1- Faculty of Medicine UPN Veteran Jakarta, Indonesia,
2- Hermina Bekasi Hospital, Bekasi, Indonesia.
3- Department of Child Health, Faculty of Medicine University of Indonesia Cipto Mangunkusumo Hospital Jakarta, Indonesia
Background: Central Nerve System (CNS) involvement in tuberculosis occurred in 10% of cases, but only 2 % developed into spinal intramedullary tuberculosis (SIMT). It is rarely found in children and often misdiagnosed as paravertebral mass.
Aims: To describe the manifestation of spinal intramedullary TB in children and to encourage awareness in diagnosing SIMT with non-invasive procedure
Case Description: A 13-year-old girl with progressive inferior paralysis, suspected as ependymoma from Magnetic Resonance Imaging (MRI). After laminectomy and biopsy procedure, chronic granulomatous tissue with positive result of acid-fast bacilli (AFB) was obtained in histopathology result. Patient got antituberculosis treatment (ATT) and rehabilitation. Gradually significant result showed after 2 months of treatment.
Conclusion: SMIT is rare in children. Early diagnose and intervention showed a good response. Though it is difficult to differ with paravertebral mass, rapid biomarker or tuberculin test could be used to diagnose SIMT before further invasive procedure.
Keywords: Diagnostic, tuberculosis, spinal tuberculosis, SIMT
Tuberculosis (TB) still become the big burden of child health in Indonesia. Until 2019, there are 543.874 TB cases in Indonesia and 11% occurs in children 0-14 years old.1 Involvement of Central Nerve System (CNS) in tuberculosis occurred in 10% of TB cases, in which meningitis TB is the common manifestation, by contrast Spinal Intramedullary Tuberculosis (SIMT) occurs only 2% among all cases of CNS TB and common in young adult patient.1-5
This case reports a rare case of 13 years old girl with a progressive paralysis of inferior limbs who is diagnosed as intramedullary thoracic mass in the beginning and had been diagnosed as Intramedullary TB after histopathology result.
A 13-year-old girl had a progressive weakness on both legs for 4 months before the hospital visit. There is no history of fever, cough, rhinitis, hard of breathing, night sweats, weight loss, or appetite loss. She had been stayed in a boarding school for 2.5 years, had a complete immunization, and no history of TB in the family.
Physical examination showed paresis of both legs with level of motoric value respectively 1111/1111 and paraesthesia as high as T10 level (Frankel Score A). No vertebral deformity and autonomic nerve dysfunction. No abnormality in the blood result. MRI revealed kyphosis curve, no listhesis, intact corpus vertebrae, no compression fracture, but an hypointense lesion was found in T1-T2FSE and T2FS intradural intramedullary as high as T8-9, rounded, demarcated with irregular edge, intensity inhomogeneity with contrast, sized 1.7 x 1.3 x 1.4 cm (Picture 1).
A laminectomy biopsy was performed for diagnostic procedure. Small fragment stroma pollinated by lymphocyte with epithelioid cells, datia langhans cells and necrotizing foci found in histopathological test and acid-fast bacilli test showed a positive result (Picture 2).
According to histopathology result, she was diagnosed as Spinal Intramedullary TB and got 1st line intensive phase of anti-tuberculosis treatment (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol). After 2 months of treatment and rehabilitation, she could walk though needed a company, nevertheless the motoric value increased to 4444/4444 (Frankel Score D).