In many countries of the world, there is now a dual epidemic of TB and HIV disease. HIV specifically eliminates the tissue macrophages and CD4 lymphocytes, the very cells that provide immunity against TB . The WHO estimates that worldwide more than 4 million people are infected with TB, 95% of them living in third-world countries. TB is once again the most frequent infectious disease. Extrapulmonary forms frequently appear with HIV-associated TB. In 10% to 25% of the cases, TB manifests itself in extrapulmonary organs. Musculoskeletal manifestations occur in only about 2% of TB cases. These manifestations can vary and present as spondylitis; osteomyelitis; or monoarthritis, oligoarthritis, or polyarthritis .
The symptoms of TB spondylitis are unspecific, and the course is creeping, making an early diagnosis difficult . Spinal TB is more common in the eastern countries than in the Western world. Pott's disease is an uncommon extrapulmonary form of TB, even among HIV-infected patients in whom extrapulmonary disease has increased [106-109]. Dissimilar data about location, diagnosis, and treatment from various hospitals and different countries are reported . The classic radiologic picture of two vertebral diseases with the destruction of the intervertebral disk is easily recognized and readily treated, but its atypical forms are often misdiagnosed and mistreated . Typical findings concerning either etiology or characteristic features of the classic spondylodiscitis are observed less often in HIV-positive patients than in HIV-negative patients; an increasingly common atypical form characterized by spondylitis without disk involvement also has been reported [112,113]. Spondylitis with osteolysis or bone sclerosis at single or multiple levels was also seen. Tuberculous lesion of the posterior arch may be present. In most cases CT scans showed a fragmentary vertebral destruction that was characteristic of the disease. MRI revealed the precise extent of the lesions into the spinal canal [113-115]. Intramedullary tuberculoma  also has been described. Poncet disease, a ReA-like form of TB infection, or tuberculous dactylitis has been increasingly reported in HIV-positive patients.
Atypical mycobacterial infection also has been increased in HIV-positive patients. Infectious arthritis and tenosynovitis caused by Mycobacterium kansasii has been observed, and infectious arthritis by M kansasii [117,118] and Mycobacterium szulgai  in this population. Mycobacterium xenopi may cause bone and joint infections, particularly spondylodis-citis in immunocompromised patients and more often in AIDS patients. Most of the cases reported to date have involved the thoracic or lumbar spine. Antibiotic combinations using fluoroquinolones, new macrolides, and etambuthol are usually prescribed .
Therapy for TB, like HAART therapy, has been associated with autoimmune and rheumatic complications. Use of rifabutin with clarithromycin may precipitate acute uveitis in patients with AIDS being treated for systemic Mycobacterium avium complex infection. Acute tendonitis may develop with the use of quinolones. Clarithromycin and fluconazole elevate levels of rifabutin by inhibiting metabolism through cytochrome P-450 pathway . Regarding surgical treatment, adequate preoperative nutritional support and compliance with antituberculous treatment are essential to get a satisfactory outcome [122,123].
Pyogenic vertebral osteomyelitis were identified in 2 of 29 patients of a retrospective report and S aureus was cultured in both . Pneumococ-cal spondylitis has been reported as the presenting manifestation of HIV infection . It is important to obtain a tissue diagnosis to exclude pyogenic vertebral osteitis. Candida sp spondylodiscitis  and cryptococcal spon-dylitis with neurologic deficit also have been described in an HIV-positive patient. Amphotericin-B and 5-flucytosine were used with a complete neurologic recovery . Because these lesions mimic spinal TB, they may be included in the differential diagnosis.
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