The patient is a 75-year-old woman presenting with three months of worsening back pain and unintentional weight loss of one stone over two months. Examination revealed tenderness over the lumbar region and right hip. MRI images showed large abscesses in the lumbar and thoracic regions of the spine. Tests confirmed active tuberculosis infection, which was treated with quadruple antibiotic therapy along with analgesics, steroids, and diet management. Pott's disease, a form of spinal tuberculosis, was diagnosed as the cause of the patient's symptoms.

1. A lady presenting with
back pain and weight loss
By Francesca Flohr and Thom O’Neill

2. “Mrs D is a 75 year old, previously well lady
presenting with three month hx of back pain
and weight loss…”
S – lumbar region
O – gradual, worsening. No trauma
C – sharp
R – no radiation or shooting pains in legs
A – no paraesthesia, no urinary/bowel symps
T – throughout day, wakes at night
E – relieved by paracetamol and lying still
S – has become severe
One stone unintentional weight loss over two
months
Systematic review revealed some dysphagia
(otherwise unremarkable)
No recent travel

3. PMHx:
Oesophageal stricture – balloon
dilatation 2012
# L tibia
Drug Hx:
Paracemtamol
(NKDA)
FHx:
Nil (specifically no malignancy or back
problems)
SHx:
Recently relocated from Glasgow to
Brighton
Lives alone (house with stairs)
Never smoked
Does not drink alcohol

4. Observations: stable, afebrile, in pain
No lymphadenopathy
Cardiovascular: HS I+II+0
Respiratory: Reduced air entry bilaterally
Neurological: Able to straight leg raise.
Power, sensation, tone and reflexes all
normal. No clonus.
Abdomen: SNT, no organomegally. BS
heard
Back: Tenderness over lumbar region and
right hip
No skin changes

5. Differential Diagnoses
The Surgical Seive Gauntlet
Malignancy
Systemic causes:
Infection (vertebral
discitis/osteomyelitis/spinal abscess)
Connective tissue disease
Mechanical causes:
Compression fracture
Lumber muscle strain
Degenerative
Disc prolapse
Referred causes:
AAA, renal colic

6. Investigations
AFB + in paraspinal abscess, -ve in
sputum and CSF
MRI spine
HIV negative
CT head

7. MRI images would
go here – removed
for public sharing of
slides.
Images showed large abscesses in
lumbar and thoracic regions of
spine with some impingement on
spinal cord.

8. Quadruple Therapy
Rifampicin
Isoniazed
Ethambutol
Pyrazinamide
Plus:
Analgesia
Steroids
Urgent Ortho r/v
MDT discussion
TB Nurse
Contact Tracing
Dietician (NG Tube + Vit D)
Daily neurological re-assessment

9. Some Extrapulmonary
manigestations of TB
Pott’s disease
Tuberculous Meningitis
Rasmussen’s aneurysm (pulm a.
erosion)
history of TB (Abridged)
Evidence of TB infection from ancient
Egyptian mummies
Folklore associates TB with vampires
Bacillus discovered by Robert Koch
Infected poor put in ‘sanatoria’

10. Scrofula
Scrofula is cervical tuberculous
lymphadenopathy
The term King’s Evil refers to the
fact that it was firmly believed that
scrofula could be cured simply by
the touch of the reigning monarch
This superstition persisted from
the 11th century up until the 18th
century
It has several mentions in the
works of Shakespeare, one of
which occurs in Macbeth

11. The earliest unambiguous
detection of M. tuberculosis
involves evidence of the disease in
the remains of bison dated to
approximately 17,000 years ago

12. Skeletal remains show
prehistoric humans (4000
BC) had TB, and
researchers have found
tubercular decay in the
spines of Egyptian
mummies dating from
3000–2400 BC

13. Red Flag
Symptoms
Trauma (absence of)
Unexplained weight loss
Neurological signs
Age > 50
Fever
IVDU
Steroids for a long time
History of malignancy

14. Any questions?

15. After taking a full history, the The Man With The X-Ray Eyes
The Hunchback of Doctor must Carry On to the can see right through you.
Notre-Dame was said to examination.
have had Pott’s disease.
Bill and Ted travel in history The surgical seive is Rifampicin turns tears
and also met Socrates. somewhat of a Gauntlet to Orange. Alternate poster
run to get to differential could be Tarantino’s Four
diagnoses. Rooms, to highlight
Quadruple Therapy.
Frankenstein’s monster was a
kind of mummy, which have
been found with TB. Folklore
The patient moved from Holmes loved investigating associates vampires with TB as
Glasgow to Brighton. Richard and looking for fine details, households would slowly drain
Attenborough owned a large like an MRI does. away and die as TB spread. Mad
estate in Scotland. Doctor could have TB
Meningitis. Hunchback had
Pott’s. Wolfman odd one out –
hypertrichosis.

16. The King’s Evil is mentioned Red flags featured in the
throughout Shakespear’s Scarlet Pimpernel, as they
work, including in Macbeth were a symbol of rebel
by Malcolm. It was thought resistence during the French
the King could cure Scrofula Revolution.
(TB lymphadenopathy)by
presenting the inflicted with
a gold coin.
Earliest trace of TB found in Well, I don’t want anyone
American Bison from around asking me anythign about TB
17000 years ago. No now do I?
evidence yet as to weather
this strain was zoonotic and
spread to humans.
Patient details,
Earliest evidence of TB in demographics and non-
humans were in ancient
Egyptian mummies. essential points all
changed and MRI images
removed for annonymity.