Journal of Korean Society of Spine Surgery Thoracic Vertebral Fracture due to Spinal Tuberculosis which was Misdiagnosed as Matastatic Cancer - A Case Report - Dae Geun Kim, M.D., Jae Hwan Cho, M.D., Jae Hyoun Kim, M.D., Jung-Ki Ha, M.D., Dong-Ho Lee, M.D., Choon Sung Lee, M.D. J Korean Soc Spine Surg 2015 Jun;22(2):55-59. Originally published online June 30, 2015; http://dx.doi.org/10.4184/jkss.2015.22.2.55 Korean Society of Spine Surgery Department of Orthopedic Surgery, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211 Eunju-ro, Gangnam-gu, Seoul Tel: 82-2-2019-3413 Fax: 82-2-573-5393 Copyright 2015 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.krspine.org/doix.php?id=10.4184/jkss.2015.22.2.55 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.krspine.org
Case Report pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2015 Jun;22(2):55-59. http://dx.doi.org/10.4184/jkss.2015.22.2.55 Thoracic Vertebral Fracture due to Spinal Tuberculosis which was Misdiagnosed as Matastatic Cancer - A Case Report - Dae Geun Kim, M.D., Jae Hwan Cho, M.D., Jae Hyoun Kim, M.D., Jung-Ki Ha, M.D., Dong-Ho Lee, M.D., Choon Sung Lee, M.D. Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Study Design: A case report. Objectives: To report the case of a patient whose preoperative imaging results seemed to show metastatic spine tumor but who actually had a vertebral pathologic fracture caused by spine tuberculosis. Summary of Literature Review: Tuberculosis spondylitis is classified into peridiscal, central, anterior, and posterior spondylitis according to the portion involved, and central spondylitis can be mistaken as a tumor. Materials and Methods: Imaging studies were performed in a 79-year-old female with progressive lower extremity weakness. We found a T12 pathologic vertebral fracture, which was suspected to be metastatic cancer. Results: We performed surgery and found spine tuberculosis in the pathological and immunological examinations. Two weeks postoperatively, the patient could walk with crutches and underwent anti-tuberculosis therapy. Conclusions: Even when the results of imaging studies predict spinal metastasis, we should keep in mind the possibility of spinal tuberculosis. Key Words: Spine, Pathologic fracture, Neoplasm metastasis, Tuberculosis, Decompression 서론 결핵은대부분폐를침범하는감염성질환인동시에우리나라에서유병률이높은질환이다. 폐에이어서골격계는결핵이침범을잘하는곳중에하나이며, 골격계중 50% 가척추가차지한다. 1) 전형적인척추결핵의경우추간판뿐만아니라척추체전방부에영향을미쳐주변추체부, 연부조직및디스크의파괴를일으키나소수에서는결핵의이러한전형적인형태를띠지않기도한다. 비전형적인척추결핵은척추의종양으로오진되어진단및치료가늦어질수있다. 2) 우리는이러한예가있어문헌고찰과함께이를보고하고자한다. 증례보고 79세여자환자는내원 2주전부터배부통증과함께진행되는하지위약감을주소로타원에서 12번흉추병적골절을진단받은후원인감별및치료를위해본원외래를내원하였다. 외상및특별한과거력은없었고, 현재고혈압약외에는복용하 는약도없었다. 1 개월전부터 5 kg 의체중감소가있다고하였 으며입원당시 38 도정도의미열이있었다. 혈액검사에서백 혈구 10600 /ul, 혈색소 12.3 g/dl, 적혈구침강속도 38 mm/ h( 정상치, 0-20 mm/h) 그리고 C- 반응성단백질은 5.65 mg/ dl( 정상치, 0-0.6 mg/gl) 이었다. 신경학적검사에는흉추부 위의통증과함께심부압통이있었고, 좌측하지는우측에비 해감각이약 80% 정도떨어져있었으며도수근력검사상 2 등 급의좌측하지근력약화가관찰되었다. 단순방사선사진에서 는 T12 의척추골절이보였고 (Fig. 1), 골절의양상을정확히파 악하기위해시행한자기공명영상에서는척추종양으로의심되 Received: September 25, 2014 Revised: November 13, 2014 Accepted: May 19, 2015 Published Online: June 30, 2015 Corresponding author: Jae Hwan Cho, M.D. Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan 88, Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea TEL: +82-2-3010-3530, FAX: +82-2-488-7877 E-mail:doctork78@hanmail.net Copyright 2015 Korean Society of Spine Surgery www.krspine.org 55
Dae Geun Kim et al Volume 22 Number 2 June 2015 는병변에의한 T12 병적골절및그에따른척수압박이관찰되었다 (Fig. 2). 함께시행한 PET-CT 에서도 T11부터 L1까지고르지못한활동성병변이관찰되어전이암이의심되었다 (Fig. 3). 원발병소를찾기위해시행한흉부전산화단층촬영에서는 Fig. 1. Anteroposterior and lateral X-rays of the T-L spine show a T12 compression fracture. Fig. 3. The 18-FDG PET-CT results led to a suspicion of metastatic cancer due to a compression fracture in T12 with uneven hypermetabolic lesions in T11 L1. A B C Fig. 2. (A) A low signal in the bone marrow of T11 and T12, as well as cord compression can be observed in the T1-weighted magnetic resonance imaging (MRI). (B) The T2-weighted MRI demonstrates a low signal in T12 with cord compression. (C) The gadolinium-enhanced MRI shows enhancement of the T11, T12, and L1 vertebral bodies and T12 bilateral pedicle with epidural soft tissue formation and dural sac compression. 56 www.krspine.org
Journal of Korean Society of Spine Surgery Spine Tuberculosis Misdiagnosed as Metastasis Fig. 4. Postoperative simple X-ray shows T12 posterior decompression with vertebroplasty and posterolateral fusion in T9 L3. 행하였으며 (Fig. 4) 추후방사선치료를하기로하였다. 수술중동결절편검사는시행하지않았고, 조직검사결과, 괴사를동반한만성육아종성염증소견을보였다 (Fig. 5). 결핵성척추염하에시행한 AFP 염색검사및 PCR에서음성으로나왔다. 마지막으로감염내과와상의하여시행한 TB interferon gamma test에서 4.52 IU/mL( 정상치, 0.3 IU/mL 이하 ) 으로양성을보여척추결핵진단하에항결핵제제를사용하면서재활중에있다. 술전감소되었던좌측하지근력저하는호전되어퇴원할때에는도수근력검사상 4등급까지향상되었으며목발보행이가능하였다. 고찰 Fig. 5. Photomicrograph from excisional biopsy shows chronic granulomatous inflammation (white arrow) with necrosis (black arrow) (hematoxylin eosin stain, 200 ). anthracofibrosis 의소견이관찰되었고, 복부전산화단층촬영에 서는큰문제점을발견하지못하였으며, 위및대장내시경에서 는정상소견이었다. 검사결과를토대로감염및종양내과, 방사선종양학과와상 의하여 1 세대세파로스포린항생제를 7 일사용하여 C- 반응성 단백질이 3.24 mg/dl 로떨어지고미열도없는상태에서, T12 척추성형술과후방감압술, T9 부터 L3 까지후외방유합술을시 영상검사의발달로척추결핵의진단율은점차향상되고있다. 영상학적검사로는단순방사선검사, 컴퓨터단층촬영및자기공명영상검사가있다. 단순방사선검사는척추체나디스크의함몰이없으면진단이어려우며, 컴퓨터단층촬영은척추체파괴나주변부농양이형성된경우에만도움이된다. 자기공명영상검사는골및주위연부조직의침범범위및정도, 척추관내의병변상태를파악하기좋기때문에척추결핵을진단하는데있어서주된영상검사이다. 결핵성척추염은전형적으로척추체의전방에서시작하여진행하면서추체가파괴되고전방종인대아래로파급되고추체주위에농양을형성하게되면서주위조직이나표면으로퍼진다. 이러한병리기전으로인하여척 www.krspine.org 57
Dae Geun Kim et al Volume 22 Number 2 June 2015 추결핵의전형적인자기공명영상소견은지연성추간판의파괴, 척추체전방의파괴, 전종인대하농양형성, 연부조직석회화등이있다. 3) 전형적인방사선학적소견이관찰되지않는경우의척추결핵을비전형적척추결핵으로정의할수있으며, 임상적으로림프종및다른악성병변등과의감별이필요하다. 4) Jahng 등 5) 에따르면척추체후방을침범하며도약병변및신경관을압박하는비전형적인척추결핵은전이성병변과상당히닮아있기때문에유의깊게살펴보아야한다고하였다. 전이암에의한병적골절은자기공명영상에서골절된추체전부가비정상신호강도를보이며, 추체후면이볼록하고, 척추경을포함한후방요소를침범할수있고, 척추주위혹은경막외종괴를형성할수있으며, 침범된부위에저신호강도의골절선이보이지않는경우가많다. 이런경우, Fluorine-18 FDG를이용한 PET- CT는결핵을포함한감염과종양의감별시민감도 90.9%, 특이도 88.9% 로높기때문에 6) 현재비전형적척추결핵과종양과의감별진단시유용하게사용되고있다. 본증례의환자처럼결핵의과거력은없으면서, 자기공영영상과 PET-CT 에서척추의전이암이의심되고원발병소가확인되지않은상태에서신경학적증상으로수술을해야할경우, 결핵성척추염의가능성은배제해서는안된다. 또한수술도중에동결절편검사를고려해야하며, 병변에결핵균수가적어검체에서결핵균이검출되지않는경우가많아서미생물학적으로결핵균이증명되는비율은낮기때문에배양검사도필수이다. 7) 주의할점은검체를포르말린에넣으면결핵균이파괴되기때문에꼭조직채취후멸균식염수에담아의뢰해야한다. 더불어임상증상및조직검사에서는척추결핵을시사하고있지만, 결핵균검사에서는음성인경우면역학적진단이도움이될수있다. 8) 특히 TB interferon gamma test 의경우결핵균항원만이용하므로투베르쿨린검사보다위양성률이낮고높은민감도와특이도로인하여척추결핵이의심되는환자에게적용할수있는좋은검사법이다 9) 하지만, 근본적으로잠복결핵감염과활동성결핵을감별할수없는문제점이있다. 10) 결론적으로영상검사에서척추전이암이의심되지만, 원발암이확실하지않고, C 반응성단백질이높을경우, 척추결핵의가능성도있으므로진단에주의를기울여야할것이다. REFERENCES 1. Joint committee for the development of guidelines for tuberculosis, prevention Kcfdca: Korea guidelines for tuberculosis first edition. 2011. 2. Sankaran-Kutty M. Atypical tuberculous spondylitis. Int Orthop. 1992;16:69-74. 3. Currie S, Galea-Soler S, Barron D, et al. MRI characteristics of tuberculous spondylitis. Clin Radiol. 2011;66:778-87. 4. Ha KY, Na KT, Kee SR, et al. Tuberculosis of the Spine: A new Understanding of an Old Disease. J Korean Soc Spine Surg. 2014;21:41-7. 5. Jahng J, Kim YH, Lee KS. Tuberculosis of the lower lumbar spine with an atypical radiological presentation - a case mimicking a malignancy. Asian Spine J. 2007;1:102-5. 6. Jeon CH, Yoon JK, Cho JH, et al. Usefulness of Fluorine-18 FDG-PET in the Diagnosis of Vertebral Pathologic Fracture. J Korean Soc Spine Surg. 2006;13:191-9. 7. Golden MP, Vikram HR. Extrapulmonary tuberculosis: an overview. Am Fam Physician. 2005;72:1761-8. 8. Dosanjh DP, Hinks TS, Innes JA, et al. Improved diagnostic evaluation of suspected tuberculosis. Ann Intern Med. 2008;148:325-36. 9. Pai M, Riley LW, Colford JM, et al. Interferon-gamma assays in the immunodiagnosis of tuberculosis: a systematic review. Lancet Infect Dis. 2004;4:761-76. 10. Dewan PK, Grinsdale J, Kawamura LM. Low sensitivity of a whole-blood interferon-gamma release assay for detection of active tuberculosis. Clin Infect Dis. 2007;44:69-73. 58 www.krspine.org
Journal of Korean Society of Spine Surgery Spine Tuberculosis Misdiagnosed as Metastasis 척추암으로오진된척추결핵으로인한흉추병적골절 - 1 예보고 - 김대근 조재환 김재현 하정기 이동호 이춘성 울산대학교서울아산병원정형외과학교실 연구계획 : 증례보고목적 : 영상검사에서척추전이암으로의심되는흉추병적골절이있는환자에서결핵성척추염으로진단되는 1예를경험하였기에보고하고자한다. 선행문헌요약 : 척추결핵은침범부위에따라추간판주위성, 중심성, 전방, 후방으로구분되며, 중심성인경우에는종양으로오인될수도있다. 대상및방법 : 외상없이내원 2주전부터진행되는하지위약감을주소로내원한 79세여자에게시행한영상검사상흉추 12번의전이암이의심되는병적골절이발견되었다. 결과 : 환자는수술을하였으며함께시행한병리및면역학적검사상결핵성척추염으로진단되었다. 환자는위약감이점차회복되어술후 2주째부터목발보행이가능하였으며, 결핵치료도병행하고있다. 결론 : 영상검사의결과척추전이암이라고진단예측되어도척추결핵의가능성도염두에두어야한다. 색인단어 : 척추, 병적골절, 전이암, 결핵, 감압술 약칭제목 : 전이암으로오진된결핵성척추염 www.krspine.org 59