by fever (100 to 101.6) after 3-4 days of neck pain started.
on 26 mar he was put on topcef 200mg 2 tabs a day for 3 days all medicines were given to patient
on 27 mar his blood was tested and report was as under
TLC 12,600,
DLC- NEUTROPHILS 69.2, LYMPHOCYTES 21.3, MONOCYTES 7.8, EOSINOPHILS 1.1, BASOPHILS 0.6
ESR(WESTREGEN'S) 102
S.G.P.T.(A.L.T.) 31.23
WIDAL TEST WAS NEGATIVE
BASED ON ABOVE TESTS DOCTOR SUGGESTED FOR CHEST X RAY
0n 29 mar he was put on topcef 200mg tab mobizox for another 3 days all medicine wr given to patient
x ray report of chest  was normal
but still fever (99 to 101) and pain continues
doctor suggested x ray cervical spine on 29 mar
report was as under
straightening of spine is seen with loss of normal curvature suggestive of muscle spasm
irregularity of articular surface of c5 seen
prevertebral soft tissue thickening is seen
cystic lesion seen anteriorly at body of c6
disc spaces are normal
no cervical rib is seen
ADVISED - MRI CERVICAL SPINE
DOCTOR REFERRED THE PATIENT TO ORTHOPEDIC BASED ON ABOVE REPORT
ortho doc put on the following treatment
inj monocef 1gm I.V - BD
inj Acenac MR  1 BD
these injections were injected for 5 days
doctor suggested for MRI cervical spine
report dated 05 apr his test report was as under
there is straightening of cervical spine
cervicodorsal vertebral bodies from c2 to d4 level reveal focal or diffuse marrow signal intensity alterations hypointense on T1W1 and hyperintense on STIR images, suggestive of marrow edema/inflation. marrow edema is most marked in c6 vertabral bodies.
large prevertabral abscess is seen in cirvicodosral region displaying hypo to isointense signals on T2W1. abscess is predominantly seen on the left side of midline involving preverbtal muscles with mild extensions on right side in right preverbtal muscles.
cranially it is extending upto c2 verteba and caudally till d4 in posterior aspect of superior mediastium. abscess is also seen to extending into left c5-6 and c6-7 neural foramina with mild posterolateral wall of oropharynx and upper esophagus.
CSF shows normal signal intensity. cord shows normal morphology and signal.
CV junction is normal.
IMPRESSION - MR imaging features aree suggeastive of infective spondylitis with large pre vertebal abscess from c2 to d4 and mild epidural extension at c6 level.
Etiology - likely tubercular
his blood test report dated 06 apr was as under
TLC 10,600
DLC- NEUTROPHILS 68.4, LYMPHOCYTES 22.1, MONOCYTES 7.6, EOSINOPHILS 1.4, BASOPHILS 0.5
ESR(WESTREGEN'S) 110
S.G.P.T.(A.L.T.) 48.57
TSH- 2.020
BASED ON ABOVE INVESTIGATIONS and his continue temp (99 to 100) and neck pain
doctor put him on
AKT 4 1 kit in morning
oflaxin 1 OD 400 mg
tab liv 52 2tabs BD
a second opinion was taken and it was suggested that patient is suffering from pott spine( cervical spine)
and he put on
AKT 4 daily for 1 month
tab pyridoxine 10 mg daily for 1 month
philadiflion collar(MGRM)
also complete bed rest was advised
the patient started taking AKT4 and pyridoxine from 06 apr as par above suggestion

another opinion was taken and it was suggested
to start phase I
rest in bed for 22 hrs for 1 and half month
tab Rcinex 300+600 mg daily in morning
tab oflox 400 mg daily in morning

shelcal-1
cobadex-1
ciplection 1
all above for 5 monthes
somi brace to be worn by pateint

kindly suggest if it is 100% sure that my son is infected with pott spine
or any other test is reqd to be done for confirmation
i want to give treatment after only 100% confirmation of the disease and not in doubt pls
how can it be confirmed
3 doctors have suggested 3 types of treatment although all 3 diagnosed same disease and other one suggested for COTS
sir, i m in total confusion
kindly advice which medicine is the best in india for pott spine
an advice from an expert doctor like u will be a real help to humankind
regards
10 apr 10
pawanj

[Dr Vinod]

Hello!

As there is fever he is being given other antibiotics like Ofloxacillin suspecting infection.

Chronic fever with spine problems is suggestive of Tuberculosis and which is called Potts spine. ESR is also high, go for Mantoux test.

You can go to the nearest DOTS centre (Tuberculosis department is present in every district hospital of India) to get him checked again and to take a final opinion and till then continue medications.

Continue AKT4 with vitamin pyridoxine and see if his fever subsides and see for any improvement in his spine which you will know in 1- 2 months. Give him calcium and protein supplements and also proper protein rich diet and milk regularly.

Take care!

[pawanj]

dear doctor sir
thanx a lot for ur valuable guidance
r u an ortho??

may i request u to kindly atleast suggest me which option i opt for the treatment of TB
right now he is on option 2, do he really need complete bed rest, what precautions he need to take, what sud he eat and wat not, any other care/advice pls
option 1
AKT 4 1 kit in morning
oflaxin 1 OD 400 mg
tab liv 52 2tabs BD

option 2
AKT 4 daily for 1 month
tab pyridoxine 10 mg daily for 1 month
philadiflion collar(MGRM)
also complete bed rest was advised

option 3
rest in bed for 22 hrs for 1 and half month
tab Rcinex 300+600 mg daily in morning
tab oflox 400 mg daily in morning

shelcal-1
cobadex-1
ciplection 1
all above for 5 monthes
somi brace to be worn by pateint

option 4
DOTS

[Dr Vinod]

Hello!

AKT4 is the drug what he needs. (Isoniazid, rifampicin, pyrizinamine and ethambutol for 2 months and followed by isoniazid and rifampicin for 6-7 months.

Ofloxacillin for me is not necessary. He can take Liv52 to protect his liver as these antibiotics will have some side effects on liver. Pyridoxine is again a vitamin which is required.

He has to wear a brace or support and also give him bed rest for a month and slowly with proper protein diet and calcium and protein supplements he can start moving.

Follow up with one orthopedician and do not take multiple suggestions.

Take only one second opinion and it is good if you can go to the nearest district tuberculosis center.

Take care!

[pawanj]

really a gr8 helping guidance
u have removed my all doubts
i never expected this correct advice
thanx from my heart
what are the protein rich diets for vegs

[Dr Vinod]

Hello!

Vegetarians are restricted to milk and eggs if he takes them for good protein.

Other than milk and eggs he can have: all types of lentils (dals), sprouts, soya chunks, tofu, milk products (cheese, curds etc).

He can eat Threptin (protein) biscuits and also add protein powders in milk and drink regularly.

Take care!

[pawanj]

my son is on AKT4 for last 2 weeks. it appears that thr is no improvement.
how we can come to know that improvement is taking place. what changes we can expect in the patient from which we can make out sm improvements and we are on the right track. one senior doctor has advised to change to
Tab R-Cinex 300 mg + 600 mg – 1 OD – 2 months (before breakfast)
Tan Ethambutol – 800mg – 1OD – 2 months (Afternoon )
Tab. Pyraziharide 750mg –1-0-1 - 2 months
Tab. Pyridoxine 20mg – 1OD – 2 months
Tab. Hifenac 100mg – 7-10 days – 1-0-1
Repeat ESR, LFT
Phildelhia Cervical Collar
what u suggest
kindly advice us on the above

[Dr Vinod]

Hello!

AKT 4 is same as the present medications, only some dose adjustments. I already confirmed to you that he needs 4 drugs isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months and followed by isoniazid and rifampicin for further 6 months for his Tuberculosis.

Regular follow up and protein diet has already been discussed with you.

Follow your senior physician's advice and believe in his diagnosis and treatment and give some time. If it is tuberculosis it will respond for sure!

Take care!

[pawanj]

dear dr vinod
how r u
as advised by u i got the tests repeat on 28 apr i am forwarding you the reports of my son nikhil
before the start of treatment of AKT4, live 52, pyridoxine 10 mg and  after 3 weeks of treatment
pls study these reports and give ur valuable advice
reports dtd 06 apr 2010 before AKT4

HAEMATOLOGY
Haematology performed on Fully Automatic 5 part differential COULTER Haematology Analyzer
Investigation Result Unit Reference Range

Haemogram
Haemoglobin. : 13.1 g/dl M : 13 - 18 g/dl
F : 11.5 - 16.5 g/dl

TLC . : 10,600 /c.mm. A : 4000 - 11000 /c.mm.

DLC.
Neutrophils : 68.4 % A : 50 - 80 %
Lymphocytes : 22.1 % A : 25 - 50 %
Monocytes : 7.6 % A : 2 - 10 %
Eosinophils : 1.4 % A : < 6 %
Basophils : 0.5 % A : < 2 %
E.S.R. (Westregen's) : 110 mm/1st Hr F : < 20 mm/1st Hr
M : < 15 mm/1st Hr

R.B.C. Count. : 4.66 mil./cmm M : 4.5 - 6.5 mil./cmm
F : 3.8 - 5.8 mil. /cmm

Packed Cell Volume : 40.2 % M : 40 - 54 %
F : 37 - 47 %

Platelets Count. : 343 thousand/cmm A : 150 - 450 thousand/cmm
M.C.V : 86 fl A : 76 - 96 fl
M.C.H : 28.2 pg. A : 27 - 32 pg.
M.C.H.C : 32.7 % A : 30 - 35 %
RDW : 11.6 % A : 11.6 - 14 %
Peripheral Blood Smear :
RBCs are normocytic normochromic. No significant anisopoikilocytosis is seen.
WBC series is normal in number & distribution. Platelets are adequate. No
haemo-parasite is seen. No abnormal / immature cell is seen

BIO-CHEMISTRY REPORT
Biochemistry tests performed on Fully Automatic ROCHE COBAS 400 INTEGRA & HITACHI 902 / Semi Auto RA-50
/ AVL 9180 / D-10
Investigation Result Unit Reference Range
B. Glucose Fasting. : 78.69 mg/dl A : 70 - 110 mg/dl

Liver Function Test
S. Bilirubin (Total) : 0.32 mg/dL A : < 1 mg/dL


---------------------------------------------------------------------------------------------------
S. Bilirubin (Conjugated) : 0.12 mg/dL A : < 0.6 mg/dL


S. Bilirubin (Unconjugated) : 0.20 mg/dL A : 0.1 - 1 mg/dL
S.G.O.T.(A.S.T) : 20.41 U/L


S.G.P.T.(A.L.T ) : 48.57 U/L

S. Alkaline Phosphatase : 74.77 U/L


S. Protein. : 8.60 gm/dL A : 6.6 - 8.7 gm/dL
S. Albumin : 4.01 gm/dL A : 3.5 - 5.2 gm/dL
S. Globulin : 4.59 gm/dl
A/G. Ratio : 0.87 : 1

  
HORMONES ANALYSIS REPORT
HORMONE ANALYSIS DONE ON COBAS e411 ELECTRO CHEMILUMINESCENCE & ABBOTT AXSYM SYSTEMS
Investigation Result Unit Reference Range
S. TSH : 2.020 uIU/ml A : 0.27 - 4.2 uIU/ml

reports dtd 28 apr 2010 after 3 weeks of treatment

HAEMATOLOGY
Haematology performed on Fully Automatic 5 part differential COULTER Haematology Analyzer
Investigation Result Unit Reference Range

Haemogram
Haemoglobin. : 14.7 g/dl M : 13 - 18 g/dl
F : 11.5 - 16.5 g/dl

TLC . : 8,300 /c.mm. A : 4000 - 11000 /c.mm.



Differential Leucocyte count
Neutrophils : 57.7 % A : 50 - 80 %
Lymphocytes : 31.7 % A : 25 - 50 %
Monocytes : 7.0 % A : 2 - 10 %
Eosinophils : 3.0 % A : < 6 %
Basophils : 0.6 % A : < 2 %
E.S.R. (Westregen's) : 45 mm/1st Hr

RBC Count                                         5.29
Packed Cell Volume (Hematocrit) : 42.7 %

Platelets Count. : 217 thousand/cmm A : 150 - 450 thousand/cmm
M.C.V : 81 fl A : 76 - 96 fl
M.C.H : 27.9 pg. A : 27 - 32 pg.
M.C.H.C : 34.5 % A : 30 - 35 %
RDW : 13.9 % A : 11.6 - 14 %
Peripheral Blood Smear :
RBCs are normocytic normochromic. No significant anisopoikilocytosis is seen.

BIO-CHEMISTRY REPORT
Biochemistry tests performed on Fully Automatic ROCHE COBAS 400 INTEGRA & HITACHI 902 / Semi Auto RA-50
/ AVL 9180 / D-10
Investigation Result Unit Reference Range
B. Glucose Fasting. : 75.46 mg/dl A : 70 - 110 mg/dl

Liver Function Test
S. Bilirubin (Total) : 0.22 mg/dL A : < 1 mg/dL

S. Bilirubin (Conjugated) : 0.10 mg/dL A : < 0.6 mg/dL

S. Bilirubin (Unconjugated) : 0.12 mg/dL A : 0.1 - 1 mg/dL
S.G.O.T.(A.S.T) : 32.47 U/L M : < 40 U/L


S.G.P.T.(A.L.T ) : 75.94 U/L M : < 41 U/L
S. Alkaline Phosphatase : 72.14 U/L M : 40 - 129 U/L
S. Protein. : 8.40 gm/dL A : 6.6 - 8.7 gm/dL
S. Albumin : 4.74 gm/dL A : 3.5 - 5.2 gm/dL
S. Globulin : 3.65 gm/dl
A/G. Ratio : 1.30 : 1

Investigation Result
S. TSH : 3.520

regards
rajni jindal 9811035568

[pawanj]

pls also give ur specific advice on raised value of SGPT(ALT)- 75.94
wat are its reasons, repercussions on lever and its remedies
do u suggest any change in medicine due to the raised value

[Dr Vinod]

Hello!

All the medications he is taking are metabolized in the liver, nothing to worry as his serum bilirubin values are normal.

Give him LIV 52 and Pyridoxine supplements and only go for some rational tests in the future. Monitor his X-rays, ESR which are sufficient.

Take care!

[pawanj]

thanx a lot sir
i have few more doubts
kindly give ur views
1.isnt sudden fall of ESR to 45 from 110 within three weeks is noticable?
2.or it may happen?
3.what is the relation  of ESR to AKT4?
4.in the report before AKT4 started the Lymphocytes was 22.1(less) but in latest report it is 31.7(within limits). is improvement due to AKT4 medicine?
5.now SGPT(ALT) wl come down or it may rise further?
6.what are the future complications on the health of lever after the AKT 4 course is completed?
7.since akt4 was started, 10 ml (2 times a day)of liv 52 and Pyridoxine 10 mg a day is being given to him. do u suggest any change in it?
8.even than akt4 can effect the liver?
9.can we go for MRI in place of X Rays?
10.is MRI more harmful than X Ray? or X Ray is more harmful?
11.what is the periodicity we go for X Rays/MRI and ESR tests?
sir, i really appreciate ur prompt and very correct response. this is really a human service u r doing to the patients
regards

[Dr Vinod]

Hello!

I will answer only relevant questions for your son.

1) ESR denotes his infection with Tuberculosis, but this is not as specific as X-rays.

3) AKT4 is a 4 drug antibiotic which kills the tuberculosis bacteria so all this improvement.

4) Lymphocyte level coming to normal is a good sign

5) SGPT may stabilize and ultimately come to normal if there are no further complications with respect to his liver.

6) Liver is a highly regenerative organ and it can withstand these antibiotics course and after 2-3 months he will only take isoniazid and rifampicin so the load will decrease.

7) Continue the same dose of LIV52 and Pyridoxine.

9) X-rays are enough and you can go for them every month for initial 2 months and then after 3 months. Furthermore 3 X-rays are enough.

10) Let his doctor suggest if he needs anything extra.

Take care!

[pawanj]

sir, again thanx a lot for ur valuable advice
as u r aware that my son is on AKT4 since 06 Apr 2010.
i want to share with you his fever chart
before the start of AKT 4 - 99 to 102
after 06 apr i.e. start of akt4 - 98.4 to 101)although most of the time it was 98.4 to 99.2)but was normal during day time i.e. before 7pm
now for last days his fever is also in day time- 98.8 to 99.4
where is his esr has come down
pls advice if it is a matter to worry due to his temp remaining whole day for last 2 days bcs there is no change in medicine or other activities
do u suggest any test in view of this to find out the cause
regards

[Dr Vinod]

Hello!

Give him paracetamol for increase in temperature above 98.6 degree Fahrenheit. If the fever does not subside it can be due to some other infection like cold or malaria also for which you would need blood tests if this continues beyond 2-3 days or if he has high fever or you can just wait if it is a low grade fever.

Take care!

[pawanj]

today again he has fever whole day. at 11am it was 99, at 3pm 99.6, at 6pm it was 100 and at 9 pm it was 100.2
prior to these 3 days he had fever only after 7pm and that too around 99
is it possible that tb has now become resistant to akt4 thats y his fever has risen due to rise in infection
i read smwhere on internet that if wt is more than 50 kg rimaficin 600 sud be given
wt of my son is 68kg
can he be moved to r cinex 600 now alongwith oflox?
wl  change to medicine at this stage may have some adverse effect?

[pawanj]

i like to mention here that R cinex 600+300 and oflox was prescribed by Dr S M Tuli on 09 apr 2010 who is considered to be best in delhi for pott spine
but we continued with akt4 on ur advice
kindly give ur valuable advice

[Dr Vinod]

Hello!

I only commented on the ofloxacilin which is not normally prescribed in India without detecting resistance to tuberculosis.

I wanted you to give your son 4 drugs as is prescribed and accepted by every district TB association in India for non resistant tuberculosis. If he develops resistance then atleast he will have 2nd line TB drugs.

I am confirming you the dosage for more than 50kg body weight: Isoniazid 300mg, Rifampicin 600mg, pyrazinamide 1500mg, Ethambutol 1000mg.

I would again suggest you to visit the nearest district tuberculosis center where you will get all the medications (free) and also a second opinion.

THE DOSES HAVE TO BE TITRATED BY THE TREATING PHYSICIAN.

He can take extra dosage other than AKT4 after his treating physician suggests.

Are you following up with any TB specialist, orthopedician in Delhi regularly?

Take care!

[indu_mm]

Dear sir, i am 22yrs/f spinal tb patient. ''how long it take to cure?'' my doctor says 2mnth bed rest (Bed rest is like a hell) and i am taking Atk-4, multi vitamin capsule 2 times per a day, a calciun capsule 1 per day. my e.s.r is 28. one and half mnth is over but still the pain is there..

[pawanj]

wat is ur body wt?
is ur pain severe?
have ur doctor given u some support system for ur spine?
which part of ur spine is effected?
wat ws esr initially?

[indu_mm]

hello sir,6mnths i am suffering frm back pain.When march 18th 2010 its recognise as a spine TB at that time my weight is 49kg.Now my wt 57k.  yes doctor given me a belt,that support when i walk n sits.and my pain is better than before.

[indu_mm]

hello sir,6mnths i am suffering frm back pain.When march 18th 2010 its recognise as a spine TB at that time my weight is 49kg.Now my wt 57k.  yes doctor given me a belt,that support when i walk n sits.and my pain is better than before.

[indu_mm]

at 1st my esr is 26 then is comes 28. after 1mnth the pain is same.i told this to doctor, he given me calcium capsule and says the bone becomes soft no knws when it bends or brks.aftr using  calcium capsule with atk4,multivitamin capsule. i feel much better.

[indu_mm]

i have one doubt, when i am start to using atk4 tablet i feel much 'hunger' i dnt knw for why? How is ur son sir?

[pawanj]

dear indu
it is better sign that u r feeling hunger now it means that u r recovering from TB
wat is ur fever chart?
when u tested ur ESR 1st time and what was the value