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CASE REPORTS
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 105-108

A rare case of tuberculosis spine on antitubercular drug succumbing to pseudomembranous enterocolitis


1 Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Pathology, Command Hospital (SC), Pune, Maharashtra, India

Date of Submission12-May-2021
Date of Decision30-May-2021
Date of Acceptance09-Jun-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Dr. Vipin V Nair
Department of Surgery, AFMC, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_52_21

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  Abstract 


Anti-tubercular therapy (ATT) drugs are the mainstay of management of tuberculosis worldwide. These medicines are used extensively across the globe in treating tubercular infections of any organ. The life-threatening complications of pseudomembranous enterocolitis (PMC) associated with ATT, especially with capsule Rifampicin is not known to most practitioners. An early suspicion during the onset of loose stools in a patient on ATT is essential for managing this life-threatening condition. This fatal case report is to create awareness among the healthcare professionals and sensitize the clinicians, about the possibility of PMC in patients on ATT. We discuss our case and the lessons learnt in this case report.

Keywords: Antitubercular agents, pseudomembranous enterocolitis, rifampicin, tuberculosis


How to cite this article:
Rehsi SS, Roy N, Nair VV, Baranwal AK, Sengupta P, Sharma P, Kumar A. A rare case of tuberculosis spine on antitubercular drug succumbing to pseudomembranous enterocolitis. J NTR Univ Health Sci 2021;10:105-8

How to cite this URL:
Rehsi SS, Roy N, Nair VV, Baranwal AK, Sengupta P, Sharma P, Kumar A. A rare case of tuberculosis spine on antitubercular drug succumbing to pseudomembranous enterocolitis. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Jan 24];10:105-8. Available from: https://www.jdrntruhs.org/text.asp?2021/10/2/105/332853




  Introduction Top


Pseudomembranous colitis (PMC) is a life-threatening complication seen in patients on antibiotics. PMC following anti-tubercular therapy (ATT) is a rare occurrence. Very few articles are available on this topic in literature. This report summarizes a fatal case of pseudomembranous enterocolitis in a young male, with paraplegia following Potts's spine, on ATT.


  Case Report Top


A 37-year-old man, a known case of Potts's spine, involving thoracic vertebrae 2 to 6 (D2 - D6), on first-line ATT, presented to the emergency department with sudden onset paraplegia on Sep 2020. He was diagnosed in the peripheral hospital Tubercular center with Reverse transcription - polymerase chain reaction (RT-PCR) evidence of tuberculosis. He was on a daily morning dose of tablet Rifampicin 600 mg, Isoniazid 300 mg, Ethambutol 1000 mg and Pyrazinamide 1500 mg since Aug 2020. He was comfortable with the medications for 2 weeks and then developed mild to moderate pain in the back which he ignored for 2 days. He reported to our tertiary care facility following development of progressive weakness of both lower limbs.

On initial clinical evaluation, he was unable to walk. There was tenderness over the dorsal vertebral area from D2 to D6 and total paraplegia. There were reduced sensations in both lower limbs, with exaggerated deep tendon reflexes. Bilateral planters were upgoing. On investigation, there was leukocytosis, renal, and liver function tests were within normal limits. Serial investigation reports are shown in [Table 1]. The magnetic resonance imaging (MRI) spine dated showed spondylolisthesis of D5 and D6 vertebrae, with epidural collection from D2 to D6, causing significant neural compression [Figure 1]a.
Table 1: Serial Investigation Chart for the Patient During Admission

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Figure 1: (a) MRI spine showing spondylodiscitis with epidural collection. (b) Contrast computed tomography scan abdomen showing Accordion sign and ascites (c) Chest computed tomography showing basal lung atelectasis and interstitial lung infiltrates

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He was diagnosed as a case of acute compressive myelopathy with paraplegia. He underwent emergency decompression of spine after admission. Intraoperatively, there was inflammatory granulation tissue present on the dorsal vertebral bodies D2--D7. Necrotic materials were removed and sent for histopathological examination. Laminectomy of the D4--D7 vertebrae body for decompression of spinal nerve roots done after necrosectomy. Posterior pedicle screw fixation from D2 to D8 achieved with long rods and screws. Postoperatively, he was started on broad spectrum antibiotics. He was comfortable for 3 days in the acute surgical ward. He developed loose motions 3 to 5 times per day, each episode around 200--300 ml, foul smelling, for next 2 days.

On postoperative day 5, he developed progressive abdominal distension with vomiting and obstipation. Blood investigations revealed leukocytosis (TLC 24,300) and normal serum electrolytes. Urgent contrast-enhanced computed tomography abdomen showed mural wall thickening and mucosal hyperenhancement of the entire colon with skip areas of the small intestine (Accordion sign) [Figure 1]b. There was associated small bowel dilatation and moderate ascites. These findings were suggestive of pseudomembranous enterocolitis. There was collapse consolidation of basal segments of both the lungs [Figure 1]c. The immunochromatography of perirectal swab was strongly positive for  Clostridium difficile Scientific Name Search in A and B and glutamate dehydrogenase. His total leucocyte count kept on increasing and developed features of severe sepsis.

He was taken up for exploratory laparotomy on the same day. Per operatively, there was nonhemorrhagic minimal free fluid in the abdomen. The colon was distended and showed no peristalsis. His small intestine was healthy and was having peristalsis. There were no signs of vascular compromise, perforation, or mesenteric lymphadenitis. Considering the extremely poor general condition of the patient, total colectomy was not done. A diverting ileostomy was performed and patient sent to intensive care unit due to hemodynamic instability. He was on ventilatory support due to severe sepsis and inability to maintain oxygen saturation. He suffered a sudden cardiac arrest. Despite effective Cardiopulmonary Resuscitation (CPR) on lines of Advanced cardiac life support (ACLS) protocols, he could not be revived and was declared dead.

The clinico-pathological autopsy conducted on September 2020 revealed anasarca with bilateral pleural effusion, pericardial effusion, and ascites on gross examination. There were cheesy white necrotic areas in the spleen and liver was nutmeg in appearance. Both right and left lungs showed consolidation with red hepatization of lower lobes. There was a pseudomembrane in the luminal surface of the large intestine. Both kidneys showed loss of cortico-medullary differentiation and examination of the brain revealed friable, cauliflower like growth in both lateral ventricles. Salient histopathological findings comprised of bilateral lobar pneumonia with features of Acute respiratory distress syndrome (ARDS), chronic venous congestion of liver, caseating granuloma within spleen, pseudomembranous enterocolitis, diffuse acute tubular necrosis with mesangiolysis and choroid plexus papilloma with psammomatous calcification in both lateral ventricles [Figure 2]a, [Figure 2]b, [Figure 2]c.
Figure 2: (a) Diffuse alveolar damage (H&E stain - Lung; 200× magnification). (b) Spleen granuloma with caseous necrosis (H&E stain; 200× magnification). (c) Colon showing volcano sign and crypts within lamina propria with inflammatory cell infiltrates suggestive of colitis. (H&E stain; colon 40× magnification)

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  Discussion Top


PMC developing due to antitubercular drugs is a rare complication. However, there are reports in the literature suggesting tablet Rifampicin as etiological factor for this severe iatrogenic condition. One of the first reports of PMC was documented by Park in a 90-year-old person on long-term ATT. The patient's ATT was discontinued and was successfully managed with injectable metronidazole. Consequent to this effective management, his ATT was resumed without tablet rifampicin.[1]

In another study by Jung et al., the mean period for PMC diarrhea after starting ATT was 19.8 days. This study had six patients with a median age of 68 years.[2] Chen et al. reported the occurrence of PMC in 28-year-old young women after 126 days of ATT.[3] The possibility of rectosigmoid sparing in PMC was reported by Yim et al. and advocated full colonoscopy in evaluating patients developing diarrhea on ATT.[4]

Recently, Lee et al. demonstrated that 94.4% of a total of 54 cases of PMC on ATT were due to tablet rifampicin. The study also highlights that ATT needs titration, as per patient requirement by the treating physician. Oral metronidazole and injection Vancomycin remains the drug of choice for PMC.[5]


  Conclusion Top


The risk of pseudomembranous enterocolitis is present in patients on antitubercular drugs. Tablet Rifampicin remains one of the drugs causing this dangerous side effect. Early diagnosis and active management will lead to a successful outcome. Clinicians need to keep this complication in the back of their mind. Diarrhea in patients on anti-tubercular drug needs serious and early active intervention to prevent PMC.

Acknowledgements

NIL.

Ethics approval

  • Necessary approval from Institutional Review Board taken.
  • Informed consent from NOK taken.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Park JY, Kim JS, Jeung SJ, Kim MS, Kim SC. A case of pseudomembranous colitis associated with rifampin. Korean J Intern Med 2004;19:261-5.  Back to cited text no. 1
    
2.
Jung SW, Jeon SW, Do BH, Kim SG, Ha SS, Cho CM, et al. Clinical aspects of rifampicin-associated pseudomembranous colitis. J Clin Gastroenterol 2007;41:38-40.  Back to cited text no. 2
    
3.
Chen TC, Lu PL, Lin WR, Lin CY, Wu JY, Chen YH. Rifampin-associated pseudomembranous colitis. Am J Med Sci 2009;338:156-8.  Back to cited text no. 3
    
4.
Yim SY, Koo JS, Kim YJ, Park SJ, Kim JN, Jung SW, et al. Rifampin-induced pseudomembranous colitis with rectosigmoid sparing. Clin Endosc 2011;44:137-9.  Back to cited text no. 4
    
5.
Lee YM, Huh KC, Yoon SM, Jang BI, Shin JE, Koo HS, et al. Incidence and clinical outcomes of clostridium difficile infection after treatment with tuberculosis medication. Gut Liver 2016;10:250-4.  Back to cited text no. 5
    


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