BMJ  2006;333:201 (22 July), doi:10.1136/bmj.333.7560.201

Letter

Low back pain

Think of tuberculosis

EDITOR—Koes et al in their clinical review on low back pain identify some red flags that may indicate underlying spinal disease in people presenting with back pain.¹

We recently completed a retrospective study of patients with spinal tuberculosis at Ealing Hospital. Of 29 adult patients diagnosed between 2002 and 2005, 23 (80%) were aged between 20 and 50 years (mean age 38.5 years). All were originally from the Indian subcontinent or Africa. Most patients had been in the United Kingdom for more than 5 (range 1-26) years. None was HIV positive, gave a history of carcinoma, or reported steroid use. Only four (14%) had a history of previous tuberculosis or close contact with someone with tuberculosis. Almost all of the patients gave a history of constitutional symptoms (fever, night sweats, weight loss, or loss of appetite). Lumbar and cervical back pain was seen more commonly than thoracic. The erythrocyte sedimentation rate was greater than 35 mm in the first hour on presentation in almost all of them (96%). Many had repeatedly sought healthcare advice from their general practitioners or the accident and emergency department before a diagnosis was made.

A delay in the diagnosis of tuberculosis exposes young patients with a treatable condition to the risk of permanent disability. Non-pulmonary tuberculosis accounts for around 40% of all tuberculosis notifications in the UK.² The incidence of tuberculosis in London has reached 48/100 000, and in areas such as Ealing, with a large immigrant population, the rates are as high as 82/100 000.³ Spinal tuberculosis is therefore a diagnosis that attending doctors need to consider early.

Patients from countries with a high prevalence of tuberculosis presenting with back pain in association with constitutional symptoms and a high erythrocyte sedimentation rate should be investigated to exclude tuberculosis. In the context of a normal spinal x ray and a high clinical suspicion, further cross sectional imaging may be warranted. This is irrespective of patients' age or duration of stay in the UK.

klavanya99{at}yahoo.com, Department of Infectious Diseases, Level 8, Pasteur Suite, Ealing Hospital, Middlesex UB1 3HW

Department of Infectious Diseases, Level 8, Pasteur Suite, Ealing Hospital, Middlesex UB1 3HW

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Competing interests: None declared.

References

1. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332: 1430-4. (17 June.)[Free Full Text]
2. Health Protection Agency. Annual report on tuberculosis cases reported in England, Wales and Northern Ireland in 2003; www.hpa.org.uk/infections/topics_az/tb/pdf/2003_Annual_Report.pdf (accessed 13 Jul 2006).
3. Health Protection Agency. London surveillance bulletin.May 2006, No 7.

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Diagnosis and treatment of low back pain

B W Koes, M W van Tulder, and S Thomas
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