A 44-year-old man, chronic smoker, was admitted to the hospital for acute inflammatory lumbar pain which appeared 3 months after the initiation of antibacillary treatment for pleural tuberculosis. Patient was treated with a standard antituberculosis treatment, consisting of Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), and Ethambutol (E) (2 months of RHZE/4 months of RH). The diagnosis of pleural tuberculosis was based on clinical data (weight loss, night sweats, dyspnea) and radiological findings (left pleurisy of average abundance). A pleural biopsy showed epithelioid granulomatous inflammatory process without caseous necrosis, Ziehl- Neelsen stain and culture for mycobacteria were negative. On admission, the clinical examination revealed an afebrile man with a weight of 46kg and BMI of 17.6 kg/m2. He had a marked spinal tenderness of the dorso-lumbar spine and important limitation of spinal motion. Our patient did not have respiratory symptoms and his neurologic examination was normal.
The laboratory evaluation showed a hemoglobin of 12.4 g/dl and a total leucocyte count of 6400/mm3with 72% polymorphonuclear cells, 20% lymphocytes. Erythrocyte sedimentation rate (1sth) and CRP were respectively 80 mm and 27 mg/l. Sputum acid-fast bacilli direct smear as well as mycobacterium culture were negative. HIV test was also negative. Investigations including an x-ray of lumbar showed osteocondensation concerning the lower shelf of L1 and upper shelf of L2, Chest x-ray showed a small pleural effusion on the left. A dorso-lumbar Magnetic resonance imaging (MRI) showed features suggestive of Ttuberculous (TB) spondylitis interesting lower shelf of L1 and upper shelf of L2, respect for the height of the vertebral bodies with discrete epiduritis. MRI also showed a collection of vertebral bodies L1L2, which communicates with another one abscessed in the left psoas (Figure 1). Computerized tomography (CT) - guided evacuation of a psoas abscess was performed, which revealed purulent material staining negative on Gram stain and Ziehl-Neelsen stain. The cultures of the abscess material showed no growth.
In view of the high prevalence rate of TB, antecedent of pleural tuberculosis and MRI appearance, the diagnosis of Pott s disease was retained and the duration of treatment was prolonged to 9 months and the patient was placed in a spinal brace for stabilization of the vertebral column. Despite good adherence to treatment, low back pain worsened. 6 months after the diagnosis of tuberculosis spondylitis, the patient developed purulent collections in the soft tissues in the gluteal and left trochanteric region. A dorso-lombar MRI showed spondylodiscitis L1L2 with a significantly increased size of the left psoas abscess (Figure 2). An abdomino-pelvic CT showed collections in left iliac psoas muscle and the left gluteal and trochanteric region (Figure 3). GeneXpert  MTB/RIF of the vertebral biopsy aspiration product CT-guided revealed a polymerase chain reaction (PCR) for mycobacterium tuberculosis positive, with resistance to Rifampicin. Hain  test of first-line anti-tubercular treatment (ATT) showed resistance to Rifampicin and high-level resistance to Isoniazid. Moreover, Hain  test of second-line ATT (FQ and SLI) showed a high-level resistance to Ofloxacin and sensibility to Kanamycin and Amikacin.
Our patient was transferred to MDR-tuberculosis Unit. The superficial collections in the left gluteal and the trochanteric region have been drained under ultrasound. Following. An observed second-line treatment was initiated using amikacin, clofazimine, prothionamide, linezolid, delamanide, pyrazinamide et ethambutol, with monitoring for adverse events. At 6 months, injectable Amikacin and Delamanide were stopped, while other oral drugs were continued. Second-line ATT was given for a total duration of 20 months. The evolution under second-line treatment was marked by an improvement in an inflammatory lumbar pain, gain in weight and a disappearance of soft tissue collections. CRP and VS were normalized. Imaging monitoring performed at 12 months of second line treatment, showed no residual collections in thoraco-abdomino-pelvic CT, MRI found a vertebral fracture L1-L2 and quasidisappearance of psoas collection, only a small collection measuring less than 1cm was found without enhancement after gadolinium injection (Figure 4). Our patient received 20 months of treatment that it was tolerated, apart from the paresthesias of the 4 limbs which was managed by vitamin therapy, with stabilization of the vertebral lesions without the appearance of new collections. He was declared cured and he is following a rehabilitation program with stretching and strengthening of the spinal muscles.