POTTS DISEASE

Definition:

Is a presentation of extra pulmonary tuberculosis that affects the spine It is named after Percivall Pott (1714-1788), a London surgeon who trained at St. Bartholomews Hospital, London. He presented the classic description of spinal tuberculosis. The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. Scientifically, it is called Tuberculosis Spondylitis and it is most commonly localized in the thoracic portion of the spine. It is an old termed for tuberculosis of the spine that caused softening and collapse of the vertebrae, often resulting kyphosis a hunchback deformity, which is called Potts Curvature

Etiology:

Causative Organism: Mycobacterium Tubercle Bacilli (present in soil, water and house dust) Spread: Hematogenous (by blood) Commonly associated with: Debilitating disease, AIDS, Drug addiction, Alcoholism.

Anatomy and Physiology

Spinal cord is the largest nerve in the body, and it is comprised of the nerves which act as the communication system for the body. The nerve fibers within the spinal cord carry messages to and from the brain to other parts of the body. The spinal cord is surrounded by protective bone segments called the vertebral column. The vertebral column is comprised of 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae and 5 sacral vertebrae. The vertebral column also provides attachment points for muscles of the back and ribs. The vertebral disc serve as shock absorbers during activity such as walking, running and jumping, they also allow spine to flex and extend.

Risk Factor: The elderly Racial and ethnic groups Lifestyle factors Home environment condition Family history of PTB Nutritional status History of trauma Poor socio-economic condition

Pathophysiology:
POTTS DISEASE

Non-modifiable Non-modifiable Age: most common in males Gender: Adult Pulmonary Tuberculosis Spread of Mycobacterium Tubercle from other Extrapulmonary Tuberculosis The infection spreads from two adjacent vertebrae into the adjoining disc space One vertebra is affected, the disc is normal. Two are involved, the avascular intervertebral disc cant received nutrients and collapse Ischemia Vertebral Narrowing Vertebral Collapse Disc tissue dies and broken down Spinal damage POTTS DISEASE

Modifiable -Environment -Activity -Lifestlye -History of PTB

Back pain Fever night sweats

Signs and Symptoms: (The disease progresses slowly.) Night sweating Spinal mass, sometimes associated with numbness, tingling or muscle weakness of the legs and paresthesia. Anorexia Weight loss Gibbus formation: progressive destruction to the anterior spine leading to collapse and kyphosis.

Complication: 1. Vertebral collapse resulting in gibbus formation. 2. Spinal cord compression 3. Paraplegia (so called Potts paraplegia)

Diagnostic Procedure: 1. Blood tests- elevated ESR 2. X-ray - X-ray of the lumbar spine, side view, showing Potts disease of the L2 vertebrae caused by vertebral tuberculosis. Potts disease is a destruction of spine associated with TB that sometimes leads to intense curvature, or hunchback. 3. Skin test (Tuberculin Test) - Strongly positive 4. CT and MRI of the spine - Demonstrate the extent of spinal compression and can show changes at an early stage than plain radiographs. Bone elements visible within the swelling or abscesses are strongly indicative of Potts disease. 5. Needle biopsy of the bone or synovial tissue - Number of tubercle bacilli are usually low but are pathognomonic 6. Gibbus formation- pathognomonic sign of Potts disease 7. Acid Fast stain culture for mycobacterium Tubercle Prevention: 1. BCG vaccination (for all types of TB) 2. Improve of socio-economic condition 3. Prevention of HIV and AIDS

Pharmacological Management:
GENERIC NAME Rifampicin BRAND NAME ACTION SIDE EFFECTS CONTRAINDICATION NURSING RESPONSIBILITY

Rifadin Antibiotic, Antitubercul otic (first line) Inhibits DNAdependent RNA polymerase activity in susceptible bacterial cells.

CNS: headache, drowsiness, fatigue, dizziness, generalized numbness, muscle weakness, visual disturbances. Dermatologic: Rash, urticaria, flushing, reddish discoloration of body fluidstears, saliva, urine, sweat, sputum. GI: anorexia, vomiting gas, cramps, diaarhea, GU: hematuria, renal insufficiency, acute renal failure, menstrual disturbances. Hematologic: thrombocytopenia , hemolytic anemia, decreased Hgb Other: pain in extremities, osteomalacia, fever, flulike symptoms.

Contraindicated with allergy to any rifamycin, acute hepatic disease, lactation. Use cautiously with pregnancy (teratogenic effects have been reported in preclinical studies; safest antituberculous regimen for use in pregnancy is considered to be rifampin, isoniazid, and ethambutol). Hypersensitivity, jaundice, severe hepatic disease. IM/SC admin. Porphyria. Not to be used for treatment of meningococcal disease.

Before: Observe 10 rights in giving medicstion. Check for any allergy to rifampicin Tell the pt. that the drug can cause red-orange discoloration of urine. During: Observe aspiration precaution After: Observe for any allergic reaction to drug Stay at the clients bedside

GENERIC BRAND ACTION NAME NAME Isoniazid Niazid Antibiotic,

SIDE EFFECTS

CONTRAINDICATION

NURSING RESPONSIBILITY

Peripheral Antituberculo neuropathy tic Nausea and Interferes vomiting

Isoniazid is contraindicated in patients who develop severe

Before: Observe 10 rights in giving medication.

with lipid and nucleic acid biosynthesis in actively growing tubercle bacilli.

Thrombocytopenia Local irritation at IM site Epigastric distress Elevated AST

hypersensitivity Check for any reactions, allergy to including drug isoniazid. induced Tell to the pt. hepatitis; that this drug previous can cause isoniazidperipheral associated neuropathy hepatic injury; which is severe adverse manifested by reactions to tingling isoniazid such as sensation on drug fever, chills, extremities. It arthritis; and can be acute liver prevented disease of any through use of etiology. supplemental vitamin B6 (pyridoxine). During: Observe aspiration precaution After: Observe for any allergic reaction to drug Stay at the clients bedside

GENERIC NAME

BRAND NAME

ACTION

SIDE EFFECTS

CONTRAINDICATION

NURSING RESPONSIBILITY

Pyrazin amide

Antibiotic, Antituberculo tic It is an antibiotic and works by stopping the growth of bacteria.This antibiotic treats only

an allergic reaction Hypersensitivity; Before: (difficulty existing liver Observe 10 breathing; closing disease; acute rights in giving of your throat; gout or medication. swelling of your hyperuricaemia. Check for any lips, tongue, or Porphyria. allergy to face; or hives); Pregnancy and pyrazinamide a fever; lactation. Tell to the pt. unusual weakness that this drug or fatigue; can cause skin nausea, vomiting, rashes or loss of appetite;

bacterial infections. It will not work for viral infections (such as common cold, flu). Unnecessary use or misuse of any antibiotic can lead to its decreased effectiveness.

yellow skin or eyes; dark urine; difficult or painful urination; painful or swollen joints; worsening gout; or a rash.

During: Observe aspiration precaution After: Observe for any allergic reaction to drug Stay at the clients bedside

Conservative Management: Knight Taylor Brace- for upper thoracic affection Jewett Brace- for lower thoracic affection Chair Back Brace- for lumbo-sacral affection Head Halter Traction- for cervical spine affection; to immobilize

Medical Management: Potts disease is treated with multiple antibiotics Treatment must be maintained for at least 6-9 months (and some doctors advise individuals to take medication for as long as 9-12 months.) Immunodeficient individuals may require lifelong drug therapy to keep the infection from recurring.

Surgical Management: Anterior Decompression Spinal Fusion- may ultimately be needed to relieve spinal cord pressure, correct abnormal curvature of the spine, or resolve spinal instability secondary to loss of bone mass.

Nursing Management: 1. 2. 3. 4. 5. 6. 7. 8. Proper positioning of patient (side lying) Monitor status of affected area. Maintain functional alignment and promote comfort. Adequate hydration or increase oral fluid intake. Area of the spine affected should be immobilized. Deep breathing exercise and coughing exercise. High fiber diet Ensure spinal alignment by turning the patient as a unit, using rolling technique when changing patients position. 9. Monitor vital signs 10. Investigate reports of pain, noting location, intensity (scale of 0-10) 11. Provide comfort measure 12. Inspect skin for presence of cold abscess 13. Keep skin clean and dry 14. Use aseptic technique in performing other procedure to prevent any further infection.