Disseminated tuberculosis following total knee arthroplasty in an HIV patient

The outcomes of total knee arthroplasty following the incidental finding of tuberculosis and its treatment: A prospective study

INTRODUCTION

Extrapulmonary tuberculosis (EPTB) accounts for 16 % of tuberculosis cases globally, with knee joint tuberculosis more prevalent in underdeveloped nations. Total knee arthroplasty (TKA) is commonly used to treat tubercular arthritis of knee, however, there is a marked paucity of research on the outcomes after an incidental diagnosis. The aim of the study is to investigate the outcomes of total knee arthroplasty after an incidental diagnosis of tuberculosis and its management.

METHODS

A prospective-observational study was conducted in NCR-Delhi from May 2019 to June 2023, wherein 533 patients had synovial tissue abnormalities and 11 patients reported with positive histopathological examination (HPE) for knee tuberculosis. All the patients whose informed consent was obtained were put on a twelve-month standard treatment (2HRZE or S/10HR) according to World Health Organization (WHO) guidelines for extrapulmonary TB after TKA and were monitored for the outcome of treatment, any postoperative complication, or implant failure.

RESULT

The mean age of the patients was 63 ± 13 years and 72.7 % of patients were female. The mean hemoglobin, Body Mass Index (BMI), and Erythrocyte Sedimentation Rate (ESR) values were 10.29 ± 1.36 mg/dl, 29.78 ± 6.1 kg/m2, and 37.37 mm/h respectively and the median of the C-reactive protein (CRP) value was 11 mg/dl at the time of operative procedure. All patients presented with knee-joint pain and swelling and were operated for knee-joint replacement surgery. After one year of standard treatment (2HRZE or S/10HR), no relapses, pain, or progressive radiolucency around the component, or postoperative neurologic or vascular complications were observed. The median range of motion (ROM) was improved from 10 - to 100 to 0-115, the average knee score improved from 44.9 ± 8.9 to 84.9 ± 7.73 points and the average function score improved from 28.82 ± 15.56 to 94.0 ± 7.68 points which were statistically significant at 95 % CI (p < 0.0001).

CONCLUSION

We concluded from this study that any abnormalities in ESR, CRP level prior to, and bone tissue or synovial tissue during operative procedure should be considered for articular tuberculosis and managed according to guidelines. This will make replacement procedures more sustainable and effective by lowering the risk of post-operative infection or implant-related complications and improving patients' quality of life.

Mycobacterium tuberculosis infection of a reverse total shoulder arthroplasty: a case report

We describe the case of a 78-years-old male with dyspnea, inappetence and weight loss over a period of two weeks. The CT scan suggested disseminated tuberculosis and T5-T6 spondylodiscitis. During hospitalization, he developed a left shoulder pain where a reverse total shoulder arthroplasty was implanted 11 years ago. Open debridement and lavage with retention of the implant was performed first and intraveinous antibiotics were administered. 3 months after surgery the patient developed a painful sinus track at the incision site. Resection of the fistula tract, soft tissue debridement and removal of the implants were performed before restarting chemotherapy. As the incidence of reverse total shoulder arthroplasty continues to increase throughout the world, periprosthetic joint infection (PJI) will probably raise as well. Diagnosing and treatment of shoulder PJI with atypical germs remains a challenge and explantation seems to be the safer surgical option to avoid recurrent surgeries on patient with increasing comorbidities.

Two-stage TKA for tuberculosis septic arthritis of the knee masquerading as pigmented villonodular synovitis: A case report

A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.

Management of Mycobacterium tuberculosis Prosthetic Joint Infection: 2 Cases and Literature Review

Prosthetic joint infection caused by Mycobacterium tuberculosis (TBPJI) is uncommon but can be encountered in immunocompromised patients or those from tuberculosis-endemic regions. A lack of clinical suspicion and experience with TBPJI often leads to a delay in diagnosis. We report 2 cases of TBPJI in a Hungarian-Canadian and Iranian-Canadian immigrant, respectively. Both were treated with concurrent surgical and medical therapy. We also performed a literature review on TBPJI case reports, outlining their diagnosis and management.

Total Knee Arthroplasty in Patients with Unsuspected Tuberculosis of the Joint: A Report of Four Cases and a Systematic Review of the Literature

OBJECTIVES

To provide a case series and systematic review that explores the clinical manifestations, treatments, and methods for defining tuberculosis diagnoses in patients who have undergone total knee arthroplasty (TKA).

METHODS

Four patients (three women, one man; average age, 59.5 ± 8.89 years; range, 48-69 years) underwent TKA and were subsequently treated for previously unsuspected knee tuberculosis between January 2013 and December 2019. We also reviewed published cases of tuberculous periprosthetic joint infections (TBPJIs) following TKA through databases of MEDLINE/PubMed, the Cochrane Library, and EMBASE. We reviewed studies that were published between January 1980 and December 2019.

RESULTS

In our four cases, the preoperative diagnoses were osteoarthritis (n = 2), rheumatoid arthritis (one case), and Charcot's arthropathy (one case). The main clinical manifestations were knee swelling and pain, without fever, weakness, or weight loss. Comorbidities included multiple joints with rheumatoid arthritis or Charcot's arthropathy, diabetes mellitus, and uremia. One patient had a history of lumbar tuberculosis treated with debridement and intervertebral fusion. Preoperative elevated erythrocyte sedimentation rates (ESRs) were detected in all cases, and elevated C-reactive protein (CRP) levels were observed in three cases. The tuberculosis diagnoses were confirmed via histopathologic analysis (three cases) and second-generation sequencing (one case). Three patients received antituberculosis therapy for 1 year, without surgical intervention. Two-stage exchange arthroplasty was performed in one patient because of prosthesis loosening. Within an average follow-up period of 24.75 months, tuberculosis reactivation was not observed and overall functional improvement was demonstrated. Forty-four TBPJI cases were reported in the literature between January 1980 and December 2019. Most (59.09%) occurred within the first year after the index arthroplasty, and the diagnoses were confirmed by culturing Mycobacterium tuberculosis in 88.64% of cases. Favorable outcomes were achieved in 90.91% of the patients who did not undergo surgery, 71.43% of those treated with debridement, 93.33% undergoing revision arthroplasty, and in 90.91% of those undergoing resection and arthrodesis.

CONCLUSIONS

Clinical manifestations of knee tuberculosis and TBPJI are atypical. Thus, attention should be paid to finding the causes of increased ESRs and CRP levels, particularly in patients with weakened immune functioning, before performing TKA. Pathological examination is an effective method for diagnosing tuberculosis, although sending multiple specimens for pathological examination is necessary.

Miliary tuberculosis with delayed-onset total knee arthroplasty Mycobacteria tuberculosis infection successfully treated with medical therapy alone: A case report and literature review

Tuberculosis (TB) affecting a prosthetic knee is an unusual and diagnostically challenging presentation of this disease. This study reported a case of an 80-year-old man with a left total knee arthroplasty (TKA) performed eight years before his presentation. He presented with left knee swelling and pain for one month. Knee X-rays showed a normal joint space with no loosening of his prosthesis. His chest X-ray showed miliary disease, and microbiological studies of his sputum and synovial fluid aspirate grew Mycobacteria tuberculosis complex. He was successfully medically treated with anti-tuberculous therapy alone for one year. His knee hardware was retained, and he did not require debridement, resection, or revision. It is believed that this is the first reported case of miliary TB with delayed-onset TKA prosthetic joint infection (PJI) in which the prosthesis was successfully retained. Thirty-eight published TB TKA PJI cases in medical literature were also reviewed.

Mycobacterium tuberculosis as a Cause of Periprosthetic Joint Infection After Total Knee Arthroplasty: A Review of the Literature

Total knee arthroplasty (TKA) has become one of the most popular and successful surgeries performed in the world. Infection remains one of the most dreaded complications following TKA, and while rare, tuberculosis as a microbial etiology remains difficult to both diagnose and treat. A review was performed using PubMed, the Cochrane Database of Systematic Reviews, and EMBASE to identify literature pertinent to Mycobacterium tuberculosis infection, TKAs, periprosthetic joint infections, and any combination of the three. The diagnosis of tuberculosis infection after TKA is difficult due to nonspecific signs and symptoms and diagnostic testing. The surgeon should use a comprehensive approach to incorporate the patient's medical history, physical exam, and blood and imaging diagnostics. Among these, bacterial culture and histopathological examination remain the gold standard of diagnosis, but Polymerase chain reaction technology offers another, more sensitive and rapid option. Treatment strategy centers around on the cornerstone of anti-tuberculosis medical therapy and surgery depending on the clinical situation. While there is a lack of primary literature and standardized guidelines for the diagnosis and treatment of tuberculosis infection after TKA, the overarching principles of the treatment of tuberculosis and the treatment of the periprosthetic infection can be implemented together. There remains room for original research and improvements in both diagnostic testing and treatment.

Management of complex tuberculosis cases: a focus on drug-resistant tuberculous meningitis

INTRODUCTION

Drug-resistant tuberculous meningitis has been reported worldwide. Isoniazid mono-resistance is the most frequent cause of drug-resistant tuberculous meningitis, a life-threatening disease. Extensive drug-resistant tuberculous meningitis has also been reported in some isolated case reports. Areas covered: We reviewed the current literature on drug-resistant tuberculous meningitis, as well as drug-resistant tuberculosis. Expert commentary: Drug-resistant tuberculous meningitis is a life-threatening disease and needs prompt diagnosis and treatment. Xpert MTB/RIF Ultra technology can detect Mycobacterium tuberculosis and rifampicin resistance in cerebrospinal fluid (CSF) even with low numbers of bacilli. The optimum antituberculosis drug regimen for multidrug-resistant tuberculous meningitis is largely unknown as no second-line antituberculosis drug-containing regimen has been tested in a randomized controlled fashion in drug-resistant tuberculous meningitis. A combination of levofloxacin, kanamycin, ethionamide, linezolid, and pyrazinamide would be an appropriate regimen because of excellent CSF profile of most of these drugs. End TB Strategy will help in checking the increasing challenge of drug-resistant tuberculous meningitis as it aims to eliminate all kinds of tuberculosis by the year 2035.

Mycobacterium tuberculosis prosthetic joint infections: A case series and literature review

OBJECTIVES

We aimed to characterize diagnosis, management, and outcome of Mycobacterium tuberculosis prosthetic joint infections (PJI).

METHODS

Cases of M. tuberculosis PJI documented in 7 referral French centers were retrospectively reviewed. Data were collected from medical files on a standardized questionnaire. We performed a literature review using the keywords 'prosthetic joint', and 'tuberculosis'.

RESULTS

During years 1997-2016, 13 patients (8 males, 5 females, median age 79 years [range, 60-86]) had documented M. tuberculosis PJI, involving hip (n = 6), knee (n = 6), or shoulder (n = 1). Median time from arthroplasty to diagnosis was 9 years [0.4-20]. The diagnosis was obtained on joint aspirates (n = 9), or synovial tissue (n = 4). PCR was positive in all cases tested (5/5). Median duration of antituberculosis treatment was 14 months [6-32]). Nine patients underwent surgery: debridement (n = 4), resection arthroplasty (n = 3), and revision arthroplasty (1-stage exchange, n = 2). PJI was controlled in 12 patients. Seventeen additional cases of documented M. tuberculosis PJI have been reported, with a favorable outcome in 79% (11/14) of patients with no surgery, 85% (11/13) with debridement, 86% (19/22) with revision arthroplasty, and 81% (17/21) with resection (NS).

CONCLUSIONS

M. tuberculosis PJI can be controlled with prolonged antituberculosis treatment in most cases, with or without surgical treatment.

Tubercular prosthetic joint infection: two case reports and literature review

PURPOSE

Tubercular prosthetic joint infection (TB-PJI) is an uncommon complication. Lack of evidence of systemic tuberculosis and clinical suspicion could bring a delay in the time of the diagnosis. The aims of this study are to underline the importance of awareness and suspicion of mycobacterial infection in the differential diagnosis in PJI and to evaluate the appropriateness of different therapeutic options.

METHODS

Case report and literature review.

RESULTS

We report two cases of TB-PJI after total knee arthroplasty in Caucasian patients without prior history of tubercular disease or exposure. In both cases, the diagnosis was obtained years after the onset of symptoms. Despite that, both patients improved during antitubercular treatment (a four-drug regimen consisting of rifampicin, isoniazid, ethambutol, and pyrazinamide for 2 months, followed by rifampicin and isoniazid). Moreover, after an 18-month course of treatment, there was no need for surgical therapy. The result of the literature review allows us to identify 64 cases of TB-PJI. Many differences in both medical and surgical management have been found, among those reviewed cases.

CONCLUSIONS

Considering our experience and the literature review, we recommend considering a conservative approach (debridement and adequate antituberculous chemotherapy) as a suitable and safe option.

[Diagnosis and treatment strategy of tuberculosis infection after total knee arthroplasty]

Objective

To review the diagnosis and treatment of tuberculosis infection after total knee arthro-plasty (TKA).

Methods

The recent literature concerning the diagnosis and treatment of tuberculosis infection after TKA were extensively reviewed and summarized.

Results

The diagnosis of tuberculosis infection after TKA is difficult. It should be combined with the patient's medical history, symptoms, signs, blood examinations, and imaging examinations, among which the bacterial culture and histopathological examination are the gold standard of diagnosis. Treatment strategy is combined with the drug treatment and a variety of surgical procedures that depends on the clinical situation.

Conclusion

At present, there is no guideline for the diagnosis and treatment of tuberculosis infection after TKA, it still needs further study and improvement.

Total knee arthroplasty in advanced tuberculous arthritis of the knee

BACKGROUND

Controversies regarding the treatment of advanced tuberculosis of the knee still exist. We retrospectively investigated protocols of total knee arthroplasty (TKA) and their efficacy in patients with advanced tuberculosis.

METHODS

Nine TKAs associated with advanced tuberculosis were performed at our institution between 2008 and 2013, with a mean follow-up of 4.4 years (range 2-7 years). In four cases with elevated inflammatory biomarkers, patients received three months of antitubercular drug treatment followed by two-stage TKA. In the remaining five cases with normal biomarkers, patients received one-stage TKA with no pre-operative drug therapy. All patients received antitubercular therapy for one year post-operatively. Clinical and radiological data during follow-up were gathered to evaluate the effects of treatment.

RESULTS

There was no tuberculosis reactivation and all cases demonstrated marked improvement in function and favorable states of prostheses. Specifically, the mean Hospital for Special Surgery (HSS) knee score increased from 44.8 (range 30-60) preoperatively to 82.7 (range 64-92) at last follow-up (P < 0.05). The average range of motion was 56° (range 10° to 90°) before surgery and 94° (range 80-110) at final follow-up (P < 0.05). Elevated erythrocyte sedimentation rates (ESR) and C-reactive protein (CRP) levels returned to normal in a mean of 4.0 months (range 3-5 months) and 3.9 months (range 3-6 months) post-operatively, respectively.

CONCLUSION

Although a consensus of views regarding surgical timing, prosthesis selection, and peri-operative antitubercular therapy has not been reached, our results suggest that TKA can be performed for advanced tuberculous arthritis.

Total knee arthroplasty for the management of joint destruction in tuberculous arthritis

PURPOSE

The purpose of this study was to evaluate our experience to clarify the suggestion that there should be a significant disease-free interval before total knee arthroplasty (TKA) and to determine the correct timing of surgery for reconstruction of the joint destruction in patients suffering from tuberculous arthritis.

METHODS

Twelve patients with advanced joint destruction and tuberculous arthritis of the knee with recent onset were reviewed in this study. The time interval from our diagnosis of active infection to arthroplasty averaged 4 ± 1.5 months. Histopathology of the biopsy specimens revealing granulomatous lesions, including epithelioid histiocytes surrounded by lymphocytes, confirmed the diagnosis of each patient. A primary knee prosthesis was performed in seven knees. In five knees, there was severe bone loss after the extensive debridement of the entire joint, and thereafter, revision prosthesis was preferred to preserve the joint line. Patients were given post-operative antituberculous treatment for a total of 1 year, whereas for three patients, whose erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values remained above normal by the sixth month, the chemotherapy was continued for up to 18 months. The Knee Society TKA roentgenographic evaluation and scoring system was used for radiological evaluation of the knees. Clinical evaluation of the knees was done preoperatively and at the time of the most recent follow-up using the American Knee Society Scoring System.

RESULTS

Within the average follow-up period of 6.1 ± 1.8 years, no reactivation of tuberculous infection was found in any of the patients. ESR was normal, less than 20 mm/h, after a mean time of 5.5 ± 2.0 months. The CRP was normal, less than 0.8 mg/dl, after a mean time of 4.6 ± 1.3 months. At the most recent follow-up, the average knee score improved from 32.4 ± 19.4 to 83.4 ± 14.0 points (p < 0.05), and the average function score improved from 33.3 ± 11.9 to 86.6 ± 7.7 points (p < 0.05). Ten knees showed good integrity, and no radiolucent lines were found in the bone-prosthesis interface in relation to any component. Radiolucent lines were apparent on the tibial side in two knees. They were less than 1 mm thick and non-progressive, and clinically, there was no evidence of loosening of the component. Culture specimens were positive for five patients.

CONCLUSIONS

TKA is a safe procedure for tuberculous arthritis with recent onset providing symptomatic relief, functional improvement and early return to activity when performed in correct time. A long disease-free interval should not be a prerequisite for arthroplasty. Wide surgical debridement is the mainstay to eradicate the disease, and post-operative antituberculous chemotherapy controls the residual foci.

LEVEL OF EVIDENCE

IV.

Tubercular prosthetic knee joint infection

This article reports a rare case of late-onset tubercular infection following total knee arthroplasty in a 60-year-old woman who had been treated with a full course of antitubercular therapy for latent tuberculosis almost 25 years ago. Because no clear guidelines exist for optimal management of disease reactivation in the prosthetic knee joint, the authors performed a literature review and attempted to provide a treatment algorithm based on the time of presentation. Two modes of presentation were identified for unsuspected tubercular prosthetic joint infections based on the onset of symptoms and time to diagnosis: an early-onset presentation that occurs within the first 6 to 8 weeks postoperatively and a late-onset presentation that usually manifests after 8 weeks. Early-onset presentations often can be treated with standard antitubercular chemotherapy alone, whereas late-onset presentation may require 2-stage reimplantation under cover of antitubercular medications. This report also highlights the fact that despite adequate treatment of latent tuberculosis, patients may remain at risk of prosthetic joint infection following total knee arthroplasty.

Peliosis hepatis due to disseminated tuberculosis in a patient with AIDS

Peliosis hepatis is a rare histopathological entity of unknown etiology. We present a case of peliosis hepatis in a 44-year-old man with disseminated tuberculosis and acquired immunodeficiency syndrome. The diagnosis of peliosis hepatis was based on liver biopsy results which were suggestive of tuberculous etiology. Diagnosis of tuberculosis was confirmed by auramine stain, rRNA amplification and culture of Mycobacterium tuberculosis from synovial fluid of the elbow joint. The patient responded favourably to tuberculostatic treatment with four drugs and the early initiation of highly active antiretroviral therapy. Histopathological evidence of peliosis hepatis, without an obvious cause, makes it necessary to rule out tuberculosis, especially in the context of immunodeficiency diseases and immigrants from endemic areas.

Prosthetic knee infection in the young immigrant patient--do not forget tuberculosis!

Skeletal tuberculosis (TB) frequently masquerades as more common etiologies and can be difficult to diagnose. We describe a case of TB knee arthritis in a young Haitian-born woman in whom the diagnosis was not initially suspected, resulting in treatment with total knee arthroplasty that subsequently failed. A long course of medical and surgical therapies was then necessary to treat this patient. Issues in the diagnosis and management of TB in the native and prosthetic knee joint are presented.

Tuberculous synovitis of the knee in a 65-year-old man

INTRODUCTION

Tuberculous (TB) synovitis is a rare, treatable, potentially lethal form of extrapulmonary TB resulting from massive lymphohematogenous dissemination of Mycobacterium tuberculosis (M. tuberculosis). We presented a case of TB synovitis of the knee in a Caucasian HIV-negative man from Romania, a high TB incidence country.

CASE REPORT

A 65-year old man presented with cough, high fever, mild wheezing, and swelling of the left knee. Chest radiography was normal. Sputum smears were Acid Fast Bacilli negative and Lowenstein-Jensen (L-J) culture negative for M. tuberculosis. Tuberculin skin test was negative. Respiratory symptoms disappeared in a week under antibiotics. Positive L-J cultures of knee punctation and favourable treatment outcome following standardized antituberculous treatment regimen confirmed the diagnosis of specific synovitis, which was also demonstrated by Magnetic Resonance Imaging (MRI).

CONCLUSION

Tuberculous synovitis is important differencial diagnosis in patients with arthropathies and risk factors for TB in all the countries and all patients' ages even when tuberculin skin test is negative.