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Case Report: A. Kumar, M. K. Varshney, V. Trikha, and S. A. Khan Isolated tuberculosis of the coccyx J Bone Joint Surg Br 2006; 88-B: 1388-1389 [Abstract] [Full text] [PDF]

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Finding the causes of coccydynia (coccygeal pain)

Patrick M. Foye   (18 January 2007)

Author's Reply

Ashok Kumar, Varshney MK, Trikha V, Khan SA   (27 October 2006)

Should coccygectomy be combined with anti-tuberculosis chemotherapy?

Kadir Bahadır Alemdaroğlu, Serkan İltar, MD, Specialist in Orthopadics   (3 October 2006)

Finding the causes of coccydynia (coccygeal pain) 18 January 2007
Patrick M. Foye, physician (M.D.), Assistant Professor of Physical Medicine and Rehabilitation University of Medicine and Dentistry of New Jersey (UMDNJ): New Jersey Medical School Send letter to journal: Re: Finding the causes of coccydynia (coccygeal pain) FoyePM{at}UMDNJ.edu Patrick M. Foye	Sir, I commend your journal and authors Kumar et al, on what appears to be the first published case of isolated tuberculosis of the coccyx. There are many causes of coccydynia (coccygeal pain) and these are often elusive. The valuable lesson from this paper is to add tuberculosis to the list of possible aetiologies. While Pott's disease (tuberculous spondyloarthropathy) has been known since the 1700s, apparently it has never before been reported to occur solely at the coccyx. I would further emphasise that this case demonstrates that coccygeal involvement by Pott's disease can occur even with a normal chest x-ray or a normal Mantoux test, and without any of the classic symptoms of fever, night sweats, anorexia or weight loss. Thus, physician diligence is required to consider tuberculosis in patients with coccydynia. I would also add that this would seem particularly important not only in developing countries where tuberculosis is more common, but also in other groups with increased rates of tuberculosis (e.g. in certain prison populations and in patients with immunosuppression due to cancer or acquired immunodeficiency syndrome). P.M. Foye, MD, Director, Coccyx Pain Service, Assistant Professor of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA.
Author's Reply 27 October 2006
Ashok Kumar, Senior Resident AIIMS,New Delhi, India, Varshney MK, Trikha V, Khan SA Send letter to journal: Re: Author's Reply ashok_k73{at}rediffmail.com Ashok Kumar, et al.	Sir, We thank Dr Alemdaroğlu for his interest in our article and for his valuable comments. We do agree that skeletal tuberculosis is an insidious disease. The most effective antitubercular drug regimen consists of Rifampin (R), Isoniazid (I), Pyrazinamide (P) and Ethambutol (E) and was established only after the discovery of Rifampin (1966), the main drug active against the persistent or dormant bacilli.1 On reviewing the references, it is noted that the 80-year-old woman in the first reference had trochanteric tuberculosis, as a young woman, in 1935, even before the discovery of Streptomycin (1943)1 and had a recurrence sixty years later(1995). It is likely she did not receive effective antitubercular treatment. The relapse rate with the current four drug regimen (E,H,R,Z) is very low in comparison to the previous antitubercular drug regimen of Streptomycin, PAS or Isoniazid.2 Relapse of tuberculosis occurs due to inadequate antitubercular treatment (ATT), replacement surgery before the complete healing of disease and revision surgery.2 The 45-year-old woman in the second reference had tuberculous coxitis in 1954 and had a hip replacement in situ for 18 years. The patient did not receive adequate antitubercular treatment and she developed tuberculous-induced septic loosening of her new prosthesis after revision surgery. Coccygectomy is controversial even for coccygodynia with variable results.3 There is a risk of rectal perforation or secondary infection due to the close proximity of the anus which may lead to a discharging sinus.4 Direct excision of affected bone in tuberculosis may lead to persistent sinuses or ulceration.2 Coccygectomy in TB coccyx may lead to a similar problem or it will unnecessarily delay the rehabilitation of the patient. We follow the well-established “middle-path” regimen which recommends initial conservative treatment with antitubercular drugs for three to four months and surgical intervention in cases of failed conservative treatment, fresh complications or recurrent disease.5 We conclude that TB coccyx may be managed by antitubercular therapy alone, without any increased risk of relapse. The preferred surgical intervention should be local debridement and coccygectomy, which should be done as a last resort when both ATT and local debridement fail. A. KUMAR MS Orth, M.K. VARSHNEY MS Orth, DNB Orth, V. TRIKHA MS Orth, S.A. KHAN MS Orth, DNB Orth, MCH, MRCS, All India Institute of Medical Sciences, New Delhi, India. 1. Bryskier A. Antimicrobial Agents: Antibacterials and Antifungals. Washington DC: ASM Press, 2005:1088-1123. 2. Tuli SM. Tuberculosis Of The Skeletal System. Second ed. New Delhi: Jaypee Brothers Publishers, 1997:20-6. 3. Maigne J-Y, Lagauche D, Doursounian L. Instability of the coccyx in coccydynia. J Bone Joint Surg [Br] 2000;82-B:1038-41. 4. Feldbrin Z, Singer M, Keynan O, Rzetelny V, Hendel D. Coccygectomy for intractable coccygodynia. Isr Med Assoc J 2005;7:160-162. 5. Tuli SM. Results of treatment of spinal tuberculosis by "middle-path" regime. J Bone Joint Surg [Br] 1975;57-B:13-23.
Should coccygectomy be combined with anti-tuberculosis chemotherapy? 3 October 2006
Kadir Bahadır Alemdaroğlu, MD, Assistant Professor Ankara Training and Research Hospital 2nd Orthopaedics and Traumatology Clinic, Serkan İltar, MD, Specialist in Orthopadics Send letter to journal: Re: Should coccygectomy be combined with anti-tuberculosis chemotherapy? balemdaroglu{at}yahoo.com.tr Kadir Bahadır Alemdaroğlu, et al.	Sir, We read this paper with interest. We want to thank the authors for reporting a very interesting case, which should be useful for readers in differential diagnosis of coccydynia and chronic sinus of the region. However, bone tuberculosis has an insidious course and the disease may relapse after many years.1,2 The coccyx is a rudimentary bone and does not have a crucial role. Excising it does not reduce patient comfort. In our experience excision is a safe procedure.3 We should beware of a relapse. K.B. Alemdaroğlu MD, Assistant Professor, S. İltar MD, Specialist in Orthopaedics, Ankara Training and Research Hospital, Ankara, Turkey. 1. Sastre S, Garcia S, Soriano A. Reactivation of ancient trochanteric tuberculosis 60 years after surgical drainage. Rheumatology (Oxford) 2003;42:1263-4. 2. Fink B, Casser HR, Zilkens KW, Ruther W. Reactivation of a tuberculous coxitis due to loosening of a total hip endoprosthesis. Arch Orthop Trauma Surg 1995;114:298-301. 3. Karalezli K, Iltar S, Irgit K, et al. Coccygectomy in the treatment of coccygodynia. Acta Orthop Belg 2004;70:583-5.