Tuberculous arthritis: A report of two cases with review of biopsy and synovial fluid findings

Pediatric Osteoarticular Infections Caused by Mycobacteria Tuberculosis Complex: A 26-Year Review of Cases in San Diego, CA

BACKGROUND

Osteoarticular infections (OAIs) account for 10%-20% of extrapulmonary Mycobacteria tuberculosis (MTB) complex infections in children and 1%-2% of all pediatric tuberculosis infections. Treatment regimens and durations typically mirror recommendations for other types of extrapulmonary MTB, but there are significant variations in practice, with some experts suggesting a treatment course of 12 months or longer.

METHODS

We conducted a retrospective review of children diagnosed with MTB complex OAI and cared for between December 31, 1992, and December 31, 2018, at a tertiary care pediatric hospital near the United States-Mexico border.

RESULTS

We identified 21 children with MTB complex OAI during the study period. Concurrent pulmonary disease (9.5%), meningitis (9.5%), and intra-abdominal involvement (14.3%) were all observed. MTB complex was identified by culture from operative samples in 15/21 children (71.4%); 8/15 (53.3%) cultures were positive for Mycobacterium bovis. Open bone biopsy was the most common procedure for procurement of a tissue sample and had the highest culture yield. The median duration of antimicrobial therapy was 52 weeks (interquartile range, 46-58). Successful completion of therapy was documented in 15 children (71.4%). Nine children (42.9%) experienced long-term sequelae related to their infection.

CONCLUSION

Among the 21 children with MTB complex OAI assessed, 8 of 15 (53.3%) children with a positive tissue culture had M. bovis, representing a higher percentage than in previous reports and potentially reflecting its presence in unpasteurized dairy products in the California-Baja region. Bone biopsy produced the highest culture yield in this study. Given the rarity of this disease, multicenter collaborative studies are needed to improve our understanding of the presentation and management of pediatric MTB complex OAI.

Differential Diagnosis of Inflammatory Arthropathy Accompanying Active Tuberculosis Infection

Objective

The study aimed to ascertain the clinical manifestations of inflammatory arthritis accompanying tuberculosis (TB) for the differential diagnosis.

Methods

We retrospectively reviewed patients with active TB who presented with inflammatory arthropathy at Seoul Medical Center. Among 2,872 patients with active TB infection, 47 had inflammatory arthropathy 14 had crystal-induced arthropathy; 12, TB arthritis; 12, Poncet's disease (PD); 8, Rheumatoid arthritis (RA); and 1, septic arthritis. The clinical characteristics and laboratory and radiographic findings of each group were analyzed.

Results

In TB arthritis, weight-bearing joints were more commonly affected than the elbow and wrist joints. When compared to TB arthritis, PD demonstrated a significantly higher proportion of polyarthritis and involved both large and small-to-medium-sized joints. The duration of arthritis symptoms after anti-TB treatment was significantly shorter in patients with PD (56 days vs. 90 days, p=0.028). When compared to PD, RA flares during active TB infection involved only small-to-medium-sized joints rather than a mixed distribution (62.5% vs. 16.7%, p=0.035). Patients with PD more commonly had fever at onset and showed a good response to nonsteroidal anti-inflammatory drugs alone or were in remission within 3 months after anti-TB treatment. The presence of rheumatoid factor or anti-cyclic citrullinated peptide and radiographic progression after 12 months was frequently observed in patients with RA flares.

Conclusion

The differential diagnosis of inflammatory arthritis accompanying active tuberculosis infection is challenging. Comprehensive history taking and physical examination, synovial fluid analysis, and a high level of clinical suspicion are essential to avoid delayed diagnosis and to reduce the significant morbidity involved.

Tuberculous Osteomyelitis Mimicking a Lytic Bone Tumor: Report of Two Cases and Literature Review

Tuberculous osteomyelitis is an uncommon form of tuberculosis (TB); the isolated involvement of the wrist joint is particularly rare. The symptoms and clinical manifestation mimic other conditions; hence, careful diagnosis is required. The authors present two cases of patients presenting with soft tissue mass and a lytic bone lesion. The biopsy revealed granulomatous osteomyelitis. Lesion culture identified Mycobacterium tuberculosis . The authors urge clinicians to include TB as a differential diagnosis when investigating the primary cause of lytic bone lesions, even in the absence of pulmonary symptoms or risk factors of TB infection. The inclusion of mycobacterial cultures when analyzing biopsies of lytic bone lesions is also advised.

Synovial Tissue Biopsy Collection by Rheumatologists: Ready for Clinical Implementation?

Synovial tissue from arthritis patients is increasingly used for both basic pathophysiological and clinical translational research. This development has been spurred by the development of biotechnological techniques for analysis of complex tissues and the validation of ultrasound guided biopsies for easier tissue sampling. This increasing use of synovial tissue raises questions on standardization of methodologies for tissue processing and cellular & molecular analyses. Furthermore, it raises the question if synovial tissue biopsy analysis may be more widely implemented in clinical practice, what are the methodological hurdles for implementation and what are the lessons that can be learned from previous experience. This will be the focus of this review.

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.

Musculoskeletal Tuberculosis

Musculoskeletal tuberculosis (TB) accounts for approximately 10% of all extrapulmonary TB cases in the United States and is the third most common site of extrapulmonary TB after pleural and lymphatic disease. Vertebral involvement (tuberculous spondylitis, or Pott's disease) is the most common type of skeletal TB, accounting for about half of all cases of musculoskeletal TB. The presentation of musculoskeletal TB may be insidious over a long period and the diagnosis may be elusive and delayed, as TB may not be the initial consideration in the differential diagnosis. Concomitant pulmonary involvement may not be present, thus confusing the diagnosis even further. Early diagnosis of bone and joint disease is important to minimize the risk of deformity and enhance outcome. The introduction of newer imaging modalities, including MRI (imaging procedure of choice) and CT, has enhanced the diagnostic evaluation of patients with musculoskeletal TB and for directed biopsies of affected areas of the musculoskeletal system. Obtaining appropriate specimens for culture and other diagnostic tests is essential to establish a definitive diagnosis and recover M. tuberculosis for susceptibility testing. A total of 6 to 9 months of a rifampin-based regimen, like treatment of pulmonary TB, is recommended for the treatment of drug susceptible musculoskeletal disease. Randomized trials of tuberculous spondylitis have demonstrated that such regimens are efficacious. These data and those from the treatment of pulmonary TB have been extrapolated to form the basis of treatment regimen recommendations for other forms of musculoskeletal TB.

Tuberculous arthritis of the hip with Staphylococcus aureus superinfection

Skeletal tuberculosis (TB) accounts for a small percentage of all cases of TB. It is often difficult to diagnose, especially in the hip joint. TB arthritis can be masked by superinfection with other pathogens, leading to a delay in diagnosis and treatment. Trauma or surgery is a reported risk factor of TB arthritis. In contrast, descriptions of TB arthritis after a closed bone fracture are rare. We herein report a case involving an 81-year-old woman with septic arthritis superinfected with methicillin-resistant Staphylococcus aureus (MRSA) and Mycobacterium tuberculosis. Three months before presentation, she sustained a bone fracture of the left femur and was treated conservatively without surgery. She developed a fever at another hospital and was transferred to our institution. Computed tomography revealed the presence of abnormal fluid around the left hip joint. MRSA was detected from the fluid and blood cultures. The patient was diagnosed with MRSA arthritis and treated with antibiotics and surgical drainage. However, her fever persisted, and the abscess further developed and enlarged around the left hip. It was punctured and cultured again. Three weeks later, Mycobacterium tuberculosis was identified from the abscess culture. The septic arthritis was confirmed to have been caused by MRSA and M. tuberculosis. After the initiation of antituberculosis therapy, her fever subsided and the treatment was continued. This case demonstrates that the diagnosis of TB arthritis can be hindered by the existence of other pathogens and that TB arthritis can occur at a closed fracture site in the hip joint.

Appearances are Deceptive: Staphylococcus Superinfection of Clavicular Tuberculous Osteomyelitis

A man, aged 25 years, presented with pain, swelling, and drainage from the right clavicular area. He had a past history of abscess at the sternoclavicular joint. The cultures from the drainage site grew methicillin-sensitive Staphylococcus aureus, and he was placed on appropriate antibiotics. As S. aureus infection of the clavicle is often secondary in nature, particularly in adults, a thorough workup was done to identify the underlying cause. Quantiferon gold, done as a part of the workup, came back positive, while the bone cultures grew S. aureus and Mycobacterium tuberculosis. He was placed on 9 months of combination therapy for tuberculosis osteomyelitis with a good clinical outcome.

Infections and arthritis

Bacteria, viruses, fungi, and parasites can all cause arthritis of either acute or chronic nature, which can be divided into infective/septic, reactive, or inflammatory. Considerable advances have occurred in diagnostic techniques in the recent decades resulting in better treatment outcomes in patients with infective arthritis. Detection of emerging arthritogenic viruses has changed the epidemiology of infection-related arthritis. The role of viruses in the pathogenesis of chronic inflammatory arthritides such as rheumatoid arthritis is increasingly being recognized. We discuss the various causative agents of infective arthritis and emphasize on the approach to each type of arthritis, highlighting the diagnostic tests, along with their statistical accuracy. Various investigations including newer methods such as nucleic acid amplification using polymerase chain reaction are discussed along with the pitfalls in interpreting the tests.

An isolated case of first metatarsal tuberculosis

An apparently healthy adolescent presented to us with multiple discharging sinuses from his right foot for the past 1 year. All serological parameters were within normal limits. X-ray picture revealed an expansile osteolytic lesion of first metatarsal. Tissue biopsy and PCR confirmed it be of tubercular etiology. The incidence of isolated occurrence of metatarsal tuberculosis is very rare and the diagnostic dilemma it brings about is briefly discussed in the following report.

Role of fine-needle aspiration cytology and fluid cytology in extra-pulmonary tuberculosis

Extra-pulmonary tuberculosis is the presence of disease in an organ without obvious involvement of the lungs (World Health Organization, Tuberculosis Fact sheet, 2006). The present article focuses on the incidence of extra-pulmonary tuberculosis as an emerging and clinically significant disease to be reckoned with in the present era. It also highlights fine-needle aspiration cytology (FNAC) as an inexpensive, less invasive procedure for early diagnosis of such tuberculosis and timely initiation of specific therapy. All cases of proved tuberculosis presenting to the M.V.J. Medical College and Research Hospital were recorded over a period of two years (2008-2010); and categorized as pulmonary and extra-pulmonary cases. A total of 96 cases of tuberculosis were observed; extra-pulmonary tuberculosis was seen in 64 cases. Of these 56 cases were from lymphnodes and 8 from extra-nodal sites which included tuberculous dactylitis (two cases), tuberculous mastitis (two cases), tuberculous synovial effusion (one case), pericardial effusion (one case), epididymo-orchitis (one case), and cold abscess (one case). The cytology patterns observed included granulomatous inflammation and necrosis with or without acid fast bacilli.

Tuberculosis of spine

Tuberculosis of the spine is one of the most common spine pathology in India. Over last 4 decades a lot has changed in the diagnosis, medical treatment and surgical procedures to treat this disorder. Further developments in diagnosis using molecular genetic techniques, more effective antibiotics and more aggressive surgical protocols have become essential with emergence of multidrug resistant TB. Surgical procedures such as single stage anterior and posterior stabilization, extrapleral dorsal spine anterior stabilization and endoscopic thoracoscopic surgeries have reduced the mortality and morbidity of the surgical procedures. is rapidly progressing. It is a challenge to treat MDR-TB Spine with late onset paraplegia and progressive deformity. Physicians must treat tuberculosis of spine on the basis of Culture and sensitivity.

Tuberculous arthritis revisited as a forgotten cause of monoarticular arthritis

BACKGROUND AND OBJECTIVES

Tuberculosis (TB) continues to be a major concern for health care workers. The number of reported cases of extrapulmonary tuberculosis, particularly osteoarticular tuberculosis, is increasing. This fact is attributed to different factors such as underestimating the disease and difficulty in diagnosis, which requires tissue sampling and can lead to a delay in the diagnosis, and can result in significant morbidity and mortality. The aim of this study was to highlight the difficulties and delay in diagnosis of articular tuberculosis, raising the need to create awareness about the importance of early diagnosis to avoid major complications of joint destruction.

DESIGN AND SETTING

Retrospective review of patients presenting to a tertiary care center between 2003 and 2009.

PATIENTS AND METHODS

We reviewed cases who presented with monoarticular joint pain and swelling that failed to respond to treatment elsewhere and were eventually diagnosed as having articular tuberculosis. We collected the demographic data, history, data on clinical examination and the relevant laboratory investigations, in addition to the data on radiological studies. All patients were treated medically with antituberculosis chemotherapy and surgically according to the severity of joint destruction.

RESULTS

Thirteen patients had a mean age was 40 years (range, 17-70 years). The average delay in diagnosis was 2 years. Only 1 patient had pulmonary TB. The hip, knee and elbow were the most common joints involved. Bacteriology was positive in 69% of the cases; and histopathology, in 92%. Fifteen percent of the patients had arthrodesis. None showed recurrence after follow-up of 4 years.

CONCLUSION

A high level of clinical suspicion is essential for early diagnosis and treatment of osteoarticular TB to reduce its significant morbidity.

Transmalleolar approach to a tubercular lytic lesion of the talar body: a case report

Tuberculosis of the talus is a rare condition, and the diagnosis can be difficult to make because of inconclusive laboratory and ancillary testing. In such cases, accurate diagnosis and appropriate treatment may require the use of a transmalleolar osteotomy to gain access to the involved portion of the talar body. In the case described in this article, a transmalleolar approach was used to gain access to a lytic lesion of the talar body so as to obtain microbiological and histopathological specimens for diagnostic purposes, and to thoroughly debride the lesion. After 6 years of postsurgical follow-up, the patient was leading a normal life with a full range of ankle and subtalar motion. The rarity of the diagnosis, and the use of the transmalleolar approach to a lytic and likely infected lesion in the body of the talus, makes this case worthy of public discussion.

Postoperative Mycobacterium tuberculosis infection after total knee arthroplasty

The tuberculosis prosthetic joint infection is a rare complication. We reported a case of tuberculosis prosthetic joint infection following total knee arthroplasty, and the infection was controlled without the removal of implant with the anti-tuberculosis drugs for 12 months and there has been no evidence of recurrence. Although the tuberculosis prosthetic joint infection is few of all prosthetic joint infection, early appropriate treatment can make good result without the removal of implant. This case appeared to be an early postoperative tuberculosis infection in a patient with no prior history of tuberculosis and hence conclusion could be made that early postoperative tuberculosis infection after total knee arthroplasty may occur in a patient with no prior history of exposure to tuberculosis.

Mycobacterium tuberculosis monoarthritis in a child

A child with isolated Mycobacterium tuberculosis monoarthritis, with features initially suggesting oligoarthritis subtype of juvenile idiopathic arthritis, is presented. This patient illustrates the need to consider the possibility of tuberculosis as the cause of oligoarthritis in high-risk pediatric populations even in the absence of a tuberculosis contact history and without evidence of overt pulmonary disease.

Tuberculous arthritis of the knee with Staphylococcus superinfection

We describe a case of septic arthritis of the knee in which the diagnosis of tuberculosis was masked by an initial culture growth of Staphylococcus aureus. This led to a delay in diagnosis and an adverse outcome. In the appropriate clinical setting, we suggest that the index of suspicion for skeletal tuberculosis be raised in developed countries in order to avoid diagnostic delay, by requesting cultures for acid-fast bacilli and synovial biopsies at arthroscopy. Moreover, antituberculosis therapy should be started whilst awaiting the results of culture if the clinical history and biopsies are strongly suggestive of the diagnosis.

Synovial fluid analysis

AsA prompt and accurate diagnosis of a painful, swollen joint is imperative, primarily in the case of a septic joint, as delayed therapy may result in progression of disease or permanent loss of function. Procurement and analysis of synovial fluid (SF) are paramount in helping the clinician to determine a patient's clinical condition and further course of treatment. Measurement of white blood cell (WBC) counts, crystal analysis by polarized microscopy, and microbiologic studies including Gram stain and culture are the SF parameters that are collectively most important in the ultimate determination by a clinician of the presence or absence of an infectious or inflammatory joint. It is important for the clinician to understand and recognize the limitations of various SF parameters to minimize under-treating patients with potentially serious joint pathology.

Mycobacterial osteomyelitis and arthritis

Physicians can expect to see more mycobacterial bone and joint disease in North America as a result of increased travel, immigration, and use of immunosuppressive medications. The first step in treating infections caused by these organisms is to consider the diagnosis early in the course of illness. Long-standing untreated mycobacterial infections typically cause significant bone destruction and loss of function. The treatment of mycobacterial bone and joint infection requires prolonged antibiotic therapy, often in conjunction with surgical intervention, particularly for spinal tuberculosis.

Lymphocytic joint fluid in tuberculous arthritis. A review of 30 cases

Several cases of tuberculous arthritis with lymphocytic joint fluid have been reported. This may explain in part the insidious course of tuberculous arthritis. We studied the characteristics of lymphocytic fluid from joints affected with tuberculosis and we looked for specific clinical, radiological, or laboratory test features, comparatively to patients with neutrophilic joint fluid.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 30 patients with tuberculous arthritis, 20 men and 10 women with a mean age of 47.7+/-21.4 years (10-75) and a mean symptom duration at diagnosis of 25.7+/-27.6 months (2-120).

RESULTS

Mean joint fluid leukocyte count was 15,181+/-15,635 per mm3 (600-40,000). In joint fluid, neutrophils predominated in 24 patients and lymphocytes in six (20%) patients. Blood cell counts showed no predominance of lymphocytes. No specific clinical, radiological, or laboratory test features were noted in the group with lymphocytic joint fluid.

CONCLUSION

We found that a predominance of lymphocytes in joint fluid from patients with tuberculous arthritis was uncommon and was not associated with specific features.

Synovial fluid analysis

Synovial fluid (SF) accumulates in the joint cavity in different conditions; this review outlines the data from those analyses that help in their differential and definitive diagnosis. The gross appearance of the fluid can provide a quick bedside orientation with regard to the amount of inflammation present in the joint: totally transparent SF originates in non-inflammatory conditions--of which osteoarthritis is the most common--and the amount of turbidity grossly relates to the amount of inflammation. Most turbid to purulent fluids usually come from infected joints, but exceptions are not uncommon. The white cell count offers quantitative information, but the boundaries between non-inflammatory and inflammatory SF and between this and septic fluid are very hazy and figures have to be interpreted in the clinical setting. Detection and identification of monosodium urate (MSU) and calcium pyrophosphate dihydrate (CPPD) crystals allow a precise diagnosis of gout and CPPD crystal-related arthropathy. Only one in five CPPD crystals have sufficient birefringence for easy detection and they are easily missed if searched for only using a polarised microscope. Instructions for beginners are given. Proper microbiological studies of the SF is the key to the diagnosis of infectious conditions.

Osteomyelitis

Bone and joint infections are painful for patients and frustrating for both them and their doctors. The high success rates of antimicrobial therapy in most infectious diseases have not yet been achieved in bone and joint infections owing to the physiological and anatomical characteristics of bone. The key to successful management is early diagnosis, including bone sampling for microbiological and pathological examination to allow targeted and long-lasting antimicrobial therapy. The various types of osteomyelitis require differing medical and surgical therapeutic strategies. These types include, in order of decreasing frequency: osteomyelitis secondary to a contiguous focus of infection (after trauma, surgery, or insertion of a joint prosthesis); that secondary to vascular insufficiency (in diabetic foot infections); or that of haematogenous origin. Chronic osteomyelitis is associated with avascular necrosis of bone and formation of sequestrum (dead bone), and surgical debridement is necessary for cure in addition to antibiotic therapy. By contrast, acute osteomyelitis can respond to antibiotics alone. Generally, a multidisciplinary approach is required for success, involving expertise in orthopaedic surgery, infectious diseases, and plastic surgery, as well as vascular surgery, particularly for complex cases with soft-tissue loss.

Use of Polymerase Chain Reaction to Diagnose Tuberculous Arthritis From Joint Tissues and Synovial Fluid

Context.—Tuberculosis of the joints and bones is a significant worldwide problem, often leading to joint and bone destruction. The diagnosis of this disease manifestation is difficult.

Objective.—To assess the role of conventional diagnostics compared to polymerase chain reaction applied to samples obtained at arthroscopy.

Design.—This was an open observational study that was blinded to the microbiologist, histopathologist, and molecular biologist responsible for assessing the main outcome measures.

Patients.—Seven patients (8 samples) with joint and bone tuberculosis and 14 patients (16 samples) with nontuberculous joint and bone disease.

Intervention.—Arthroscopic examination and tissue sample collection.

Main Outcome Measures.—Mycobacterium tuberculosis staining, culture, and histopathologic assessment of caseating granulomas vs polymerase chain reaction.

Results.—Polymerase chain reaction was positive in all cases of true tuberculosis and falsely identified 2 samples as positive, both however, in patients who had lung tuberculosis in the past.

Conclusions.—Conventional bacteriological methods for demonstration of M tuberculosis are not very sensitive and can be time-consuming. Polymerase chain reaction of arthroscopically obtained joint tissue biopsies appears promising in the early diagnosis of tuberculous arthritis.

Tuberculous tenosynovitis and carpal tunnel syndrome as a presentation of HIV disease

We describe a patient who presented with carpal tunnel syndrome secondary to tuberculous tenosynovitis and who was subsequently shown to have HIV infection. Recognition of this atypical presentation of tuberculosis is important for early, effective treatment.

Two cases of chronic arthritis of the forearm due to Mycobacterium tuberculosis

In the absence of coexisting active pulmonary disease, tuberculosis is frequently not considered in the differential diagnosis of chronic inflammation of the joints. The cases of two immigrant patients with tuberculous arthritis involving the forearm are reported. In both cases non-specific arthritis or trauma was suspected, resulting in a delay between the onset of symptoms and institution of specific therapy of 21 and 24 months, respectively. Diagnosis was achieved by histological and microbiological examination of synovial biopsy material. Polymerase chain reaction for Mycobacterium tuberculosis complex was positive in only one patient. Treatment consisted of antituberculosis chemotherapy, surgical synovectomy, and debridement of the affected joints. These cases serve as a reminder that, although rare, tuberculosis can cause chronic arthritis.

Septic arthritis in children

Because of its seriousness, septic arthritis should be considered early in the differential diagnosis of any child presenting with joint inflammation. Physicians who care for children should be aware of the early signs and symptoms of septic arthritis and be aggressive about establishing the diagnosis so that treatment is not delayed. Early orthopedic consultation and a low threshold for performing arthrocentesis are prudent. Prolonged and appropriate antimicrobial therapy is warranted to achieve optimal results.

Culture of joint specimens in bacterial arthritis. Impact of blood culture bottle utilization

The advantage of inoculating blood culture bottles (BCB) with a bulk volume of joint fluid was studied by analyzing results for 155 positive specimens cultured in parallel in BCB and on conventional solid media. The specimens came from both natural and artificial joints of 89 patients treated in 1975-1994. One third of the specimens from patients not on antibiotics and half of the specimens from patients on antibiotics were positive by BCB culture only. Some fastidious or slow-growing organisms were detected exclusively by this method. Additional contaminants were also picked up, but the inconvenience was relatively minor. Alternative procedures for detecting microbes in joint specimens are discussed.

Total knee arthroplasty in tuberculous arthritis

Sixteen cases of tuberculosis of the knee treated by total knee arthroplasty with followup of 3.4 to 11 years were reviewed. Eight cases were treated with antituberculous chemotherapy for 2 to 20 months before and 1 year after the arthroplasty. Another 8 cases were not diagnosed primarily and therefore received only postoperative antituberculous chemotherapy. Five cases had a recurrence of tuberculosis. Four of these 5 cases did not receive preoperative antituberculous treatment. The infection in 1 case was controlled satisfactorily with chemotherapy alone, and for the other 3 cases, chemotherapy was supported by surgical debridements. The last case of recurrent infection occurred in a patient who had received long- standing corticosteroid therapy. He required an excisional arthroplasty to control the infection. The mean functional knee score was 30.5 points before surgery and 82.6 points at the time of the last followup. These results suggest that arthroplasty may be formed for knees badly damaged with tuberculous infection, and good results may be expected for those patients who have received effective antituberculous chemotherapy both before and after surgery. There is a substantial risk of reactivation of tuberculous infection for those patients not treated before surgery or for patients dependent on corticosteroids.

MR imaging of tuberculous arthritis: clinical and experimental studies

Signal-intensity characteristics of magnetic resonance (MR) images were assessed in five patients and in 10 rabbits with tuberculous arthritis. MR imaging findings were compared with histologic findings in the animal study. In both of clinical and experimental cases, tuberculous lesions showed both intermediate and high signal intensity on T2-weighted images, while they showed heterogeneously intermediate signal intensity on T1-weighted images. As T2-weighted images were compared with pathologic specimens, intermediate signal intensity corresponded to caseous necrosis, whereas high signal intensity related to granulomas or effusion. Postcontrast T1-weighted images showed enhancement at the peripheries rather than the centers of tuberculous lesions. These results indicate that tuberculous arthritis should be included in the differential diagnosis when intra-articular lesions with low or intermediate signal intensity are found on T2-weighted images.

Tuberculous arthritis in children. Diagnosis by needle biopsy of the synovium

In two children ages 8 months and 4 years, tuberculous synovitis of the knee was suggested by pathologic examination of synovial tissue obtained through needle biopsy. Culture of the biopsy material was positive for Mycobacterium tuberculosis in one case. In this child, the tuberculin test was negative, in the absence of anergy, at the time the child was first evaluated, and the primary lung lesion was not identified by the radiologist. Tuberculous synovitis has not previously been recognized as part of primary tuberculosis during the early weeks when the tuberculin skin test may be negative. Magnetic resonance imaging (MRI) is a sensitive modality for demonstrating joint fluid, synovial hypertrophy, and associated osteomyelitis, if present. With the increasing frequency of cases of tuberculosis in the population, greater awareness of the risk of tuberculous arthritis in childhood is important in order to recognize this unusual presentation. If negative early on, the tuberculin skin test should be repeated after 6 weeks of arthritis. A needle biopsy of the synovium is helpful and appropriate in all children with monoarticular arthritis who have a positive tuberculin skin test.

A review of peripheral tuberculous arthritis

There is a clear difference between TB infection and TB. Transition from the former to the latter involves host factors and perhaps environmental elements. Currently, more individuals with immunosuppressive situations caused by aging, debilitating diseases, immunosuppressive therapies, and HIV-III infection are predisposed to secondary forms of TB. Different patterns of clinical presentation, at variance with those previously described, could result from these changes in the host. PTBA is a good example. In the present review of 52 patients, we found that patient age is rising, as has been reported in other western countries. We also found that oligoarthritis and involvement of non-weight-bearing joints is becoming more common. From the diagnostic point of view, histological studies and cultures of synovial tissue remain the most reliable tests. Awareness of these factors, recognition of changing patterns, proper use of diagnostic procedures, and early treatment should improve the outcome of patients.

Tuberculous rheumatism (Poncet's disease) in a child

A 2-year-old boy who had increasing difficulty walking and had large, warm, sterile knee and ankle effusions was found to have active vertebral tuberculosis and a large prevertebral abscess. Lymphocyte proliferation assays demonstrated increased purified protein derivative-induced reactivity of synovial fluid lymphocytes compared with peripheral blood lymphocytes. The arthritis responded rapidly to antituberculous and antiinflammatory drugs. This patient's disease represented an example of tuberculous rheumatism (Poncet's disease).

Arthroplasty in tuberculosis of the knee. Two cases of missed diagnosis

Active tuberculosis arthritis was diagnosed in two patients after they had undergone total knee replacement. Antituberculous therapy was successful.

Meningitis associated with tuberculous arthritis of the knee

This case report describes two uncommon manifestations of tuberculosis, meningitis and arthritis, occurring in a patient without pulmonary disease. Difficulties in diagnosis and results of treatment are discussed.

Tuberculosis in the geriatric patient

Active tuberculosis is highly prevalent in the geriatric population. The clinical syndromes and diagnostic indications of the different forms of tuberculosis are described. Reactivation pulmonary tuberculosis and miliary tuberculosis in the elderly are particularly difficult to diagnose. A high index of suspicion, a tuberculin skin test, and appropriate laboratory studies are essential for early diagnosis. Therapy for tuberculosis in the elderly must consider efficacy, patient compliance, and toxicity.

Tuberculous arthritis of the shoulder: delayed diagnosis aided by arthrography

Tuberculous arthritis of the shoulder was not diagnosed in an 80-year-old man with Addison's disease until the appearance of a draining abscess in his arm. Initially signs, symptoms, x-rays and laboratory studies were consistent with calcific tendonitis and degenerative arthritis. Then an arthrogram demonstrated a connection between the shoulder joint and the abscess. A high level of suspicion for tuberculous arthritis should be maintained in an elderly patient whose past medical history is suspicious for tuberculosis and whose articular complaints are chronic.

Tuberculosis of the hand. Case report

Three patients with tuberculosis of the hand are reported. In each patient the onset and course of the disease was insidious and the diagnosis was obscured by lack of systemic symptoms and the absence of other foci of infection. The diagnosis was established only after open biopsy and synovial tissue culture. The wounds healed without complications even prior to appropriate chemotherapy. Combined conservative and surgical treatment resulted in definitive cure of the local manifestation in two of the patients.

Interpretation of synovial fluid data

The routine battery of tests for synovial fluid analysis includes culture and Gram staining, polarizing microscopy, and total WBC and differential counts. If the volume of fluid collected is low, culture and polarizing microscopy have highest priority. Synovial fluid data are diagnostic in only two diseases: septic arthritis and crystal-induced arthritis. In traumatic arthritis, degenerative joint disease, rheumatoid arthritis, and systemic lupus erythematosus, synovial fluid data may provide evidence supporting the diagnosis.