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CASE REPORT  
Year : 2013  |  Volume : 6  |  Issue : 5  |  Page : 575-577
Isolation and identification of Mycobacterium tuberculosis from pediatric patient having Pott's disease: Case report of two cases


Department of Microbiology, Smt Kashibai Navale Medical College and Hospital, Narhe Ambegaon, Pune, Maharashtra, India

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Date of Web Publication3-Jun-2014
 

   Abstract 

A 4-year-old young male child was investigated for spinal tuberculosis (TB) and Mycobacterium tuberculosis was isolated from the sample. In another case, a 2-year-old male patient with Potts spine, M. tuberculosis was isolated from the pus sample. In both cases, Bacillus Calmette-Guιrin (BCG) scar was absent. BCG vaccination may prevent bone TB.

Keywords: Extrapulmonary tuberculosis, Mycobacterium tuberculosis, Pott′s spine

How to cite this article:
Ghadage DP, Wankhade AB, Mali RJ, Bhore AV. Isolation and identification of Mycobacterium tuberculosis from pediatric patient having Pott's disease: Case report of two cases. Ann Trop Med Public Health 2013;6:575-7

How to cite this URL:
Ghadage DP, Wankhade AB, Mali RJ, Bhore AV. Isolation and identification of Mycobacterium tuberculosis from pediatric patient having Pott's disease: Case report of two cases. Ann Trop Med Public Health [serial online] 2013 [cited 2019 Jun 26];6:575-7. Available from: http://www.atmph.org/text.asp?2013/6/5/575/133747

   Introduction Top


Tuberculosis (TB) is a major public health problem in India, which contributes significantly to the morbidity and mortality. According to World Health Organization, one-third of world population is infected with TB. Global annual incidence of TB is 9.4 million cases. Annual incidence of TB in India is 1.98 million. Nearly 6-8% children die annually due to TB. [1]

Bacillus Calmette-Guérin (BCG) vaccine introduced in 1924 has not made the impact in prevention of TB that was expected, however it modifies the course of the disease. The coverage of BCG vaccination is still poor and childhood TB problem still prevails.

Pott's disease is the vertebral osteomyelitis due to Mycobacterium tuberculosis. This is the most common osteoarticular manifestation and it has the potential to cause serious morbidity, including permanent neurologic deficits and deformities. Osteomyelitis is also caused by atypical mycobacteria. It can be differentiated by culture of the specimen. Herewith, we are reporting two cases of Pott's spine in pediatric patients. Both these children in this study were not vaccinated for BCG. This case report focus on importance of BCG vaccination in prevention of bone TB in children.


   Case Reports Top


Case 1

This was a case report of a 4-year-old male child was presented with low grade fever and backache since 1 month. The patient was from lower socio-economic status. The parents were wonderer having seasonal stalls on street without having any permanent location. On examination of child, no BCG scar was found and when the mother asked about BCG vaccination, she was unknown about the vaccination. There was no past history of TB in this child and also no family history of TB. The clinical diagnosis was made as Pott's spine. Pus after the laminectomy from the site of lesion was received in the microbiology laboratory for culture and Zeihl-Neelsen (ZN) staining. Pus was yellowish and thick in consistency. Gram stain examination was performed and revealed plenty of pus cells with no organism. No growth was observed on aerobic culture. Samples were inoculated on Lowenstein-Jenson's slopes (LJ slopes) in duplicate. When the colonies appeared, the colonies were rough, tough and buff colored. Phenotypic tests to differentiate it from non-tuberculous mycobacteria (NTM) were carried out. Semi-quantitative catalase test was weakly positive, nitrate reductase test and Niacin test were positive. The organism was identified as M. tuberculosis. Sensitivity test for isoniazid (INH), rifampicin, ethambutol and streptomycin was put by proportion method and it was sensitive to all first line drugs used for treatment of TB.

Magnetic resonance imaging (MRI) scan of spine was done and revealed abnormal single intensity lesion involving T12, L1 and L2. Chest X-ray was found to Be normal. The complete blood count values were: Hemoglobin-10.5, white blood cell-7300 cu/mm, neutrophil-52%, lymphocyte-43%, monocyte-1%, eosinophill-4%, erythrocytic sedimentation rate (ESR) was raised and it was 42 mm (wintriness). Therapy with INH, rifampicin and pyrazinamide was started.

Case 2

Here we report a case of a 2-year-old male child presented with low grade fever and weight loss since 1 month. The patient was irritable. The mother was literate and had given history of complete national immunization scheduled along with BCG. However, the BCG scar was absent. In family, mother was having pulmonary TB and was on anti-tubercular drugs since 2 months. The clinical diagnosis was Pott's spine.

The pus sample was received in the microbiology laboratory for culture and ZN staining. Gram stain revealed plenty of pus cells with no organism. No growth was observed on aerobic culture. Sample was inoculated on LJ slopes in duplicate. The colonies observed were rough, tough and buff colored. Phenotypic tests to differentiate it from NTM were carried out. The organism was identified as M. tuberculosis. Sensitivity was done by proportion method for first line of drugs and it was sensitive to it. MRI spine revealed abnormal single intensity lesion involving L1 and L2. Chest X-ray was normal. Hemogram was normal except Hemoglobin, which was-9.5 g/dl and ESR was 50 mm (wintrobes). Therapy with INH, rifampicin and pyrazinamide was started.


   Discussion Top


TB world-wide accounts for 1.7 billion infections and 2 million deaths per year. Skeletal TB continues to be prevalent in countries where pulmonary TB is still extensive. [1] India is burdened with highest number of TB cases in the world. [1] Incidence of Pott's disease in developing countries is about 2% of total cases of TB and 40-50% cases are of Pott's disease of musculoskeletal TB. The disease was 1 st described in the medical literature by Dr. Percival Pott in England in 1779.

In the present study, both the patients were male and age less than 5 years. In previous study it was seen that Pott's disease affects males more than females. [3] In the USA, it affects mostly adults but in the countries where it is commonest it affects mostly children. Pott's disease is still a prevalent disease in developing countries, mainly in children. Gupta et al. (2009) [4] reported the more prevalence of TB in age group 0-4 years. The probable reason for this may be due to low resistance and malnutrition. In TB endemic countries, Pott's disease usually occurs in older children and young adults. [5]

Higher incidence of the extrapulmonary TB was seen in non-vaccinated children. [6] Low economic status and unawareness of vaccination still pose a problem for fighting with infection like TB in developing countries like India. BCG vaccination is protective against childhood forms of TB. This might be the reason of tuberculous lesions in both the unvaccinated pediatric patients. In the tribal population many of the children are non-immunized against TB.

Spinal TB can be confidently diagnosed by clinical and radiography tools. But in early phases, the clinical presentation and radiographic imaging are often non-specific. [6] ZN stain and culture will help in the definitive diagnosis and differentiating it from pyogenic osteomyelitis. However, the bacilli are sparse and smear and culture of pus or tissue are positive in half of cases.

Spinal tuberculoses are a result of hematogenous dissemination from primary focus in the lungs and lymph nodes. [4] in most of the pediatric patients, the source of infection remain unknown, which was observed in first case also in this study. [5]

Vertebral osteomyelitis due to NTM like Mycobacterium xenophi, Mycobacterium avium complex have been reported. [7] Mycobacteriological culture is helpful for diagnosis and establishment of treatment and is necessary for reducing morbidity and mortality due to TB.

To summaries, the above cases, Pott's disease is still a prevalent disease in developing countries, mainly in children. Poor economic status, malnutrition poor immunization coverage are the factors responsible for the extrapulmonary TB. Mycobacteriological culture is helpful for diagnosis and establishment of treatment and is necessary for good outcome.

 
   References Top

1.WHO. Global Tuberculosis Control: Survillance, Planning and Financing. WHO Report 2010. Geneva: WHO.  Back to cited text no. 1
    
2.Fitzgerald D, Hass DW. Mandell, Duglas and Bennett′s Priciple and practice of infectious diseases. 6 th Ed. Philadelphia: ELSEVIER CHURCHILL LIVINSTONE; 2005.  Back to cited text no. 2
    
3.Benzagmout M, Boujraf S, Chakour K, Chaoui Mel F. Pott′s disease in children. Surg Neurol Int 2011;2:1.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Kumar R. Spinal tuberculosis: With reference to the children of northern India. Childs Nerv Syst 2005;21:19-26.  Back to cited text no. 4
[PUBMED]    
5.Gupta R, Garg A, Venkateswara V, Kanitkar M. Spectrum of childhood tuberculosis in BCG vaccinated and unvaccinated children. Med J Armed Forces India 2009;65:305-7.  Back to cited text no. 5
    
6.Pulickal AS, Fernandez GV. Comparison of the prevalence of tuberculosis infection in BCG vaccinated versus nonvaccinated school age children. Indian Pediatr 2007;44:344-7.  Back to cited text no. 6
    
7.Petitjean G, Fluckiger U, Schären S, Laifer G. Vertebral osteomyelitis caused by non-tuberculous mycobacteria. Clin Microbiol Infect 2004;10:951-3.  Back to cited text no. 7
    

Top
Correspondence Address:
Archana Bhimrao Wankhade
Department of Microbiology, Smt Kashibai Navale Medical College and Hospital, STES Narhe Campus, Off Pune-Bangalore Westerly Bypass Highway, Narhe Ambegaon, Pune - 411 041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.133747

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