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Effect of delayed diagnosis on severity of Pott’s disease

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Abstract

Purpose

We analysed delay in diagnosis (DID) and disease severity in patients with vertebral tuberculosis (TB) in India.

Methods

We interviewed 228 patients with vertebral TB and reviewed their diagnostic magnetic resonance images (MRIs). We examined patient characteristics at the time of presentation and associations between socioeconomic background, access to care, DID and radiographic disease severity at the time of diagnosis.

Results

The most common presenting symptom was localised back pain (84%), followed by fever (40%) and pain elsewhere (28%). The median DID was five months [interquartile range (IQR) 3–9]. In multivariate logistic regression, Muslim and older patients had a higher risk of extreme (more than ten months) DID [adjusted odds ratio (aOR) 2.91; 95% confidence interval (CI) 1.20–7.08 and 2.33; 95% CI 1.23–4.94, respectively]. One hundred and two patients (64%) had vertebral abscesses. Median local kyphotic deformity was 11.7° (IQR 0–18.5°). Fifty-four (34%) patients had radiologically severe disease at the time of diagnosis. Older patients and those with higher education were less likely to have severe disease at the time of diagnosis (aOR 0.32; 95% CI 0.13–0.76 and 0.20 95% CI 0.06–0.62, respectively). Patients who experienced extreme DID were more likely to have severe disease (aOR 2.67; 95% CI 1.05–6.99).

Conclusions

Most patients in this cohort experienced long delays in diagnosis, and such delay was significantly associated with the presence of severe disease. Clinicians in TB-endemic areas must consider vertebral TB early and obtain imaging in patients who complain of persistent back pain. Improved diagnostic criteria are needed to identify patients at higher risk of disease.

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Acknowledgements

The authors thank Drs. S.M. Tuli, Oheneba Boachie, Rick Hodes and Ellie Schoenbaum for their guidance in the development of this project, Drs. D. Prabhakaran, N. Tandon, V. Narayan and M. Ali for their support throughout the project, the Center for Chronic Disease Control in New Delhi, and Meredith Blevins for her biostatics consultations. JCMB is supported by the National Institutes of Health (K23 AI083088). This work was supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Center, National Eye Institute, National Heart, Blood, and Lung Institute, National Institute of Dental and Craniofacial Research, National Institute On Drug Abuse, National Institute of Mental Health, National Institute of Allergy and Infectious Diseases, and National Institutes of Health Office of Women’s Health and Research through the Fogarty International Clinical Research Scholars and Fellows Program at Vanderbilt University (R24 TW007988) and the American Relief and Recovery Act.

Conflict of interest

The authors have no financial disclosures or other conflicts of interest.

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Correspondence to Eli Kamara.

Appendices

Appendix A

Variable

Options

Level

Educational status

Illiterate, literate with no formal education

Low

Up to primary school (up to class IV), secondary school (ITI course, class XII/X or intermediate)

Medium

Graduate (B.A/B.Sc/B.Com/Diploma etc.), professional degree/post graduate

High

Monthly income

Refuse/Don't know

Unknown

<10,000

Low

10,001–30,000

Medium

>30,001

High

Current profession

Unemployed

Unemployed

Housewife/retired

Normal unemployed

Student

Student

Unskilled manual labourer, landless labourer

Low

Skilled manual labourer, small business owner, small farmer, marginal landowner, rickshaw driver, army jawan, carpenter, fitter

Medium

Professional, big business, landlord, university teacher, class IAS/services officer, lawyer, trained, clerical, medium business owner, middle level farmer, teacher, maintenance (in charge), personnel manager

High

Appendix B

Anterior vertebral body percent loss [25]

  • For a lesion affecting a single vertebra:

    • The heights of the normal vertebra above [A] and below [B] the lesion are measured

    • The average of these values is taken; this value is the presumed normal height of the diseased vertebra in the lesion C = [(A + B)/2]

    • The actual height of the diseased vertebra is measured on the x-ray [D]

    • Anterior vertebral body percent loss is calculated by taking the difference of the measured height [D] from the presumed normal height [C] and dividing this difference by [C]

  • For a lesion affecting multiple vertebrae:

    • The heights of the normal vertebra above and below the lesion are measured and the average is taken (as in the single lesion case)

    • This number is multiplied by the number of vertebrae affected; this value is the presumed normal height of the diseased vertebrae in the lesion

    • The actual height of the diseased segment is measured

    • Anterior vertebral body percent loss is then calculated as in a single lesion

Local kyphotic deformity (Konstam’s angle, or cobb’s angle in the sagital plane) [18, 26][27]

  • A straight line is drawn through the superior surface of the first normal vertebra cranially from the lesion

  • A second line is drawn through the inferior surface of the first normal vertebra caudally from the lesion

  • These two lines cross and form an acute angle which is the local kyphotic deformity

  • In mild angles, perpendiculars can be drawn, with angle a measured at their intersection (angle A in diagrams below)

    figure a
  • If multiple levels are affected non-consecutively, there will be an equal number of Konstam’s angles

  • If multiple levels are affected consecutively, there will be a single Konstam’s angle measured from the first normal vertebrae above and below the lesion.

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Kamara, E., Mehta, S., Brust, J.C.M. et al. Effect of delayed diagnosis on severity of Pott’s disease. International Orthopaedics (SICOT) 36, 245–254 (2012). https://doi.org/10.1007/s00264-011-1432-2

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  • DOI: https://doi.org/10.1007/s00264-011-1432-2

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