A review of peripheral tuberculous arthritis

Tuberculosis of navicular bone: An exceptional localization of osteoarticular tuberculosis

Osteoarticular tuberculosis (OAT) is defined by the set of pathological manifestations secondary to the attacks of osteoarticular structures of the locomotor system by the Bacillus of Koch (BK). We report a case of tuberculosis of the navicular bone, which is a rare location of OAT, on a female patient who consulted for chronic pain (mixed appearance) evolving for more than 7 years and for whom we realized a radiological assessment based on standard radiography and magnetic resonance imaging and a biological assessment. The foot is rarely involved, accounting for about 10% of cases of osteoarticular tuberculosis. The diagnosis is often made at a late stage because osteoarticular tuberculosis is paucibacillary, and it is difficult to isolate or culture Koch's bacillus. Clinical manifestations are aspecific; pain and joint swelling are the 2 usual signs. Pain may be mechanical, inflammatory, or mixed. The standard radiography allows first to orient the diagnosis by the demonstration of a lytic process; a biological inflammatory syndrome and the magnetic resonance imaging allow to give more arguments in favor, then the biopsy comes to confirm the diagnosis. Tuberculosis of the navicular bone is a rare localization of OAT; its diagnosis is the same as well as the treatment.

Flexor tenosynovitis of the wrist with carpal tunnel syndrome

Tubercular tenosynovitis of the wrist with carpal tunnel syndrome (CTS) is a rare occurrence. The authors present a case of tubercular flexor tenosynovitis of the wrist with CTS. A 60-year-old female presented with complaints of swelling in the volar aspect of the right wrist with numbness of the first three fingers for the past 6 months. Clinical and radiological diagnosis of chronic flexor tenosynovitis with median nerve compression neuropathy was made. The patient was operated with carpal tunnel release and total tenosynovectomy. Histopathology showed features suggestive of Koch's etiology. The patient was started with antitubercular therapy (ATT) and followed up regularly. Carpal tunnel symptoms subsided immediately after surgery and there was no recurrence of swelling at the last follow-up. Carpal tunnel release and tenosynovectomy should be performed at the earliest possible and followed up with ATT for better outcomes in tubercular tenosynovitis of the wrist with CTS.

Multifocal osteoarticular tuberculosis in a systemic lupus erythematosus (SLE) patient: a rarity or an underdiagnosed condition?

Tuberculosis (TB) and its association with rheumatic diseases have been widely recognised. Occurrence of multifocal skeletal involvement constitutes <5% of all skeletal TB cases. We present a Malay patient with multifocal osteoarticular TB (OATB). A 35 year-old SLE woman with background usage of corticosteroid therapy and Azathioprine presented with lupus nephritis flare. Renal biopsy revealed diffuse proliferative lupus nephritis and intravenous (IV) Cyclophosphamide 0.5 g/m² (850 mg) was initiated. One week later, patient complained dorsum of left hand and right knee swelling. On physical examination, patient was afebrile and the left hand swelling was cystic in consistency while right knee was warm and tender. Erythrocyte Sedimentation Rate (ESR) was 50 mm/hr and C-Reactive Protein (CRP) was 9.4 mg/L. Her Mantoux test was positive with 20 mm induration. Wrist radiograph and chest radiograph was normal. Musculoskeletal ultrasound showed 4th extensor compartment tenosynovitis with Doppler signal and right knee effusion with synovial proliferation. Extensor tenosynovectomy and right knee aspiration was performed. Left hand excised tissue and right knee synovial fluid for acid-fast bacilli (AFB) stain, TB PCR, bacterial and fungal cultures were negative. Urgent histopathological examination of the excised tissue showed necrotising granulomatous inflammation. Patient was empirically started on TB treatment and subsequent mycobacterial culture confirmed the diagnosis of TB. The joints swelling resolved after one month of TB treatment. Multifocal OATB is an infrequent form of extrapulmonary TB and diagnosing OATB requires high index of suspicion particularly in SLE patient on immunosuppression. Prompt investigations are essential to the diagnosis of this rare condition for early initiation of anti-tuberculous therapy.

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.

Osteoraticular Tuberculosis-Brief Review of Clinical Morphological and Therapeutic Profiles

Osteoarticular tuberculosis (OATB) is a rare form of tuberculosis (TB) whose incidence rose significantly nowadays especially in the underdeveloped countries. The main risk factors predisposing to this new challenge for the medical system are the Human Immunodeficiency Virus (HIV) epidemic, the migration from TB endemic areas and the development of drug and multidrug-resistant strains of Mycobacterium tuberculosis (Mt). The disease affects both genders and any age group although the distribution depending on gender is controversial and that depending on age has a bimodal pattern. In most cases the initial focus is elsewhere in the organism and the most frequent pathway of dissemination is lympho-haematogenous. The clinical picture includes local symptoms as pain, tenderness and limitation of motion, with some particularities depending on the segment of the osteoarticular system involved, sometimes accompanying systemic symptoms specific for TB and other specific clinical signs as cold abscesses and sinuses. The radiographic features are not specific, CT demonstrates abnormalities earlier than plain radiography and MRI is superior to plain radiographs in showing the extent of extraskeletal involvement. Both CT and MRI can be used in patient follow-up to evaluate responses to therapy. TBhas been reported in all bones of the body, the various sites including the spine (most often involved) and extraspinal sites (arthritis, osteomyelitis and tenosynovitis and bursitis). Two basic types of disease patterns could be present: the granular type (most often in adults) and the caseous exudative type (most often in children) one of which being predominant. The algorithm of diagnosis includes several steps of which detection of Mt is the gold standard. The actual treatment is primarily medical, consisting of antituberculosis chemotherapy (ATT), surgical interventions being warranted only for selected cases. It is essential that clinicians know and refresh their knowledge about manifestations of OATB.

[Osteo articular tuberculosis (Pott disease excluded): about 120 cases in Abidjan]

Introduction

La tuberculose ostéoarticulaire (TOA) représente 2 à 5% de l'ensemble des tuberculoses. Elle demeure d'actualité surtout dans les pays à forte endémicité tuberculeuse. L'objectif était de déterminer la prévalence, les aspects topographiques, radiologiques de la TOA en milieu hospitalier ivoirien.

Méthodes

Les auteurs rapportent une expérience de 11 ans, à travers une étude rétrospective de 120 dossiers de patients atteints de la tuberculose ostéoarticulaire (le mal de Pott est exclu de cette étude). N'ont pas été inclus dans l’étude les dossiers ne comportant pas d'imagerie.

Résultats

L'atteinte extra vertébrale représentait 09,2% de la tuberculose ostéoarticulaire. Il s'agissait de 54 hommes et 66 femmes, l’âge moyen était de 43,13 ans. On notait 123 cas d'ostéoarthrites, et 8 cas d'ostéites des os plats. L'atteinte des membres inférieurs prédominait dans 91,87% des cas. La hanche était la première localisation (45,04%), suivie du genou (25,19%). Les atteintes étaient multifocales dans 20% des cas. L'atteinte osseuse était associée à une tuberculose pulmonaire dans 05,83% des cas. Des localisations inhabituelles ont été rapportées: poignet (n = 2), branches ischiopubiennes (n = 4), atteinte sternoclaviculaire (n = 4), médiopieds (n = 2). Les lésions radiologiques étaient avancées (stades III et IV) dans 55,73% des cas. A la TDM, la prévalence des abcès était de 77%. Un geste chirurgical a été réalisé sur 16 articulations (2 épaules, 13 genoux, une cheville).

Conclusion

La TOA des membres est peu fréquente contrairement à l'atteinte vertébrale. La hanche est la principale localisation. Le retard au diagnostic explique l’étendue des lésions anatomoradiologiques.

Persistent Posttraumatic Wrist Pain - Tuberculosis Infection Should be in the Differential Diagnosis. A Rare Case Report

INTRODUCTION

It is uncommon for hand surgeons to diagnose and treat persistent post-traumatic radius fracture on the lines of tuberculosis infection even in developing countries especially when the clinical picture resembles more of a complex regional pain syndrome (CRPS). Although it works for many patients, some conditions that affect the wrist don't fall in this category and worsen with this treatment practice. We present a patient who had an extra articular distal radius fracture treated initially with percutaneous pinning and was treated as CRPS for the next ten months by local physician. He was eventually diagnosed with advanced tuberculosis of the wrist and a total wrist arthrodesis was performed. Only one such case was ever reported in literature.

CASE REPORT

A 50-year-old male, came to our institute with the history of pain and fullness in the wrist since one year. One year ago he had developed an extra articular fracture of the distal radius which was initially treated with percutaneous pinning and a below elbow cast for six weeks. On removal of the cast one pin was found loose and the other removed eventually after two more weeks of immobilization. Patient continued to have pain with fullness around the wrist which was treated at local place with anti inflammatory agents and ice application. Patient had complaint of other constitutional symptoms. Initially patient had full range of motion which gradually decreased. X-ray showed characteristic signs suggesting of extensive tuberculosis of distal radius which was operated with wrist arthrodesis. Per operatively, fine rice granular granulation tissue was found, histopathological examination of which confirmed the diagnosis of tuberculosis.

CONCLUSION

Though rare, every case of distal radius fracture complaining of chronic pain and signs suggestive of CRPS should have tuberculosis as one of the differential diagnosis, even if patient does not present any signs of tuberculosis or any primary focus is not identified. Even though skeletal tuberculosis per se is hematogenous in origin, inoculation from the pin site can be a cause and hence proper sterilization techniques should be used.

Tuberculosis arthritis of the metatarsal phalangeal: a rare location

Tuberculosis TB is common in countries constituting endemic areas like Morocco, spinal sites represents half of osteo-articular locations, while peripheral locations in the limbs are rare. The authors relate in this observation the case of a particular location of tuberculosis arthritis. It is osteoarthritis of the metatarsophalangeal joint of the 2(nd) ray of the foot. Clinical signs were characterized by a moderately painful swelling of the dorsum of the foot with slow evolution. The definitive diagnosis was histologically obtained. Clinical cure was achieved after 09 months of medical treatment.

Total hip replacement for patients with active tuberculosis of the hip: a systematic review and pooled analysis

The timing of total hip replacement (THR) in patients with active tuberculosis (TB) of the hip is controversial, because of the potential risk of reactivation of infection. There is little information about the outcome of THR in these patients. We conducted a systematic review of published studies that evaluated the outcome of THR in patients with active TB of the hip. A review of multiple databases referenced articles published between 1950 and 2012. A total of six articles were identified, comprising 65 patients. TB was confirmed histologically in all patients. The mean follow-up was 53.2 months (24 to 108). Antituberculosis treatment continued post-operatively for between six and 15 months, after debridement and THR. One non-compliant patient had reactivation of infection. At the final follow-up the mean Harris hip score was 91.7 (56 to 98). We conclude that THR in patients with active TB of the hip is a safe procedure, providing symptomatic relief and functional improvement if undertaken in association with extensive debridement and appropriate antituberculosis treatment.

Tuberculous tenosynovitis presenting as ganglion of wrist

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the hand and wrist at presentation is extremely rare, and the diagnosis is often missed. A 57 years old male presented with swelling over the left wrist since 3 years Three swellings over dorsal aspect of the left wrist Soft in consistency Non tender Non compressible Mobile at right angles to the plane of the wrist joint. ESR: 45 mm in 1 hr and rest blood investigations were normal. Ultrsonography showed giant cell tumor of Extensor Digitorum sheath. X-ray: soft tissue swelling and MRI was suggestive of extensor tendon sheath extraskeletal synovial Koch's, or giant cell tumor of tendon sheath. Excision of swelling was planned and intraoperatively, rice bodies were seen inside it. Histopathological examination showed caseous necrosis with granuloma formation. Patient was put on DOT1 therapy. Tuberculous tenosynovitis was first described by Acrel in 1777. Rice bodies occurring in joints affected by tuberculosis were first described in 1895 by Reise. Rice bodies will be diagnosed on plain radiographs when mineralization occurs. More than 50% of cases recur within 1 year of treatment. The currently recommended 6-month course is often adequate with extensive curettage lavage and synovectomy should be performed. Surgery is essential, but the extent of surgical debridement is still debatable. The surgeon has to be aware of the significance of loose bodies when performing routine excision of innocuous looking wrist ganglia.

Glenohumeral joint tuberculosis that mimics frozen shoulder: a retrospective analysis

BACKGROUND

Although the incidence of osteoarticular tuberculosis is increasing, glenohumeral joint tuberculosis is rare and often misdiagnosed in its early stages. Our objective was to study the incidence of the initial misdiagnosis as frozen shoulder and the duration of the prediagnostic period among patients with glenohumeral joint tuberculosis.

METHODS

The clinical records of 21 patients with tuberculosis of the shoulder joint were retrospectively analyzed.

RESULTS

Among the 16 patients with glenohumeral joint tuberculosis, 14 (87.5%) were initially diagnosed as having frozen shoulder instead of glenohumeral joint tuberculosis at their primary care clinics. Two patients actually showed both shoulder pain and limited range of motion, although they did not have a record of initial diagnosis with frozen shoulder. Consequently, 14 (87.5%) of the patients in our study with glenohumeral joint tuberculosis were likely misdiagnosed as having frozen shoulder. On the other hand, this group accounted for 3.6% (n = 16) of 450 patients who, during the same period, had been initially diagnosed with frozen shoulder at our institution. The mean prediagnostic period to attain the final, correct diagnosis of glenohumeral joint tuberculosis for this group was 14.5 months.

CONCLUSION

It appears that misdiagnosis is common and early diagnosis of tubercular infection in the glenohumeral joint has become increasingly difficult. Glenohumeral joint tuberculosis should be suspected in cases of longstanding pain in the shoulder. It is necessary to re-examine these frozen shoulder patients with repeated plain radiographs followed by further imaging studies, especially magnetic resonance imaging, if conservative therapy fails.

Tuberculous extensor tenosynovitis of the hand

Tuberculous tenosynovitis is a rare manifestation of extrapulmonary tuberculosis (Tb), especially if solely the dorsal hand compartment is affected. In this report, we present the medical history of an immuno-competent 32-year-old man presented with a painful swelling of the right dorsal wrist. Initial inflammation onset had occurred 6 months before he consulted our service, resulting in consultation of several physicians and extensive diagnostic procedures without gaining a specific diagnosis. Finally, after extensive diagnostic tests, a tenosynovectomy was performed and tuberculosis-induced extensor tenosynovitis was detected. The diagnosis was established by positive histology, repeated specific PCR and T-SPOT.TB. Tuberculous tenosynovitis can easily be overlooked as a cause of chronic tenosynovitis particularly in immunocompetent young people lacking any risk factors.

Characterization of Mycobacterium tuberculosis isolated from cancer patients with suspected tuberculosis infection in Egypt: identification, prevalence, risk factors and resistance pattern

Data are sparse on Mycobacterium tuberculosis infection among patients with cancer in Egypt. We sought to detect the presence of tuberculosis (TB) disease among patients with malignant conditions and suspected TB and to study the main risk factors. Also, we compared different diagnostic procedures and detected the antimicrobial susceptibility of M. tuberculosis isolates against rifampin and isoniazid. One hundred patients were included in this study, all of them had malignant conditions and were suspected by the clinicians of having TB. Identification of M. tuberculosis in different specimens was performed by smear microscopy, followed by Lowenstein-Jensen medium and Mycobacterium growth indicator tube (MGIT) cultures and artus(®) real-time PCR. In addition, an indirect MGIT anti-TB susceptibility test was carried out against rifampin and isoniazid. A total of 76% of studied cases were found to be TB positive. The frequencies of TB-positive cases in the bronchogenic, haematological and solid tumour malignancy groups were 21%, 25% and 30%, respectively. Significant differences between pulmonary and extrapulmonary TB in different malignancy groups were recorded. Real-time PCR showed the highest overall diagnostic efficiency. Multidrug-resistance of M. tuberculosis to both rifampin and isoniazid was detected in 28.6% of examined isolates. Infection in cancer patients with TB was significantly more often recorded among elderly patients and those suffering from poverty. Pulmonary TB is more common than extrapulmonary TB in patients with malignancy. Real-time PCR is the most accurate and rapid method for TB diagnosis. MGIT-rifampin resistance may be used as a reliable marker for detection of multidrug-resistant TB. Diagnosis and instituting treatment course for active or latent TB infection are crucial before starting anticancer therapy.

Osteoarticular tuberculosis mimicking rheumatoid arthritis

Tuberculosis (TB) remains a global burden despite extensive efforts to control it. TB arthritis commonly manifest as monoarthritis of weight-bearing joints. We report a rare presentation of osteoarticular TB involving multiple small joints of the hands, which mimicked rheumatoid arthritis (RA). Magnetic resonance imaging showed tenosynovitis. The patient was initially treated for seronegative RA but failed to respond. Subsequently, synovial biopsy led to the diagnosis. Antituberculosis treatment was given for 1 year.

Bilateral recurrent wrist flexor tenosynovitis and rice body formation in a patient with sero-negative rheumatoid arthritis: A case report and review of literature

INTRODUCTION

Rice body formation has been traditionally observed in the joint and tendon sheaths of patients with tuberculosis. Few case reports exist that describe rice body formation in patients with rheumatoid arthritis. We describe a case report of bilateral recurrent wrist flexor tenosynovitis with rice body formation in a patient with sero-negative rheumatoid arthritis.

PRESENTATION OF CASE

This case report describes a 72 year old lady presenting with severe bilateral, flexor tenosynovitis of the wrists. Ultrasonography revealed significant echogenic fluid on the palmer aspect of wrist joint surrounding flexor tendons with intact neurovascular bundles and no bony erosion. Laboratory tests demonstrated elevated erythrocyte sedimentation rate (50 mm/h) and negative rheumatoid factor. A sequential subtotal flexor tenosynovectomy was carried out with decompression of the carpal tunnel. During the operation, multiple rice bodies among the flexor tendons with adherent synovitis were found. Histology revealed disrupted synovial tissue containing several areas of fibrinoid necrosis, bounded by a layer of vaguely pallisaded histiocytes but no epitheloid granulomata or germinal centre. A revision surgery with debulking of the fibro-osseous canal was undertaken following recurrence. The patient presently has complete resolution of symptoms at one year follow-up.

DISCUSSION

The combined clinical, laboratory, ultrasound and histology findings of the patient indicated that the cause of the rice body formation was due to a sero-negative arthritis rather than tuberculosis.

CONCLUSION

Rice body formation can be caused by sero-negative arthritis. Bilateral wrist flexor tensosynovitis can recur within five months of a previous synovectomy in a patient with sero-negative arthritis.

Arthroscopic operations in knee joint with early-stage tuberculosis

INTRODUCTION

Due to atypical clinical presentation, wide use of antibiotics and lack of specificity in diagnosis, misdiagnosis is common, and diagnosis of tubercular infection in a joint is increasingly difficult. The use of arthroscopy for the diagnosis and treatment of early-stage knee TB has rarely been reported. Through this case series we describe the usefulness of arthroscopy for the management of synovial tuberculosis of the knee joint.

MATERIALS AND METHODS

Synovectomy and synovial membrane biopsy were performed using arthroscopy in ten subjects suffering from synovial tuberculosis. This was combined with intra-articular isoniazid injection and systemic antituberculosis drugs.

RESULTS

In all cases, continuous passive motion exercise was started 2 days after operation and they were followed up from 6 months to 3 years. The flexion angles 90 degrees +/- 5 degrees preoperatively increased to 120 degrees +/- 14 degrees in nine patients following surgery, the extension limit angle also improved from an average 20 degrees +/- 3 degrees preoperatively to 5 degrees +/- 1 degrees postoperatively. There was a significant difference in knee function index between preoperation and postoperation (t = 6.9, t = 6.3, P < 0.01). Japanese Institute of Plastic Surgery synovial disease treatment success criteria was also improved from 44.4 +/- 8.4 points before surgery to 81.5 +/- 10.4 following surgery (t = 8.749, P < 0.01). The joint swelling disappeared or was relieved after 2 months. No relapse of tuberculosis was found at the time of follow-up.

CONCLUSION

Combined use of arthroscopy and antituberculosis medication appears to be advantageous for the management of early-stage synovial tuberculosis of the knee joint. Arthroscopic removal of the pannus allows better nutrition of the cartilage and thus greatly improves the joint function.

Total hip replacement in active advanced tuberculous arthritis

We describe the results of cemented total hip replacement in 23 patients (23 hips) with active tuberculous arthritis of the hip with a mean follow-up of 4.7 years (4 to 7). In two patients the diagnosis was proved by pre-operative biopsy, whereas all others were diagnosed on a clinicoradiological basis with confirmation obtained by histopathological examination and polymerase chain reaction of tissue samples taken at the time of surgery. All patients received chemotherapy for at least three months before surgery and treatment was continued for a total of 18 months. Post-operative dislocation occurred in one patient and was managed successfully by closed reduction. No reactivation of the infection or loosening of the implant was recorded and function of the hip improved in all patients. Total hip replacement in the presence of active tuberculous arthritis of the hip is a safe procedure when pre-operative chemotherapy is commenced and continued for an extended period after operation.

A report of two cases of tuberculous arthritis of the ankle

Tuberculosis (TB) is a major global health problem, and musculoskeletal TB occurs in approximately 10% of extrapulmonary cases. In this article we describe 2 cases of ankle joint tuberculous arthritis. Both of the patients were immunocompromised and presented with chronic pain and swelling. Both patients described a history of antecedent ankle trauma. The clinical presentations were consistent with chronic septic arthritis and were nonspecific as to a particular etiology. The pathology and microbiology results revealed infection with Mycobacterium tuberculosis. Tuberculous infection of bone and joint must be considered when predisposing epidemiological factors are present to avoid delay in therapy. Further exploration into the relationship of trauma to tuberculosis recrudescence is warranted.

LEVEL OF CLINICAL EVIDENCE

4.

Osteoarticular tuberculosis in patients with systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) patients are at increased risk of developing tuberculosis (TB), particularly extrapulmonary TB (ExP-TB).

AIM

The present study was undertaken to investigate whether SLE patients showed increased susceptibility to develop osteoarticular TB (OA-TB).

DESIGN AND METHODS

We retrospectively reviewed and compared the frequency of ExP-TB, in particular OA-TB, in patients with SLE at a tertiary hospital in South Africa, to a non-SLE control TB group seen at the same hospital.

RESULTS

TB was diagnosed 111 times in 97 (17%) of the 568 SLE patients. The relative frequency of ExP-TB in the SLE group (25.2%) was significantly lower than in the control group (38.5%) (OR = 1.9, P = 0.006). In contrast, OA-TB was diagnosed in the SLE group in nine (8.1%) patients (seven with peripheral arthritis and two with TB spine) compared to 54 (0.4%) in the overall control group (OR = 20.8, P < 0.001) and 13 (0.2%) in the subgroup of known HIV positive patients in the control group (OR = 44.4, P < 0.001). Within the SLE group, Black ethnicity (P = 0.003), lymphopaenia (P = 0.001), C3/C4 hypocomplementaemia (P = 0.05), corticosteroids [maximum dose (P = 0.002) and duration of treatment (P = 0.02)] and immunosuppressive agents (P = 0.02) were risk factors for TB. Duration of corticosteroid therapy was the only risk factor for OA-TB (P = 0.04).

CONCLUSION

While the relative frequency of ExP-TB was lower in the SLE group compared to the control group, our findings suggest that SLE patients are at particular risk of developing OA-TB. Further prospective studies are needed to better understand the mechanisms that predispose SLE patients to OA-TB.

DISSEMINATED REFRACTARY TUBERCULOSIS WITH BICEPS TENDON INVOLVEMENT IN AN IMMUNOCOMPETENT PATIENT

OBJECTIVE

The authors report a rare case of disseminated tuberculosis which had compromised the long head of biceps tendon and shoulder joint, during standard drug therapy.

METHODS

On a first sight, the accurate diagnosis wasn't accomplished and the patient had been treated with physiotherapy for rotator cuff tear. However, the patient presented with a fast growing mass in anterior region of the proximal third of the arm, complaining of pain increase. Aspirative punction of the mass revealed a yellow fluid and the laboratorial analysis confirmed infection by M. Tuberculosis. The patient was treated with surgical debridement and his drug therapy was changed.

RESULTS

Resolution of infectious status and complete shoulder function restoration was succeeded.

CONCLUSION

Due to its high prevalence in Brazil, tuberculosis must always be considered as a possible cause of inflammatory joint disease, even in immunocompetent patients.

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.

Patients with pulmonary tuberculosis are frequently positive for anti-cyclic citrullinated peptide antibodies, but their sera also react with unmodified arginine-containing peptide

OBJECTIVE

The anti-cyclic citrullinated peptide (anti-CCP) enzyme-linked immunosorbent assay (ELISA) has high sensitivity and specificity for rheumatoid arthritis (RA). However, detection of anti-CCP in patients with active pulmonary tuberculosis (TB) has recently been reported. To determine whether this activity was specific for the citrullinated residue, the specificity of anti-CCP-positive sera for CCP versus that for unmodified arginine-containing peptide (CAP) was examined in patients with TB and compared with that in patients with RA.

METHODS

Anti-CCP and anti-CAP in sera from patients with pulmonary TB (n = 49), RA patients (n = 36), and controls (n = 18) were tested by ELISA. Sera were available at diagnosis from most TB patients. All TB patients were treated with a combination of 2-4 antibiotics for at least 6 months, and sera were collected over time.

RESULTS

Anti-CCP was found in 37% of TB patients and in 43% of RA patients. CAP reactivity was more common in TB than in RA. High anti-CCP:anti-CAP ratios (>2.0) were seen far more commonly in anti-CCP-positive RA patients than in anti-CCP-positive TB patients (94% versus 22%). Anti-CCP was inhibited by CCP peptide in sera from RA patients, but not in sera from TB patients. A slight increase in anti-CCP was common after initiating treatment for TB, although the anti-CCP level decreased after 1-2 months.

CONCLUSION

Anti-CCP is frequently present in patients with active TB. However, many anti-CCP-positive TB sera also reacted with CAP, and anti-CCP:anti-CAP ratios in TB sera were low. Anti-CCP:anti-CAP ratios should be useful clinically for distinguishing CCP-specific reactivity seen in RA from reactivity with both CCP and CAP frequently seen in pulmonary TB.

Polyarticular arthritis secondary to Mycobacterium bovis infection: an unusual clinical presentation

We describe a 37-year-old Mexican man with incapacitating polyarticular arthritis secondary to Mycobacterium bovis infection. A dermatologist diagnosed psoriasis two years before admission. One year later due to symmetric ankle and knee arthritis, he was treated with three doses of etanercept. The arthritis extended to the carpus and metacarpophalangeal joints. Multifocal dactylitis and a left ankle periarticular abscess were documented. Concomitantly he developed fever, cough, and adenopathies. Ankle MRI showed osteomyelitis of the calcaneous with a posterior abscess. A CT-body scan documented mild pleural effusion that corresponded to an exudate. An ankle aspiration yielded a caseous fluid with acid-fast bacilli. Knee and ankle synovial biopsies documented a granulomatous synovitis. A lymph node biopsy showed granulomas with caseous necrosis. After 1 month, Mycobacterium bovis was isolated from these tissues. Antituberculous regimen was started with satisfactory response. Although largely eradicated, bovine tuberculosis still occurs. Nevertheless, the clinical presentation as polyarthritis is very uncommon and represents a diagnostic challenge.

The ever-expanding association between rheumatologic diseases and tuberculosis

We summarized most of the rheumatologic manifestations of tuberculosis (TB) and the occurrence of Mycobacterium tuberculosis disease associated with rheumatologic diseases. We established 4 different categories: (1) direct musculoskeletal involvement of M. tuberculosis, including spondylitis, osteomyelitis, septic arthritis, and tenosynovitis; (2) M. tuberculosis as an infectious pathogen in rheumatologic diseases, particularly with the use of newer agents such as tumor necrosis factor-alpha inhibitors; (3) antimycobacterial drug-induced rheumatologic syndromes, including tendinopathy, drug-induced lupus, and others; and (4) reactive immunologic phenomena caused by TB, such as reactive arthritis, erythema nodosum, and others. In addition, Bacille-Calmette-Guérin vaccination used for the prevention of TB or as a chemotherapeutic agent for bladder carcinoma also may be associated with musculoskeletal adverse events. We conclude that M. tuberculosis can directly or indirectly affect the musculoskeletal system.

RADIOLOGIC ABNORMALITIES OF THE APPENDICULAR SKELETON OF THE LION (PANTHERA LEO): INCIDENTAL FINDINGS AND MYCOBACTERIUM BOVIS-INDUCED CHANGES

Thoracic and pelvic limbs from 15 euthanized free-ranging lions (Panthera leo), ranging in age from 16 to 144 months, underwent standard radiographic evaluation. All lions had tested positive for Mycobacterium bovis by means of a modified intradermal tuberculn test. The radiographs of six lions were normal and nine had incidental findings of which six had more than one lesion. Seven lions had lesions suspected to be associated with tuberculosis, which was confirmed in specific joints in two lions. Incidental pathology was classified as traumatic injuries and degenerative or trauma-associated joint disease. The traumatic lesions were fractures of which the most remarkable was a femur malunion. Four lions had fibula and another three lions had metacarpal/tarsal and phalangeal fractures. Joint lesions included glenoid, humeral head, and accessory carpal bone osteophytes. There was evidence of a cranial cruciate ligament rupture in an 8-year-old male. Trauma induced joint lesions were seen in four stifles (fragmented or displaced sesamoid bones, fragmented meniscal ossicle, or mineralized fragments). Radiological abnormalities believed to be caused by M. bovis were present in one stifle, one radiocarpal three tibiotarsal, and one tarsometatarsal joints. These had evidence of septic arthritis with extensive bone formation and capsular mineralization. In one 20-month-old lion, changes typical of a bone abscess were found in a proximal tibia. Radiologic evidence of elbow hygromas were seen in three elbows, all believed to be caused by M. bovis. Lions appeared to cope fairly well with a variety of traumatic injuries and were also susceptible to some of the aging/incidental radiologic findings seen in dogs and cats. The suspected M. bovis osseous lesions were more likely to involve the joints, particularly the tarsal joint and were mainly proliferative.

Tuberculosis of the shoulder joint

OBJECTIVES

Skeletal tuberculosis is less common than the pulmonary form. The involvement of the shoulder joint is infrequent. We report our experience treating tuberculosis of the shoulder in 11 patients.

METHODS

There were seven men and four women, ranging in age from 19 to 55 years (average 28.09 years). The duration of their complaints at presentation ranged from 3 to 24 months. The most common presentation was pain, which was seen in 10 joints. All of the patients had mild to moderate restriction of motion of the shoulder. On laboratory examination, the erythrocyte sedimentation rate was increased mildly. No patient had an active tuberculosis lesion or history of pulmonary disease. The diagnosis was based on the clinical picture and radiographic features, and was confirmed by open biopsy. The diagnosis was not confirmed by biopsy in one patient, but the family history and clinical and radiological features were highly suggestive of tuberculosis. Surgical debridement was done in two patients and open biopsy in eight patients in order to obtain samples for pathology. Arthrodesis was done in only one patient. In all patients, treatment began with a four-drug regimen for 2 months, followed by a two-drug regimen for 10 months.

RESULTS

The mean follow-up period after the end of treatment was 28.72 months (range, 22-52 months). At the time of the last visit, all the lesions had healed without recurrence. Five cases had a painless, mobile shoulder, while three had mildly restricted shoulder motion without pain, and three had residual limitation of motion of the affected shoulder.

CONCLUSIONS

Tuberculosis of the shoulder can be difficult to diagnose in the early stages. If not diagnosed early, bony tuberculosis may reduce the quality of life. Therefore, tuberculosis should be suspected in cases of long-standing pain in the shoulder. It is necessary to keep tuberculosis in the differential diagnosis of several osseous pathologies. Arthrodesis should be reserved only for lesions that fail to heal after adequate chemotherapy and rehabilitation.

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.

Tuberculous tenosynovitis

Tuberculous tenosynovitis is rare and may be overlooked as a cause of chronic tenosynovitis. This report presents a case of a young woman with tuberculosis tenosynovitis of the wrist, and highlights the clinical, imaging, histological, and laboratory features most commonly seen in this disease.

Osteoarticular tuberculosis in a general hospital during the last decade

OBJECTIVE

To study clinical features of skeletal tuberculosis diagnosed in our laboratory over the last 10 years.

METHODS

We carried out a retrospective observational study of 26 patients with osteoarticular tuberculosis recording clinical and microbiological data.

RESULTS

Pain was the main clinical presentation. The median time from the onset of symptoms to the diagnosis was 8 months. Synovial fluid was the most common sample obtained. Bone disease and previous or concurrent pulmonary tuberculosis were the most important predisposing factors. The tuberculin test reaction was positive in 83.3% of the patients. The outcome was favorable in 69% of the patients. Weight-bearing joints were the most commonly involved sites.

CONCLUSIONS

A high degree of suspicion is still needed to avoid a delayed diagnosis that might complicate the outcome.

MRI features of tuberculosis of peripheral joints

The aim of this article is to present the magnetic resonance imaging (MRI) features of peripheral tubercular arthritis. The clinical presentation of peripheral tubercular arthritis is variable and simulates other chronic inflammatory arthritic disorders. MRI is a highly sensitive technique which demonstrates fine anatomical details and identifies the early changes of arthritis, which are not visible on radiographs. The MRI features of tubercular arthritis include synovitis, effusion, central and peripheral erosions, active and chronic pannus, abscess, bone chips and hypo-intense synovium. These imaging features in an appropriate clinical setting may help in the diagnosis of tubercular arthritis. Early diagnosis and treatment can effectively eliminate the long-term morbidity of joints affected by tuberculosis.

Multifocal tuberculosis presenting with osteoarticular and breast involvement

BACKGROUND

Polyarticular involvement, wrist and ankle arthritis are uncommon presentation of skeletal tuberculosis. Tuberculosis of the breast is also extremely rare.

CASE PRESENTATION

Wrist, ankle and breast involvement were detected in the same patient. Mycobacterium tuberculosis was isolated from both synovial and breast biopsy specimen cultures.

CONCLUSIONS

In general, tuberculosis arthritis is a frequently missed diagnosis, especially in different clinical patterns. A high level of suspicion is required particularly in high-risk populations and endemic areas.

Acute septic arthritis

Acute septic arthritis may develop as a result of hematogenous seeding, direct introduction, or extension from a contiguous focus of infection. The pathogenesis of acute septic arthritis is multifactorial and depends on the interaction of the host immune response and the adherence factors, toxins, and immunoavoidance strategies of the invading pathogen. Neisseria gonorrhoeae and Staphylococcus aureus are used in discussing the host-pathogen interaction in the pathogenesis of acute septic arthritis. While diagnosis rests on isolation of the bacterial species from synovial fluid samples, patient history, clinical presentation, laboratory findings, and imaging studies are also important. Acute nongonococcal septic arthritis is a medical emergency that can lead to significant morbidity and mortality. Therefore, prompt recognition, rapid and aggressive antimicrobial therapy, and surgical treatment are critical to ensuring a good prognosis. Even with prompt diagnosis and treatment, high mortality and morbidity rates still occur. In contrast, gonococcal arthritis is often successfully treated with antimicrobial therapy alone and demonstrates a very low rate of complications and an excellent prognosis for full return of normal joint function. In the case of prosthetic joint infections, the hardware must be eventually removed by a two-stage revision in order to cure the infection.

Tuberculous arthritis mimic arthritis of the Sjögren's syndrome: findings from sonography, computed tomography and magnetic resonance images

A patient with a history of Sjögren's syndrome developed chronic arthritis of left ankle. It was diagnosed as arthritis of the Sjögren's syndrome initially. However, joint pain persisted despite corticosteroid therapy. Sonography disclosed a multiloculated cystic lesion with peripheral hyperechoic enhancement around left ankle and extended to Achilles tendon and subcutaneous region. Computed tomography (CT) confirmed the findings. Magnetic resonance imaging (MRI) revealed increased signal intensity of the lesion after gadonillium enhancement on T1-weighted images. These abnormalities showed inhomogenous high signal intensities on T2-weighted images. Tuberculous arthritis was diagnosed by positive synovial tuberculous culture. Sonography is a valuable tool that offers significant advantages for the initial evaluation of arthritis of the Sjögren's syndrome and help early suspicious of tuberculous arthritis, because of its cost-effectiveness, superior differentiation between the cyst and solid lesions, convenience for guiding biopsy and drainage.

MRI of musculoskeletal extraspinal tuberculosis

PURPOSE

The aim of this study was to describe the MR findings in extraspinal musculoskeletal tuberculosis (EMT).

METHOD

A retrospective review was conducted of the MR findings of 18 patients with microbiologically and/or pathologically proven EMT. All MR studies were performed using T1-and T2-weighted spin echo sequences. T1-weighted spin echo sequences after Gd-DTPA injection were obtained for 12 patients. The MR images were evaluated for abnormalities in joints, bones, and soft tissues, and the results were grouped by anatomic localization, frequency distribution of structures affected, and morphologic patterns of involvement.

RESULTS

Isolated soft tissue tuberculosis was found in 10 (55.5%) patients and involvement of more than one structure in 8 (44.4%). Pyomyositis (n = 6) and arthritis with involvement of adjacent soft tissues (n = 7) were the most common forms of presentation. One patient presented with isolated fascial superficial tissue involvement in one leg. Isolated pyomyositis involving one (n = 3) or two (n = 3) muscles was homogeneous in six cases and showed intermediate (n = 6), low (n = 2), or high (n = 1) signal intensity on T1-weighted images and a high and very hyperintense signal on T2-weighted images. The tenosynovitis synovial fluid was homogeneous (n = 1) or heterogeneous with multiple tiny hypointense nodules (n = 1) on T2-weighted images. The subdeltoid bursitis fluid was characterized by homogeneous low signal intensity with a hyperintense rim (n = 2) on T1-weighted images and homogeneous (n = 1) or heterogeneous hyperintense signals with areas of low signal intensity (n = 1) on T2-weighted images. In tuberculous arthritis, the synovial joint fluid (n = 7) showed heterogeneous (n = 4) or homogeneous (n = 3) low signal intensity on T1-weighted images and high or very high signal intensity on T2-weighted images. Where involved, the adjacent muscle(s) (n = 8) were usually hypointense on T1-weighted images and very hyperintense on T2-weighted images. Associated cellulitis was found in arthritis with involvement of neighboring soft tissues (n = 5), pyomyositis (n = 2), and tenosynovitis (n = 1). The images obtained after Gd-DTPA showed peripheral (n = 10) or heterogeneous (n = 1) enhancement or no enhancement (n = 1).

CONCLUSION

The MR findings for EMT are variable. Although diagnosis is dependent largely on prior presumption and clinical context, MRI provides valuable guidelines in defining the extent of the lesions to select the appropriate treatment and for follow-up of abnormalities.

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.

Granulomatous tenosynovitis: a rare musculoskeletal manifestation of tuberculosis

A patient with tenosynovial tuberculosis affecting the extensor tendons of the wrist and hand is presented. This case highlights the clinical and magnetic resonance features of tuberculous tenosynovitis, and seeks to increase awareness of what may represent a resurgent musculoskeletal entity.

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.