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A gibbus in puerperium

Rakesh Biswas, Vijay Baghel, Shiv Shanker

People’s College of Medical Sciences, Bhopal, 462010, India

Correspondence to:
rakesh7biswas{at}gmail.com

A 20-year-old woman started experiencing severe low back ache during the second month of her fourth pregnancy. She continued to have intermittent backache with low grade fever and had a spontaneous vaginal delivery in the eighth month.

The infant died 10 h after birth.

Four days after delivery she noticed a deformity in her back (fig 1).

View this figure (106K): in this window | in a new window | PowerPoint for Teaching   Figure 1 Physical appearance of patient’s back.

 

On examination she had a lump in the left iliac fossa and ultrasound revealed a mass which was confirmed to be a psoas abscess. An x ray of dorso-lumbar spine revealed a wedge shaped compression fracture of the 12th thoracic vertebra (fig 2). Her chest x ray showed military mottling.

View this figure (103K): in this window | in a new window | PowerPoint for Teaching   Figure 2 Radiography revealing compression fracture of the 12th thoracic vertebra.

 

She was started on antitubercular therapy (World Health Organization category 1) and recovered gradually.

In a prospective series from India, women with disseminated tubercular involvement had higher rates of antenatal hospitalisation, produced infants with low Apgar scores (6) soon after birth, and with low birth weight.¹ In a prospective case series from the UK a predominance of disseminated tuberculosis was noted in recent Indian immigrants; the diagnosis was delayed as the disease was frequently extrapulmonary with few symptoms.² The incidence rate of spinal tuberculosis in a recent series was 1.17 per 100 000 females and 0.916 per 100 000 males. The thoracic spine was affected in 42% of the cases. About 32% presented with incomplete paraplegia.³

In the presence of low grade fever and other symptoms specific to organ involvement in pregnancy, one needs to be vigilant for tubercular dissemination. This approach is likely to be very familiar to health professionals working in areas where tuberculosis is endemic, but may be under-appreciated by those who care for patients at higher risk of the disease in areas where tuberculosis is not endemic.

All the health professionals of People's College of Medical Sciences who were involved in the care of this patient.

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication

1. Jana, N, Vasishta, K, Saha, SC, et al. Obstetrical outcomes among women with extrapulmonary tuberculosis. N Engl J Med 1999; 341: 645–9.[Abstract/Free Full Text]
2. Llewelyn, M, Cropley, I, Wilkinson, RJ, et al. Tuberculosis diagnosed during pregnancy: a prospective study from London. Thorax 2000; 55: 129–32.[Abstract/Free Full Text]
3. Godlwana, L, Gounden, P, Ngubo, P, et al. Incidence and profile of spinal tuberculosis in patients at the only public hospital admitting such patients in KwaZulu-Natal. Spinal Cord 2008; 46: 372–4.[Medline]

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