Kristensen, Kristina Langholz

Podlekareva, Daria

Ravn, Pernille

English

The still increasing global migration affects the epidemiology of tuberculosis (TB) in European countries. We present the case of an asylum seeker from a TB high-endemic country, who presented with severe TB spondylodiscitis and need for emergency surgery. The patient had a history of recurrent sterile axillary and perianal abscesses for years, but TB was never properly ruled out. The patient underwent surgery, responded well to antibiotics and regained the ability to walk. After 6 month of treatment the patient was lost to follow-up. In light of the increasing migration from TB high-endemic countries to low-endemic countries, this case illustrates the paramount importance of minding TB as a differential diagnosis.</p

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u n i ve r s i t y  o f  co pe n h ag e n  Københavns UniversitetDelayed diagnosis of severe tuberculous spondylodiscitis in an asylum seekerKristensen, Kristina Langholz; Podlekareva, Daria; Ravn, PernillePublished in:Respiratory Medicine Case ReportsDOI:10.1016/j.rmcr.2017.04.021Publication date:2017Document versionPublisher's PDF, also known as Version of recordDocument license:CC BY-NC-NDCitation for published version (APA):Kristensen, K. L., Podlekareva, D., & Ravn, P. (2017). Delayed diagnosis of severe tuberculous spondylodiscitisin an asylum seeker: patient or doctors delay? Respiratory Medicine Case Reports, 21, 145-146.https://doi.org/10.1016/j.rmcr.2017.04.021Download date: 03. Feb. 2020lable at ScienceDirectRespiratory Medicine Case Reports 21 (2017) 145e146Contents lists avaiRespiratory Medicine Case Reportsjournal homepage: www.elsevier .com/locate/rmcrCase reportDelayed diagnosis of severe tuberculous spondylodiscitis in an asylumseeker; patient or doctors delay?Kristina Langholz Kristensen, MD a, *, Daria Podlekareva, MD, PhD a, b,Pernille Ravn, MD, PhD aa Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Dyrehavevej 29, 3400 Hilleroed, Denmarkb Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmarka r t i c l e i n f oArticle history:Received 30 March 2017Accepted 28 April 2017Keywords:TuberculosisImmigrantRefugeesExtrapulmonal* Corresponding author. Department of PulmonaNordsjællands Hospital, Dyrehavevej 29, 3400 HillerøE-mail address: Kristina.langholz@gmail.com (K.L.http://dx.doi.org/10.1016/j.rmcr.2017.04.0212213-0071/© 2017 The Authors. Published by ElsevierDownloaded for Anonymous UFor personal use only.a b s t r a c tThe still increasing global migration affects the epidemiology of tuberculosis (TB) in European countries.We present the case of an asylum seeker from a TB high-endemic country, who presented with severe TBspondylodiscitis and need for emergency surgery. The patient had a history of recurrent sterile axillaryand perianal abscesses for years, but TB was never properly ruled out. The patient underwent surgery,responded well to antibiotics and regained the ability to walk. After 6 month of treatment the patientwas lost to follow-up. In light of the increasing migration from TB high-endemic countries to low-endemic countries, this case illustrates the paramount importance of minding TB as a differentialdiagnosis.© 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).1. IntroductionTuberculous spondylodiscitis accounts for <5% of all tubercu-losis (TB) cases and is a rare but extremely serious clinical condi-tion, which, if undiagnosed, can lead to compression of medullacausing severe and disabling neurological sequela [1].We present the case of an asylum seeker living in a refugeecamp, who had a history of recurrent axillary and perianal ab-scesses for years, before eventually presenting with cauda equinasyndrome, severe TB spondylodiscitis and need for emergencysurgery.In light of the increasing migration from TB high-endemiccountries to low-endemic countries, this case illustrates the para-mount importance of minding TB as a differential diagnosis.2. Case presentationA 40-something-year-old asylum seeker originating from a TBhigh-endemic country, staying in a refugee camp in Denmark for 8years with no recent travel history, was admitted to the emergencydepartment complaining of 3 days of severe pain in the lowerry and Infectious Diseases,d, Denmark.Kristensen).Ltd. This is an open access article user (n/a) at BS - University of Copenh No other uses without permission. Coabdomen and lower back with projection to both legs. Dysesthesialocated to the lower limbs was noted and ability to walk wasslightly impaired. After pain relief the patient appeared unaffectedand was found neurologically intact. There was no history ofcoughing, fevers, night sweat, fatigue or weight loss. Laboratorytests revealed slightly elevated inﬂammatory markers. HIV test wasnegative. Chest radiography was normal. A computed tomography(CT) of the spine showed a local destruction in vertebrae L4 withsurrounding soft tissue involvement suspicious for spondylodisci-tis. While awaiting a magnetic resonance imaging (MRI), the pa-tient developed perianal and saddle numbness, decreased analtone, urinary retention and lost the ability to walk. Acute MRIshowed spondylodiscitis with an abscess at L4, inﬂammationreaching into the psoas and backmuscles and dura compressed anddislocated consistent with cauda equina syndrome. Emergencysurgical decompression revealed an intraspinal abscess containingcaseous material. Histopathology detected necrotizing granulo-matous inﬂammation, no acid-fast bacilli (AFB) and no signs ofmalignancy. Standard microscopy and culture of pus were withoutmicroorganisms. Empirical standard anti-TB regimen (isoniazid,ethambutol, pyrazinamide and rifampicin) was initiated. Due to thepossibility of multidrug resistant TB (MDR-TB), moxiﬂoxacin wasadded. Microscopy for AFB and PCR for Mycobacterium tuberculosis(MTB) were negative. After 30 days fully susceptible MTB weregrown from the bone biopsy. Thereafter, moxiﬂoxacin was dis-continued. The patient tolerated the treatment well, slowlynder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).agen from ClinicalKey.com by Elsevier on May 14, 2018.pyright ©2018. Elsevier Inc. All rights reserved.K.L. Kristensen et al. / Respiratory Medicine Case Reports 21 (2017) 145e146146improved and regained full bowel- and bladder control. After 4months of treatment, the patient slowly regained the ability towalkwithout support, but the paraesthesia persisted. The patient waslost to follow-up after 6 month of treatment and has left thecountry.The patient had a history of several hospitalizations withrecurrent sterile abscesses prior to this emergency situation; Aperianal abscess had been removed 7 years prior and a perianal andan axillary abscess had been surgical drained 2 years prior. At bothoccasions standard microscopy and culture of pus had been nega-tive. No materiel had been sent for speciﬁc mycobacterial micro-scopy, PCR or culture. At the last contact a QuantiFERON-TB (QFT))test was performed and found positive, a chest radiography wasnormal, however, no further diagnostic tests for TB were performedand no further follow up was planned.3. DiscussionTB remains one of the most widespread infectious diseases inthe world, mostly in low-income countries. The still increasingglobal migration from TB high-endemic countries is affecting theepidemiology of TB in low-endemic countries [2]. In Scandinaviaapproximately 70% of new TB cases occur in immigrants from TBhigh-endemic countries and the majority are infected in theircountry of origin [3]. Pulmonary TB is the most frequent manifes-tation, however extrapulmonary TB is common among people fromTB high-endemic countries and a high level of medical awarenessmust be encouraged [4]. Spinal- and perianal TB are rare manifes-tations of TB and in line with our ﬁndings a diagnostic delay isfrequently reported in patients with abscesses [5,6]. Due to ourpatient's history of recurrent “sterile” abscesses and the subsequentdiagnosis of spinal TB we strongly suspect that the recurrent ab-scesses were due to MTB. Thus TB could potentially have beendiagnosed earlier.Since 2014, many Western European countries have experi-enced an increase inmigrants and refugees, which poses challengesfor the control of TB [2]. This case illustrates the challenges of TBdiagnostic in refugees from high-endemic countries: In the low-endemic Western countries, TB is forgotten by many clinical spe-cialists and is not considered as differential diagnosis [7]. Refugeesare considered at increased risk of developing TB due to malnu-trition, stress from long journeys, staying in areas of conﬂict andwar, crowded refugee camps and the lack of access to healthcareand there can be several barriers to timely diagnosis of TB amongrefugees such as language, social barriers and a fear of stigmatisa-tion [8]. Authorities, as well as medical personal, and personal atrefugees' camps must be aware of these barriers in order to preventdelays in TB diagnostic and treatment. Furthermore healthcaresystems and personnel should be aware of the health conditionsand diseases that might follow these population groups and beadjusted accordingly.In Denmark, unlike other Scandinavian and most Western Eu-ropean countries, mandatory screening for active TB among asylumseekers at arrival to the country has not yet been implemented.Optimally, the policy of TB screening upon arrival should be theDownloaded for Anonymous User (n/a) at BS - University of CopFor personal use only. No other uses without permissionsame for all European countries, but for now signiﬁcant differentscreening practices exist among countries [9]. Systematic screeningfor TB among migrants/refugees from TB high-endemic countriesmay help to timely identify and treat people with active TB disease.This will beneﬁt not only a single person (by treating the disease),but also the general population e by preventing further spread ofthe infection. Furthermore when we screen for TB among a highlyvulnerable group as refugees, we need an adequate and reasonablefollow-up plan, which has appeared to be a major challenge [9]especially regarding insufﬁcient tracking [7]. However, while thedebate on cost-effectiveness of different screening approaches andfollow-ups are on-going [10], we need to underline for cliniciansand other medical personnel the importance of considering TB as adifferential diagnosis among migrants.FundingThis research did not receive any speciﬁc grant from fundingagencies in the public, commercial, or not-for-proﬁt sectors.Conﬂicts of interestNone.Author contributionsThe authors alone are responsible for the content and writingthe paper.References[1] E.M. Trecarichi, E. Di Meco, V. Mazzotta, M. Fantoni, Tuberculous spondylo-discitis: epidemiology, clinical features, treatment, and outcome, Eur. Rev.Med. Pharmacol. Sci. Italy 16 (Suppl 2) (2012 Apr) 58e72.[2] W. Europe, A. Tb, G.T.B. Programme, P.H. Sciences, State-of-the-art series ontuberculosis and migration 20 (10) (2016) 1280e1281.[3] Statens Serum Institut. EPINYT - Tuberkulose 2014. 2016.[4] I.S. Johansen, S.L. Nielsen, M. Hove, M. Kehrer, S. Shakar, A.V.T. Woyen, et al.,Characteristics and clinical outcome of bone and joint tuberculosis from 1994to 2011: a retrospective register-based study in Denmark, Clin Infect Dis 61(4) (2015 Aug 15) 554e562, http://dx.doi.org/10.1093/cid/civ326.[5] P.C. Jutte, J.H. van Loenhout-Rooyackers, M.W. Borgdorff, J.R. van Horn, In-crease of bone and joint tuberculosis in The Netherlands, J. Bone Jt. Surg. Br.Engl. 86 (6) (2004 Aug) 901e904.[6] S. Sultan, F. Azria, P. Bauer, M. Abdelnour, P. Atienza, Anoperineal tuberculosis:diagnostic and management considerations in seven cases, Dis. Colon Rectum.U. S. 45 (3) (2002 Mar) 407e410.[7] C. Papan, U. von Both, M. Kappler, B. Kammer, M. Griese, J. Huebner, Pott'sDisease: a Major Issue for an Unaccompanied Refugee Minor. Thorax[Internet], 2016, pp. 1e2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27872320.[8] M. Norredam, M. Olsbjerg, J.H. Petersen, I. Bygbjerg, A. Krasnik, Mortality frominfectious diseases among refugees and immigrants compared to nativeDanes: a historical prospective cohort study, Trop. Med. Int. Heal 17 (2) (2012)223e230.[9] M. Dara, I. Solovic, G. Sotgiu, L. D'Ambrosio, R. Centis, R. Tran, et al., Tuber-culosis care among refugees arriving in Europe: a ERS/WHO Europe Regionsurvey of current practices, Eur. Respir. J. Engl. 48 (3) (2016 Sep) 808e817.[10] M.J. van der Werf, K. L€onnroth, Pre-entry, post-entry, or no tuberculosisscreening? Lancet Infect. Dis. 14 (12) (2014) 1171e1172.enhagen from ClinicalKey.com by Elsevier on May 14, 2018.. Copyright ©2018. Elsevier Inc. All rights reserved.

Delayed diagnosis of severe tuberculous spondylodiscitis in an asylum seeker:patient or doctors delay?

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Delayed diagnosis of severe tuberculous spondylodiscitis in an asylum seeker:patient or doctors delay?

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