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\begin{document}

\title{Tuberculous myelitis as an unusual presentation of a common disease in
Sudan}



\author[1]{Eetadal Ibrahim}%
\author[2]{Khalid Mohammed Mohammed}%
\author[3]{Lina Hussain  Mustafa}%
\author[4]{Khabab  Mohamed Ahmed}%
\author[2]{Mohammed Omer}%
\affil[1]{Al-Neelain University Faculty of Medicine}%
\affil[2]{University of Gadarif Faculty of Medicine and Health Science}%
\affil[3]{The National center for Neurological Sciences }%
\affil[4]{University of Khartoum Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
Tuberculosis(TB) is a common disease in Sudan .Neurological consequences
of TB are frequently encountered in our practice of neurology
particularly tuberculosis of the spine(Pott,s disease).There are few
case reports of tuberculous myelitis in literature.%
\end{abstract}%



\sloppy


\textbf{Tuberculous myelitis as an unusual presentation of a common
disease in Sudan}

\textbf{Etedal Ahmed A Ibrahim\textsuperscript{1,2},Khalid Mohammed
Ali\textsuperscript{3},Lina Hussain Mustafa\textsuperscript{4}}

Khabab Abbasher Hussien Mohamed Ahmed\textsuperscript{\textbf{5}}

Mohammed Eltahier Abdalla Omer 6

1/National Center of Neurological Sciences,Consultant Neurologist,
Sudan.

2/ Al-Neelain University, Faculty of Medicine, Neurology department,
Sudan

3/ Neurologist, Gadarif University Faculty of Medicine and Health
Sciences, Gadarif, Sudan.

4/National Center of Neurological Sciences, Khartoum, Sudan .

5/ Medical student, University of Khartoum Faculty of Medicine,
Khartoum, Sudan.

6/ Teaching Assistant, Internal Medicine Department, Gadarif University
Faculty of Medicine and Health Sciences, Gadarif, Sudan.

\textbf{Key message :}

\textbf{Our case highlights that tuberculous myelitis should be
considered in most of patients in Sudan who present with features
suggestive of TB of spine because early use of iv methyle prednisolone
will remarkably affect the prognosis.}

\textbf{ABSTRACT}

\textbf{Tuberculosis(TB) is a common disease in Sudan .Neurological
consequences of TB are frequently encountered in our practice of
neurology particularly tuberculosis of the spine(Pott,s disease).There
are few case reports of tuberculous myelitis in literature.}

\textbf{Background}

Transverse myelitis (TM) is a rare neurological disease in which the
spinal cord is inflamed. \emph{Transverse} implies that the inflammation
extends across the entire width of the spinal cord.{[}1{]} Pott's
disease or Pott's disease is a form of tuberculosis that occurs outside
the lungs whereby disease is seen in the vertebrae{[}2{]}
Tuberculosis(TB) is a common disease in Sudan .Neurological consequences
of TB are frequently encountered in our practice of neurology
particularly tuberculosis of the spine(Pott\textsuperscript{,}s
disease). Pott\textsuperscript{,}s disease can lead to lower limbs
weakness due to predilection to involve thoracic vertebrae.Involvement
of spinal cord may take several forms; compression,myelitis and
ischaemic effect as a result of endarteritis obliterans.There are few
case reports of tuberculous myelitis in literature.

During our practice we faced by a considerable number of cases that have
been managed successfully with iv methyl prednisolone therefore we
decided to start reporting such uncommon cases. Literature search we
found some case reports more or less with similarity to our case.A case
report from India :Tuberculous myelitis can occur as a secondary event
in the course of common forms of tuberculous meningitis. It is an
important and not an uncommon cause of paraparesis in Indian
setting.{[}3,4{]} Tuberculous myelitis generally occurs when the
diagnosis has been delayed and thick exudates form with spinal blocks.
Occasionally, the infection may begin in the spinal area resulting in
backache and involvement of the spinal cord and roots at multiple
levels. In the early stages, this may be confused with other forms of
viral myeloradiculopathies, but the evidence of elevated CSF protein,
reduction of sugar, largely lymphocytic cellular count and presence of
acid fast bacilli should confirm the diagnosis. PCR for Mycobacterium
tuberculosis of the cerebrospinal fluid is a very specific test in its
diagnosis. The patient should be treated with antituberculous drugs
rifampicin, isoniazid, pyrazinamide, streptomycin and/or ethambutol. Use
of steroids is recommended.{[}5{]} Gouri Devi has advocated the use of
intrathecal hyaluronidase, for arachnoiditis{[}6{]}, but double blind
control studies are needed before this treatment can be routinely
advocated. With the advent of M.R.I. identification of such lesions have
become much more easier.Intramedullary. The most common central nervous
system (CNS) manifestations of TB is tuberculous meningitis (95~\%),
followed by cerebral tuberculoma and tuberculous abscess. OThe most
common central nervous system is \# 40, CNS, and \# 41; the
manifestations of tuberculosis are tuberculous meningitis (95\%),
followed by cerebral tuberculoma and tuberculous abscess. Other
infrequent manifestations are cranial tuberculosis, tuberculous
pachymeningitis (Tariq and Ahmed 2012) and spinal arachnoiditis (Naidoo
et al. 1991). Intramedullary spinal tuberculosis is a rare presentation.
Few cases of intramedullary spinal tuberculosis have been reported in
the literature (Lin et al. 1994). Longitudinally Extended Transverse
Myelitis (LETM) is characterized by an immune-mediated contiguous
inflammatory lesion of the spinal cord that extends to three or more
segments of the spinal cord (West 2013).Tuberculosis is a rare cause of
LETM. {[}5{]}Find articles by Rajendra Singh Jain

Sunil Kumar

Department of Neurology, Sawai Man Singh Medical College, Jaipur,
Rajasthan India

Find articles by Sunil Kumar

Shankar Tejwani

Department of Radiology, Sawai Man Singh Medical College, Jaipur,
Rajasthan India

Find articles by Shankar Tejwani

Department of Neurology, Sawai Man Singh Medical College, Jaipur,
Rajasthan India

Department of Radiology, Sawai Man Singh Medical College, Jaipur,
Rajasthan India

Rajendra Singh Jain, Phone: +919414073579, Email: moc.oohay@niajsrrd.

Contributor Information.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
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Corresponding author.

Received 2015 May 1; Accepted 2015 Aug 10.

Copyright \selectlanguage{ngerman}© Jain et al. 2015

Open AccessThis article is distributed under the terms of the Creative
Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided
you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons license, and indicate if changes
were made.

\textbf{Case Description}

A 47 year old man, farmer from eastern Sudan presented with lower limbs
weakness which was gradually progressive over 20 days ,the patient
became completely unable to walk 8 days prior to admission. The weakness
associated with lower back pain, numbness of lower limbs as well as
urine retention and constipation. No headache , convulsions or loss of
consciousness, no symptoms related to cranial nerve nor the upper limbs
,no neck pain and no history of trauma. There was history of fever,
night sweating loss of appetite . No loss of weight chronic cough.The
condition is not preceded by URTI nor gastroenteritis. Not known to be
diabetic , hypertensive or any chronic illness. Family history:Nothing
was significant Drug history: Not on LTM. Not known allergic to certain
drug. Social history:Married with 2 kids, neither smoker nor alcohol
consumer. Looked unwell, average size not pale , jaundiced or cyanosed
PR: 70/min. regular ,RR: 20/min , \textbf{BP::160/90} .Chest / CVS /
abdomen : were normal \textbf{Neurology examination:} Conscious ,fully
oriented with intact memory and speech a Cranial nerves were intact
including the fundus .Normal neck examination. Normal upper limbs
examination. Lower limbs examination revealed hypertonia hyperreflexia
power was grade 2 with impaired sensation up to D7.Planter were up
going. Back examination revealed lower back tenderness , no
deformities.CBC:HB 12.9g/dl TWBCs 7.8c/cm PLT 262c/cm . Blood urea
41g/dl S.Cr 1.0mg/dl S.k 4.3mmol/l

RBG:100 gg/dl BFFM --ve LFT: normal HIV --ve HBV screening --ve HCV
screening --ve ESR : 70 mm/hour PSA :2.4 PCR +ve for Tuberculosis in the
CSF. Chest x-ray: Normal. Initial MRI Doral spine were shown below which
was reported as :Discitis at the level D8 and D9\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Management:} Methylprednisolone 1g in 500 ml normal saline once
/ day for 5 days followed by oral prednisolone 60 mg daily tapered every
2 weeks according to the response. Then anti tuberculous therapy for 12
months.

Follow up: After completing the 5 days iv methylprednisolone,the patient
start to walk with 2 person support(the power was grade 4).4 Weeks later
he walk with one person support(the power was 4+). Follow up MRI is
shown below:\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Discussion}

In our case we match between the clinical sense and image results so we
came with a preliminary diagnosis that was infection and we came with a
final diagnosis of myelitis rather than discitis alone because the later
couldn't explain the weakness unless it was complicated by abscess which
is easy to be detected by MRI .On the other hand myelitis may not need
high quality MRI to be shown. Despite the report of MRI which came as
Discitis at the level D8 and D9,but this does not explain the
paraparesis with sensory level at D7 and urine rention. So considering
discitits is going more with infectious causes so we consider TB as a
common problem in Sudan particularly in the Eastern states (the origin
of our patient).we made a clinical diagnosis of TB myelitis and manage
initially with iv methyl prednisolone according to evidence
based.{[}3{]}

\textbf{Conclusion}

Our case highlights that tuberculous myelitis should be considered in
most of patients in Sudan who present with features suggestive of TB of
spine because early use of iv methyle prednisolone will remarkably
affect the prognosis. The clinician need to use their clinical sense in
concordance with the investigations to finalize the diagnosis. Further
reporting of such cases is recommended.

\emph{Declarations:}

\textbf{Ethics approval:}

Not applicable

\textbf{Consent to participate:}

Verbal and written consents were obtained from the patient before
writing the case or using investigations.

\textbf{Consent for publication:}

Written consent to publish this information was obtained from the
patient. The patient gave written consent for his personal clinical
details along with his MRI images to be published in this study. This
patient has not been reported in any other submission by the authors or
anyone else.

\textbf{Availability of data and material} s:

The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.

\textbf{Competing interests:}

The authors have no conflict of interest to declare.

\textbf{Funding:}

The study was funded by the authors themselves.

\textbf{Authors' contributions:}

EIA: The first author collected the data, analysed the results and wrote
the manuscript. KMA,LHM, KH, MEO:authors wrote the manuscript, revised
the manuscript and did editing. All authors read and approved the final
manuscript.

\textbf{References}

1.\^{} \textsuperscript{a} \textsuperscript{b}
\textsuperscript{cd}Transverse myelitis''. Genetic and Rare Diseases
Information Center (GARD) -- an NCATS Program. Retrieved 3 January 2018.

2.TB Symptoms. 2013-01-18. Archived from the original on 2013-10-31.
Retrieved 2013-07-11.

3. Wadia NH, Dastur DK. Spinal meningitides with radiculomyelopathy :
Clinical and radiological features. J Neurol Sci 1969; 8: 239-60.

4. Ahuja GK, Venkataraman S, Roy S et al. Tuberculous
radiculomyelopathy. Neurology (India) 1978; 26: 135-9.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

5.A rare association of tuberculous longitudinally extensive transverse
myelitis (LETM) with brain tuberculoma.Rajendra Singh Jain, Sunil Kumar,
and Shankar Tejwani.The article cited by other articles in PMC.Rajendra
Singh Jai\ldots{}.Department of Neurology, Sawai Man Singh Medical
College, Jaipur, Rajasthan India s

6. Gour Devi M, Satishchandra P. Hyaluronidase as an adjuvant in the
management of tuberculous spinal arachnoiditis. J Neurol Sci 1991; 102:
105-11.

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