By Pankajbala R Patel

WHEN a friend of ours was suddenly informed that his MRI results clearly indicated skeletal tuberculosis, we were shocked. We didn’t know there were several kinds of TB and there is tuberculosis and tuberculosis – not just of the lungs or pulmonary kind, but also of the bones and brains and spine. Generally speaking tuberculosis is a contagious infection that usually attacks your lungs but it can spread to almost every part of the body courtesy a bacteria called Mycobacterium tuberculosis.
What do you know of tuberculosis in this country and how ancient it is! In fact, one may say that tuberculosis is more prevalent in still impoverished countries like India. It is so serious a disease that the government of India pays TB patient and the person who motivates him/her to complete the TB medicines prescribed in something like a 6-month course to cure the disease.
Tuberculosis is curable and many patients are in remission today — despite the challenge for a patient to take the medicine which is said to be horribly red-colored, bitterish and so impractically made up of large oblong tablets — which weaker and older patients may choke on while swallowing them!
SKELETAL tuberculosis is one of the most painful forms of the disease. It spreads in the bones and/or joints of the skeleton and interestingly this kind of spinal or skeletal TB has been found in Egyptian mummies of old dating back 9000 years (also an analysis of 483 pre-Columbian skeletons in Chile showed lesions consistent with bony TB in 2% cases). Tuberculosis is aptly said to be disease of poverty, starvation, poor immune, old age and accompanying malnutrition.
Skeletal TB is not as rare as you may think. It is said that this bone tuberculosis spreads through the blood if you come in contact with an infected person’s body fluids or pus. Skeletal tuberculosis can also be caused by pulmonary tuberculosis. Bacteria spread from lungs to bones, spine or joints through blood vessels.
One may not take TB of the skeleton lightly. It is a serious condition since it destroys the thoracic and leads to bone deformity. You will see it in a lot of senior citizens suffering from poor health. Hence, the need to be conscious of the symptoms plaguing us in day-to-day life … tuberculosis is curable if detected early enough but unfortunately, most of us live like the blind, deaf and dumb in our rat-race lifestyles and miss the coughing and moaning of members of the family complaining of pain here and there. We as a people in India rarely take ourselves seriously and continue to suffer like it is a badge of honour or so to speak.

NOT INFECTIOUS
NOT all forms of tuberculosis are infectious or contagious. Mercifully, skeletal TB which we are discussing here, is generally not contagious because the disease spreads through coughed-up active virus particles and unless you come in contact with a patient’s pus, you are safe. However, this is to say please do not neglect any form of TB because untreated tuberculosis can affect your lungs and other parts of the body and tuberculosis complications mean a lot of severe pain.
An MRI offers the best diagnosis of any kind of bone TB so if you suspect that you may be suffering initial symptoms of this disease get an MRI done without wasting time. MRI offers excellent visualization of the bone and soft tissue components of spinal tuberculosis and helps to identify disease at distant asymptomatic sites. CT is useful in assessing bone destruction, but is less accurate in defining the epidural extension of the disease and therefore its effect on neural structures.
The fact is that when bones are in trouble so is the nervous system and the muscles system riding on it. Slight movements may trigger off agonizing, wretched pain. How is such bone TB treated? Taking medicines are the first line of treatment and duration of treatment lasts from six to 18 months. The most common drug medicines used are called rifampicin, ethambutol, isoniazid and pyrazinamide.

CLINICAL MANIFESTATIONS
THE clinical manifestations of tuberculosis are vast and varied and can range from spondylitis (Pott disease) to arthritis of the wrist and of the hip and more. The pathology is that during initial infection the bacteria may lead to seeding of organisms in bone and/or synovial tissues. In most cases, small infection is confined by our immunity and infection is subclinical. However, following primary infection, reactivating foci are usually contained by the cellular immune response. CD4 and CD8 lymphocytes play important roles, as does interferon-gamma.
It is true that that the progression of the disease increases with failing local immune defences and this in turn points to malnutrition in advancing age, or HIV infection, or advancing kidney disease. Spinal involvement is usually a result of spread of the infection into the dense vasculature of the bones of the vertebral bodies – the primary infection site is either a pulmonary lesion or an infection of the genitourinary system. Spread occurs either via the arterial or the venous route….spread of the infection via the venous system may be responsible for central vertebral body lesions.
In spinal or skeletal tuberculosis, characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to the characteristic angulation and gibbus (palpable deformity because of involvement of multiple vertebrae) formation. The upper lumbar and lower thoracic spine are most frequently involved sites. More than one vertebra is typically affected, and the vertebral body is more frequently affected than the posterior arch. Distortion of spinal column leads to spinal deformities. Paraplegia is the most devastating complication of this kind of tuberculosis and there is early-onset paraplegia and paraplegia of healed disease (late-onset paraplegia).

SLOW PROGRESS
MAKE a note of the characteristic clinical features of skeleton tuberculosis: Local pain, local tenderness, stiffness and spasm of the muscles, a cold abscess, gibbus, and a prominent spinal deformity. The cold abscess slowly develops when the infection extends to adjacent ligaments and soft tissues. Cold abscess is characterized by lack of pain and other signs of inflammation.
The progression of skeletal tuberculosis is slow and insidious. The total duration of the illness varies from few months to few years, with average disease duration ranging from 4 to 11 months. Usually, patients seek advice only when there is severe pain, marked deformity, or neurological symptoms. The take home message here is that the classical features of tuberculosis indicating presence of an active disease are malaise, loss of weight and appetite, night sweats, evening rise in temperature, generalized body aches, and fatigue. You will find the patient is constantly asking you to rub balm on his/her back. Back pain is the most frequent symptom of skeletal tuberculosis. The intensity of pain varies form constant mild dull aching to severe disabling. It is aggravated by spinal motion, coughing, and weight bearing, because of advanced disk disruption and spinal instability, nerve root compression, or pathological fracture. Chronic back pain as the only symptom often observed in 61% of cases of skeletal tuberculosis.

NUTRITIONAL POWER
ARE there any nutritional ways to treat tuberculosis? Yes, up your intake of fresh foods and fruit which are rich in enzymes, vitamin A, C and E or the ACE vitamins as they are called. Include natural painkillers and antibiotics like garlic, onions, citrus fruit, salad of greens and the salad veggies of carrots, tomatoes; Indian gooseberry and guava are rich in vitamin C and so are capsicums…include these in your daily regime if you are a TB patient!
Remember that nutritional inputs are just to help you heal faster, but you have to cure TB the fastest way through the two antibiotics (soniazid and rifampician) for six months, 2 additional antibiotics (pyrazinamide and ethambutol) for the first two months of the six-month treatment protocol in mainstream modern medicine.
Other than all this it is well said that a sanatorium of old is a better please to cure yourself of tuberculosis of anything – than a hospital! Remember the old stories of how TB patients were sent off to a sanatorium to recuperate…the curing was done by sunshine, fresh air, natural foods, naturopathy treatments and much else to relax the mind and make the heart happy! Get rid of stress and anxiety from life – which is of course, easier said than done. Incidentally, vitamins D and C are known to have antibacterial properties. You might do a bit of homework if you want to cure yourself of tuberculosis of any kind – indulge yourself with that glass of pineapple or beetroot/carrot/celery juice!