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Exercise 1: NATURAL HISTORY OF DISEASE AND

LEVELS OF PREVENTION

Framework for the Natural History of Disease and Levels of Prevention

Catalina is a 46-year old Filipina overseas worker from Dumaguete. She is the
youngest of five and is happily married, having two sons and a daughter. She is a
registered nurse who used to work in the infectious ward of her local provincial hospital
before she landed her current job as an intensive care unit (ICU) nurse in a hospital in
Riyadh, Saudi Arabia, a shift meant to better support her family.

On a current vacation here in the Philippines, Catalina began complaining of back

pain but noted no neurological deficit. Subsequently, she developed significant
weakness of the right leg with associated difficulty ambulating. She also reported a
persistent cough of a few weeks but denied having fever, chills, and hemoptysis (i.e.,
coughing up of blood). On examination, the patient was afebrile. She had good
strength in both the upper and left lower extremities, but the right lower extremity
exhibited noticeable weakness in hip and knee flexion and extension, and ankle flexion
and extension. The lungs were clinically clear, and cardiac examination was generally
normal. Lumbosacral radiography revealed apparent fusion of bodies of T12 to L2
vertebrae. Chest radiograph was unremarkable. She was admitted for management
of her neurological deficit and persistent back pain. During her stay in the hospital, the
patient continued to have severe back pain, despite being given adequate doses of
narcotics and muscle relaxant.

Because of strong clinical suspicion and continued patient deterioration, biopsy and
culture of the lesion between the T12-L1 vertebral bodies was performed. The
specimen grew Mycobacterium tuberculosis. She was immediately started on anti-
Koch medication with continued rehabilitation. The patient's back pain gradually
diminished and reported slight improvement in ambulation during subsequent follow-
up.
1. Using the Framework for the Natural History of Disease, explain the stages in the disease process of TUBERCULOSIS
INFECTION and POTT’S DISEASE (SPINAL TUBERCULOSIS).

PATHOGENESIS
PRE-PATHOGENESIS
EARLY LATE
HOST CLINICAL STAGE
We look into the various
characteristics of a host that will make OUTCOME
him/her susceptible to acquiring

PRODROME
tuberculosis and/or Pott’s disease.
(i.e., A.K.A. tuberculosis spondylitis)

FRANK ILLNESS

CHRONIC STAGE
Among the various risk factors, the
following may be considered as
significant contributors to the
development of tuberculosis infection,
including Pott’s disease (in general):
• living / home environment
• occupational hazard / working
environment and conditions
• possible genetic predisposition
• previous infection with
Mycobacterium tuberculosis
• existing comorbid conditions (if
any)
• lifestyle characteristics ---
smoking habits, diet, substance
use and abuse, etc.
• immune variables
AGENT PRODROME
The organism that has been The classical non-specific constitutional features of tuberculosis indicating presence of an
identified as causing Pott’s disease active disease are malaise, loss of weight and appetite, night sweats, evening rise in
is Mycobacterium tuberculosis . The temperature, generalized body aches, and fatigue.
primary mode of transmission is
hematogenous, allowing the FRANK ILLNESS to CHRONIC STAGE
bacterium to travel to the spine Characteristic clinical features of spinal tuberculosis (Pott’s disease / tuberculosis
often from an extraspinal site of spondylitis) include local pain, local tenderness, stiffness and spasm of the muscles, a cold
infection. It is common to travel abscess, gibbus, and a prominent spinal deformity. The cold abscess slowly develops when
from the lungs in adults, but the tuberculous infection extends to adjacent ligaments and soft tissues.
primary site of infection is often
unknown in children. The infection The level of spinal cord involvement determines the extent of neurological manifestations.
has also been found to spread In cervical spinal tuberculosis, patients manifest with symptoms of cord or root
through the lymphatic system also. compression. The earliest signs are pain, weakness, and numbness of the upper and
Once the Mycobacterium has lower extremities, eventually progressing to tetraplegia. If the thoracic or lumbar spine is
spread, the infection can target involved, upper extremity function remains normal while lower-extremity symptoms
vertebrae, intervertebral discs, the progress over time eventually leading to paraplegia.
epidural or intradural space within
the spinal canal and adjacent soft Patients with cauda equina compression due to lumbar and sacral vertebral damage have
tissue. When the infection is weakness, numbness, and pain, but have decreased or absent reflexes among the
developing, it can spread up and affected muscle groups.
down the vertebral column,
stripping the anterior and posterior
longitudinal ligaments and the Clinical Horizon
periosteum from the front and
sides of the vertebral bodies. This SUB-CLINICAL STAGE
results in loss of the periosteal INCUBATION PERIOD
blood supply and distraction of the
anterolateral surface of the The total duration of the illness varies from few months to few years, with average
vertebrae. disease duration ranging from 4 to 11 months.

With proper anti-Koch’s medication,

Potts’s disease can be adequately
managed, often requiring physical
therapy sessions also.
ENVIRONMENT
Tuberculosis, in all forms, remains to
be a major public health in the
Philippines. According to the
Department of Health, 60-70 Filipinos
die of tuberculosis complication daily,
as of May 2019. From a global
perspective, the Philippines has a high
burden of pulmonary tuberculosis
(PTB), topping the most number of
diagnosed cases of PTB as of
September 2018.

In the above scenario, Mycobacterium

tuberculosis is often transmitted in
health care settings when health care
workers and patients come in contact
with individuals who have
unsuspected TB disease, who are not
receiving appropriate anti-Koch’s
medications, and who have not been
isolated from others despite having
active TB disease.

Poor living and working conditions

(e.g., filthy, crowded, and congested
areas) make the transmission of
Mycobacterium tuberculosis more
likely.

About 95% of cases and 98% of

deaths due to TB occur in tropical
countries while, in temperate low
incidence countries, a
disproportionate portion of TB cases
is diagnosed in immigrants.

Urbanization, poverty, poor housing

conditions and ventilation, poor
nutritional status, low education level,
the HIV co-epidemic, the growing
impact of chronic conditions, such as
diabetes mellitus, are the main
determinants of the current TB
epidemiology in tropical areas. TB
care in these contests is complicated
by several barriers such as
geographical accessibility,
educational, cultural,
sociopsychological and gender issues.
High quality microbiological and
radiological facilities are not widely
available, and erratic supply of anti-
TB drugs may affect tropical areas
from time to time. Nevertheless in
recent years, TB control programs
reached major achievements in
tropical countries as demonstrated by
several indicators.
2. What are the DIFFERENT LEVELS OF PREVENTION that may be recommended for patients with TUBERCULOSIS
INFECTION and POTT’S DISEASE (SPINAL TUBERCULOSIS)?
Primordial and Primary Prevention
Tuberculosis (TB) Infection Control
Measures
Controlling the spread of tuberculosis is
the only way available to prevent spinal
tuberculosis / Pott’s disease.
• airborne precautions
• prompt detection of TB disease
• ensuring proper cleaning,
sterilization, or disinfection of
equipment that might be
contaminated (e.g., endoscopes)
• educating, training, and counseling
health care workers, patients, and
visitors about TB infection and
disease and on respiratory hygiene
and the importance of cough
etiquette procedures.
• using posters and signs to remind
patients and staff of proper cough
etiquette (i.e., covering mouth when
coughing) and respiratory hygiene
• controlling the source of infection by
using local exhaust ventilation (e.g.,
hoods, tents, or booths) and diluting
and removing contaminated air by
using general ventilation
• controlling the airflow to prevent
contamination of air in areas adjacent
to the source airborne infection
isolation (AII) rooms; and cleaning
the air by using high efficiency
particulate air (HEPA) filtration, or
ultraviolet germicidal irradiation
From a public health perspective, it is
imperative to highlight healthy living for
the general public to prevent onset of
tuberculosis in all its forms (i.e., HEALTH
PROMOTION). Healthy lifestyle must
be advocated --- proper diet and
nutrition, adequate levels of sleep and
rest, cigarette smoking cessation,
environmental health, etc.
Increasing public health awareness on
tuberculosis can also help curb the TB
burden. In the Philippines, as part of
the advocacy campaign of the
Department of Health, August is
recognized as National Tuberculosis
Month.
SPECIFIC PROTECTION may also be
necessary. Vaccination with BCG can
protect infants from acquiring
complicated extrapulmonary tuberculosis
infections, such as TB meningitis.
Chemoprophylaxis may also be warranted
in a few sectors of society (e.g., anti-
microbial prophylaxis for primary Koch’s
infection in children).
Secondary Prevention
EARLY DIAGNOSIS
For tuberculosis in general, several
screening and confirmatory tests may be
done. These will include the purified
protein derivative (PPD), chest
radiograph, direct sputum smear
microscopy (DSSM), and TB culture.
Diagnosis of spinal tuberculosis, however,
depends on presence of characteristic
clinical and neuroimaging findings.
Etiological confirmation requires the
demonstration of acid-fast bacilli on
microscopy or culture of material
obtained following biopsy the lesion.
Polymerase chain reaction (PCR) is
also an effective method for
bacteriological diagnosis of tuberculosis.
The most recent update on the diagnosis
of tuberculosis is via GeneXpert.
Screening of the whole spine should be
done to look for non-contiguous vertebral
lesions.
Imaging for Pott’s Disease
Conventional radiographs give a good
overview; computed tomography (CT)
visualizes the disk-vertebral lesions and
paravertebral abscesses, while magnetic
resonance imaging (MRI) is useful in
determining the spread of the disease to
the soft tissues and to determine the
extent of spinal cord involvement.
Cytological and Microbiological
Confirmation
Etiological confirmation can be made
either by demonstration of acid-fast
bacilli on pathological specimen or
histological evidence of a tubercle or the
mere presence of epithelioid cells on the
biopsy material.
Polymerase Chain Reaction and
Other Immunological Tests
Conventional microbiological methods,
like Ziehl–Neelsen staining for acid-fast
bacilli and culture of M. tuberculosis on
Lowenstein Jensen media, have low
sensitivity and specificity. The
QuantiFERON-TB Gold assay detects
cell-mediated inflammatory responses in
vitro to tuberculosis infection by
measuring interferon-gamma harvested
in plasma from whole blood incubated
with the M. tuberculosis specific antigens.
Since tuberculosis is generally
communicable, intimate household
contacts must also be screened for Koch’s
infection.
Tertiary and Quaternary Prevention
DISABILITY LIMITATION
In some circumstances concerning Pott’s
disease, surgery appears to be beneficial
and may be indicated. Potential benefits
of surgery include less kyphosis,
immediate relief of compressed neural
tissue, quicker relief of pain, higher
percentage of bony fusion, quicker bony
fusion, less relapse, earlier return to
previous activities, and less bone loss. It
may also prevent late neurological
problems due to kyphosis of the spine if
fusion has not occurred. Indications for
surgery are refractory disease, severe
kyphosis, an evolving neurological deficit,
and clinical deterioration or lack of clinical
improvement.
In cases where motor and sensory
deficits develop secondary to
impingement of spinal nerves in the back
region (i.e., cord compression), the
patient may have various degrees of
paralysis. In such patients, regular
caregiver may be needed for all activities
of daily living (ADLs) and transfers.
Thus, it is also prudent to assess family
members for possible caregiver fatigue
syndrome, which at times may result in
neglect of debilitated patients with Pott’s
disease and subsequently poor quality of
life. In such scenarios, family counseling
and family intervention may be necessary
as part of the holistic management of
minimizing disabilities.
REHABILITATION AND PHYSICAL
THERAPY
For those with neurologic deficit or
when spinal decompression surgery is
warranted, regular physical therapy
sessions may be recommended to
correct structural deformity and to
prevent further neurological
complications.
AVOIDING OVER-TREATMENT
Sometimes, doctors may
indiscriminately prescribed antibiotic
therapy even for common viral
infections, which are generally self-
limiting even in the absence of anti-
microbials. The non-judicious use of
antibiotics can lead to higher drug
resistance levels, which may involve
the second line anti-Koch’s agents
(e.g., fluoroquinolones). Thus, anti-
microbial stewardship is also
encouraged.
 PROMPT TREATMENT
For Newly Diagnosed Extra-
Pulmonary TB of the Bones –
CATEGORY 1a (2HRZE/10HR):
In the 2-month intensive phase, anti-
tuberculous therapy includes a
combination of four first-line drugs:
Isoniazid (H), Rifampicin (R),
Pyrazinamide (Z), and Ethambutol
(E). In the 10-month continuation
phase, two drugs (Isoniazid and
Rifampicin) are given.

While on-going anti-Koch therapy, it is

also important to monitor liver and kidney
functions. The giving of vitamin B
complexes may also be necessary to
address the potential adverse effect
associated with the use of anti-
tuberculosis agents.

References
• US Centers for Disease Prevention and Control (CDC). Guidelines for Preventing
the Transmission of Mycobacterium tuberculosis in Healthcare Settings, 2005.
MMWR 2005; 54(No. RR-17).
• Gard RK, Somvanshi DS. Spinal Tuberculosis: A Review. J Spinal Cord Med.
2011;34:440–54.
• Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control
of Tuberculosis in Adult Filipinos: 2016 Update.