Multi-Drug Resistance Tuberculosis Spondylitis

Presentation
on
MDR-TB Spondylitis
Presented by:
Sandip Baniya
B.Sc. Biotechnology
VIII Semester
SANDIPBANIYA41@GMAIL.COM 1

History

Introduction
Caused by germs which spreads through air, (M. Tuberculosis
and its sub species, (mycoti, bovis, africanum).
It usually effects lungs(pulmonary TB) but it also effects other
body parts such as brain, kidneys, or the spine(extra pulmonary
TB).
The incident of tuberculosis is highest in among the adults.
It is one of the topmost researched topic today,.

How deadliest is
Tuberculosis?
Source: Global tuberculosis report 2019

Epidemiology
TB is world’s most deadly infectious disease(WHO) killing more
than 3 millions of lives per year by 2019,
One third of world’s population is supposed to infected with
Tuberculosis Bacillus,
Extra pulmonary TB is observed in 15-20% of the whole TB cases;
Skeletal TB comprises about 10% of those cases,
Among skeletal TB 50% and more cases accounts for TB
Spondylitis,
And recent study shows that 5000 cases in global TB Spondylitis
are Multi Drug Resistance Type,

Cont.
Countries such as India, China, and South Africa has reported a
higher trouble in TB including Nepal,
MDR-TB spondylitis is found to be due to the evolutionary
resistance from the precedent treatment method, or can be due
to the direct transmission from the patient with MDR-TB,
31,664 registered population in Nepal by 2017/18. TB 46%
cured, 45% complete treatment, 1% resistance, 3% died 2% lost to
follow up and 2% were not evaluated, [Nepalntp.gov.np. (2020)].

Source: Goni, Baba Waru et al. “Extrapulmonary TB in North Eastern Nigeria: A 10-Year Retrospective Review.” (2016).

Tuberculosis Spondylitis
Fig: MRI image of Lumbar Spine
© 2015 KAMMS. Korean Acupuncture & Moxibustion Medicine Society
 It is also known
as Pott disease,
 Spine is the
preferred region
for infection,
 The common
symptom are
back pain and
lower limb
weakness or
paraplegia

Bacilli through blood stream
reach Disc Space
Pathogenesis of TB Spondylitis
Step 1

Step 2
Once infected, Nuclear center and fibrous
annular wall weakens, decays and collapse
This leads the Disc squeezing down on
neve root causing sever pain,

Step 3
 Then the infection spreads in
surrounding vertebral bodies
via above and below the disc.

Step 4
The bone becomes so weak that it has high
possibility to be collapsed under the weight
of human body.

Step 5
Now the distorted Spinal column
compresses Spinal Cord producing
functional weakening.

Step 6
Over time, the deformed vertebrae heal
and get fused,
This results compress in nerve roots
causing pain and neurological
deficit(Kyphosis/hunchback).

Regional Distribution of TB
Spondylitis
Cervical-12%
Cervico-Dorsal-5%
Dorsal-42%
Dorsolumbar-12%
lumbar-26%
lumbosacaral-3%
Cervical spine
Thoracic spine
Lumbar spine
Sacrum and coccyx

MULTIDRUG Resistance
o General definition for MDR is “resistance to more than two
antimicrobial agent.”
o In another words, resistance to the available drugs against the
pathogen,
o Irregular Medication, Therapy and bad health practice by a
patient is supposed to develop the MDR cases in case of TB
Spondylitis,

Resistance Pattern
4.1% of new TB patients have multi drug resistance tuberculosis
as per the latest update in 2017,
Drug resistance pattern is more in developing countries, india
has reported to have 2.8% of new multidrug resistance cases,
The prevalence of Multi-drug resistance in Indian region was
found to be 3.7% and extreme drug resistance tuberculosis was
found to be 0.4%,

How does an antibiotics works?
Source: flickr.com/photos/niaid/26516255486/
Fig: Mechanisms of action of TB drugs under development.

Characterization of Medicine according to WHO
First-line Anti-TB
Drug
 Ethambutol
 Isoniazid
 Pyrazinamide
 Rifampicin
 Streptomycin
Second-line Anti-
TB Drug
 Aminoglycosides
 Polypeptides
 Fluoroquinolone
s
 Cycloserine
 Terizidone
Third-line Anti-TB
Drug
 Rifabutin
 Linezolid
 Thioacetazone

Graph showing Patients
Resistance to the Drugs for TB

Diagnosis
 Classical symptoms of pulmonary TB such as cough, hemoptysis,
fever, weight loss, and night sweats,
TB spondylitis may present with chronic back pain, typically for
more than 3 months, local kyphosis, and a neurologic deficit, i.e.,
bowel or bladder incontinence, lower extremity weakness, sensory
deficits, or paraplegia
Imaging is recommended, of the entire spine in patients with TB
spondylitis; preferably a whole spine sagittal magnetic resonance
imaging (MRI)

Medical Management
 Drug Susceptibility Testing (DST) based treatment,
 the first-line drugs for TB, ethambutol and pyrazinamide can be
used after DST is conducted, and M. tuberculosis is found to be
susceptible to these drugs,
Ethambutol susceptibility should be confirmed with this
technique whenever resistance to isoniazid or rifampin is noted,
Moxifloxacin should be added for its excellent bone penetration,
possibly better in vitro activity,
Linezolid has recently been identified by the WHO as a core drug,
and its excellent bone penetration should be considered for
inclusion in the treatment regimen

Treatment
Fig: Success rate of Tuberculosis treatment in 2019(WHO)

Treatment
Chemotherapy Bed Rest Spinal Braces
Fig: Treatment of Tuberculosis Spondylitis Patient.

Is it necessary in Nepal to
study about MDR TB
Spondylitis?

Live case Found in Nepal
Pus
Accumulation
Fig: MRI of the Lumbo-Sacral Spine
Source: Jeebanta Advanced Kathmandu Imaging Pvt. Ltd.

Fig; Molecular line probe assay for identification of M. Tuberculosis complex
and its resistance to fluoroquinolone & aminoglycosides.
Source: National Anti-Tuberculosis Association (GENETUP)

Reference
1. Hershkovitz I, Donoghue HD, Minnikin DE, Besra GS, Lee OY, Gernaey AM, et al. Detection and molecular
characterization of 9,000-year-old Mycobacterium tuberculosis from a Neolithic settlement in the Eastern
Mediterranean. PLoS One. 2008;3:e3426. [PMC free article] [PubMed] [Google Scholar]
2. Arriaza BT, Salo W, Aufderheide AC, Holcomb TA. Pre-Columbian tuberculosis in Northern Chile:
Molecular and skeletal evidence. Am J Phys Anthropol. 1995;98:37–45. [PubMed] [Google Scholar
3. Polley P, Dunn R. Noncontiguous spinal tuberculosis: Incidence and management. Eur Spine J.
2009;18:1096–101. [PMC free article] [PubMed] [Google Scholar]
4. Moon MS. Tuberculosis of the spine. Controversies and a new challenge. Spine (Phila Pa 1976)
1997;22:1791–7. [PubMed] [Google Scholar]
5. Held M, Laubscher M, Zar HJ, Dunn RN. GeneXpert polymerase chain reaction for spinal tuberculosis: An
accurate and rapid diagnostic test. Bone Joint J. 2014;96-B:1366–9. [PubMed] [Google Scholar]
6. WHO. WHO treatment guidelines for drug-resistant tuberculosis. Geneva: WHO Press; 2016. [Google
Scholar]
7. World Health Organization. (2020). Global tuberculosis report. [online] Available at:
https://www.who.int/tb/publications/global_report/en/ [Accessed 26 Jan. 2020].
8. Goni, Baba Waru et al. “Extrapulmonary TB in North Eastern Nigeria: A 10-Year Retrospective Review.”
(2016).

Thank
You!

Multi-Drug Resistance Tuberculosis Spondylitis

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