Mycobacterial osteomyelitis and arthritis

A case report of coexisting breast cancer with peritoneal, cutaneous tuberculosis, and potential Pott's disease: therapeutic and diagnostic challenges

Introduction

Breast cancer affects one in eight women during their lifetime; it may coincide with other diseases due to its high prevalence. Different pathologies that occur simultaneously with breast cancer, or later during its course, lead to multiple interactions with cancer and have a significant impact on its management.

Presentation of case

A 58-year-old Syrian female was admitted to our hospital for compliant of abdominal distension. Following complete examination, obtained biopsies confirmed the diagnosis of peritoneal tuberculosis. At a subsequent time, she suffered back pain and the computed tomography showed vertebral lesion with breast mass that was diagnosed as invasive lobular carcinoma (ILC) of the left breast. Vertebral lesion that appeared on radiologic assessment was diagnosed as cancer metastasis. However, the interaction of this metastasis with the proposed management diverted the attention towards its non-cancerous entity. Five months after completing the chemotherapy, biopsies revealed the recurrence of triple-negative (ER-, PR-, HER2- neu-) ILC of the breast. Ultimately, the patient was followed up for an overall duration of 4 years.

Discussion

Latent tuberculosis infections may be activated by chemotherapy regimens that suppress immunity. Therefore, initial management of tuberculous infection is preferred when it coexists with cancer.

Conclusion

Breast cancer is common and may co-present with other diseases, which, in some cases, produce mimicking lesions that alter its diagnosis. Pott's disease, albeit a rare entity, has shown a resurgence in developed countries and should be considered in the differential diagnosis of vertebral lesions in patients with breast cancer.

Composition of pathogenic microorganism in chronic osteomyelitis based on metagenomic sequencing and its application value in etiological diagnosis

BACKGROUND

Traditionally, conventional microbiological culture methods have been used to detect pathogenic microorganisms in chronic osteomyelitis. However, these methods have been found to have a low detection rate, complicating the precise guidance of infection treatment. This study employed metagenomic next-generation sequencing (mNGS) to detect these microorganisms in chronic osteomyelitis with three main objectives: 1). Gain a deeper understanding of the composition of pathogenic microorganisms in chronic osteomyelitis. 2). Compare the microbial detection rates between mNGS and the standard culture methods used in laboratories to enhance the effectiveness of the traditional culture methods. 3). Explore the potential of mNGS in etiological diagnosis.

METHODS

Fifty clinically confirmed intraoperative bone tissue samples of chronic osteomyelitis from January 2021 to December 2021 were collected and subjected to mNGS and microbiological testing, respectively. The orthopaedic surgeon combined clinical manifestations and related examinations to determine the causative pathogens.

RESULTS

The culture method obtained 29 aerobic and parthenogenic anaerobic bacteria, 3 specific anaerobic bacteria, and 1 yeast-like fungus. Thirty-six aerobic and parthenogenic anaerobic bacteria, 11 specific anaerobic bacteria, and 1 yeast-like fungus were obtained by mNGS, and 2 Mycobacterium tuberculosis(MTB) strains were detected. However, there was no significant difference in the overall positive detection rate between mNGS and the culture method (P = 0.07), and the two were not statistically significant in detecting aerobic and partly anaerobic bacteria (P = 0.625). But, mNGS was significantly superior to culture in detecting anaerobic bacteria and Mycobacterium tuberculosis (P<0.05).

CONCLUSIONS

The mNGS method has enhanced our understanding of the distribution of pathogenic microorganisms in chronic osteomyelitis. Traditional culture methods help isolate and cultivate aerobic and facultative anaerobic bacteria, and fungi, and are also utilized for antibacterial drug sensitivity tests. However, mNGS has shown superior capabilities in detecting anaerobic bacteria, MTB, and mixed infection bacteria. This finding offers invaluable guidance for improving laboratory microbial culture and detection conditions. Hence, mNGS should be judiciously used for chronic osteomyelitis, and PCR can be implemented for certain difficult-to-culture microorganisms, such as MTB.

Tuberculous arthritis of native joints - a systematic review and European Bone and Joint Infection Society workgroup report

Introduction: The aim of this systematic review was to assess the existing published data on the diagnosis and management of tuberculosis (TB) arthritis involving native joints in adults aged 18 years and older. Methods: This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). Results: The systematic review of the literature yielded 20 data sources involving 573 patients from nine countries. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The diagnosis was mostly made by microbiological tissue culture. Medical management involved a median of 12 months of anti-tubercular treatment (interquartile range, IQR, of 8-16; range of 4-18 months). The duration of preoperative treatment ranged from 2 to 12 weeks. Surgery was performed on 87 % of patients and varied from arthroscopic debridement to complete synovectomies combined with total joint arthroplasty. The mean follow-up time of all studies was 26 months (range of 3-112 months). Recurrence rates were reported in most studies, with an overall average recurrence rate of approximately 7.4 % (35 of 475 cases). Conclusions: The current literature on TB arthritis highlights the need for the establishment of standardized guidelines for the confirmation of the diagnosis. Further research is needed to define the optimal approach to medical and surgical treatment. The role of early debridement in active TB arthritis needs to be explored further. Specifically, comparative studies are required to address questions around the use of medical treatment alone vs. in combination with surgical intervention.

Tuberculosis revisted: classic imaging findings in childhood

Tuberculosis (TB) remains one of the major public health threats worldwide, despite improved diagnostic and therapeutic methods. Tuberculosis is one of the main causes of infectious disease in the chest and is associated with substantial morbidity and mortality in paediatric populations, particularly in low- and middle-income countries. Due to the difficulty in obtaining microbiological confirmation of pulmonary TB in children, diagnosis often relies on a combination of clinical and radiological findings. The early diagnosis of central nervous system TB is challenging with presumptive diagnosis heavily reliant on imaging. Brain infection can present as a diffuse exudative basal leptomeningitis or as localised disease (tuberculoma, abscess, cerebritis). Spinal TB may present as radiculomyelitis, spinal tuberculoma or abscess or epidural phlegmon. Musculoskeletal manifestation accounts for 10% of extrapulmonary presentations but is easily overlooked with its insidious clinical course and non-specific imaging findings. Common musculoskeletal manifestations of TB include spondylitis, arthritis and osteomyelitis, while tenosynovitis and bursitis are less common. Abdominal TB presents with a triad of pain, fever and weight loss. Abdominal TB may occur in various forms, as tuberculous lymphadenopathy or peritoneal, gastrointestinal or visceral TB. Chest radiographs should be performed, as approximately 15% to 25% of children with abdominal TB have concomitant pulmonary infection. Urogenital TB is rare in children. This article will review the classic radiological findings in childhood TB in each of the major systems in order of clinical prevalence, namely chest, central nervous system, spine, musculoskeletal, abdomen and genitourinary system.

Like a shot-through manubrium: A rare presentation of skeletal tuberculosis

A 22-year-old Vietnamese woman presented with anterior chest swelling. Computed tomography revealed an osteolytic lesion in the manubrium, whereas MRI showed an extra-osseous expansion. A needle biopsy showed granuloma formation, whereas a 3-week mycobacterial culture indicated Mycobacterium tuberculosis infection. Manubrium/sternum involvement in tuberculosis is extremely rare but should be considered.

Osteoarticular tuberculous infection of the first tarsometatarsal joint - a case report

Introduction

The prevalence of osteoarticular tuberculosis is increasing. Tuberculous infection in midfoot is rare. Establishing the diagnosis is difficult, leading to delay in management and leave many complications.

Case presentation

An 18-year-old man presents to our clinic with pain on his foot for the last 1 year. No other remarkable signs and symptoms. X-ray of his foot shown destruction of the 1st tarsometatarsal joint, later confirmed with MRI that shown synovitis and bone edema. Mantoux test and biopsy were done and established the diagnosis of tuberculous infection.

Clinical discussion

Intensive phase of anti-tuberculosis chemotherapy was given for 2 months, followed by continuation phase for 7 months. Surgical management of debridement and arthrodesis were performed as adjunctive treatment. At 10 months follow-up patient was pain free, fully weight-bearing and no signs of further destruction.

Conclusion

Osteoarticular tuberculosis is difficult to diagnose, a high index of suspicion is required to avoid delay treatment and complications. Anti-TB chemotherapy is still the treatment of choice, with surgical management is reserved for advance case.

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Tuberculous infection in midfoot is rare, especially in young healthy patient

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Establishing the diagnosis is difficult, since laboratory and radiological findings often give non-spesific results

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Surgeon who works in endemic area has to have a High suspicion to the disease

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Conservative treatment with anti-TB chemotherapy is still the first-line treatment, with surgical management is reserved for late and advance presentation

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.

Novel strategies to diagnose prosthetic or native bone and joint infections

INTRODUCTION

Bone and Joint Infections (BJI) are medically important, costly and occur in native and prosthetic joints. Arthroplasties will increase significantly in absolute numbers over time as well as the incidence of Prosthetic Joint Infections (PJI). Diagnosis of BJI and PJI is sub-optimal. The available diagnostic tests have variable effectiveness, are often below standard in sensitivity and/or specificity, and carry significant contamination risks during the collection of clinical samples. Improvement of diagnostics is urgently needed.

AREAS COVERED

We provide a narrative review on current and future diagnostic microbiology technologies. Pathogen identification, antibiotic resistance detection, and assessment of the epidemiology of infections via bacterial typing are considered useful for improved patient management. We confirm the continuing importance of culture methods and successful introduction of molecular, mass spectrometry-mediated and next-generation genome sequencing technologies. The diagnostic algorithms for BJI must be better defined, especially in the context of diversity of both disease phenotypes and clinical specimens rendered available.

EXPERT OPINION

Whether interventions in BJI or PJI are surgical or chemo-therapeutic (antibiotics and bacteriophages included), prior sensitive and specific pathogen detection remains a therapy-substantiating necessity. Innovative tests for earlier and more sensitive and specific detection of bacterial pathogens in BJI are urgently needed.

Retrospective Study of Bone-TB in Oman: 2002-2019

Objective: Little information is available about the etiology, pathophysiology, risk factors, and epidemiologic features of Bone Tuberculosis (Bone-TB). In this work, we present the epidemiological data about the Bone-TB in the Sultanate of Oman.

Methods: Retrospectively, we identified and assessed those patients who were diagnosed with Bone-TB between January 2002 and December 2019 at Khoula Hospital. The following data were collected: demographics, clinical presentation, anatomical location, diagnosis, and treatment of the Bone-TB.

Results: During the study period, 115 cases of Bone-TB were diagnosed. Males were affected more than females (57.4% and 42.6%, respectively). About 30% of Bone-TB cases were primary diagnosed in other organs particularly the lungs and then after disseminated to the bone. However, the Bone-TB was detected in hip, leg, hand, shoulder, and skull bones, the most detected Bone-TB was in spine (66% of cases). After vaccination the Bacillus Calmette–Guérin (BCG) strains were identified in the bones of eight babies. Tubercle bacilli were detected by Acid-Fast Stain (AFS) in 59% of cases, and the rest of cases were confirmed using polymerase chain reaction (PCR) tests. There are two used treatment regimens, with 12.4% relapse. The gastrointestinal tract (GIT) disturbances were the most related side effects. The resistance has been detected to pyrazinamide in six cases, rifampicin in three cases, and isoniazid, streptomycin and kanamycin were detected in one case.

Conclusion: The most predominant Bone-TB cases were spine-TB that were mainly disseminated from the lungs. AFS failed to detect tubercle bacilli in 40% of cases. There is no statistical significance in relapse between the used two regimens. The death was predominant among skull-TB cases.

Non-axial osteoarticular tuberculosis in the paediatric age

INTRODUCTION AND OBJECTIVES

Osteoarticular tuberculosis, caused by a member of the Mycobacterium genus, represents approximately 10% of the total extrapulmonary tuberculosis in pediatric patients. Its low prevalence and nonspecific clinical presentation lead to a late diagnosis and elevated risk of sequelae.

PATIENTS AND METHODS

This retrospective study included seven pediatric patients with non-vertebral osteoarticular tuberculosis diagnosed between 2006 and 2019. The patients were classified in accordance with the radiographic criteria of Kerri and Martini.

RESULTS

The mean patient age was 7,4 years (median, 5 years; range, 2-16 years). The mean follow-up time was 18,5 months (range, 10-32 months). The mean diagnostic delay was 4,7 months (range, 1-8 months). The locations were femoral head osteoarthritis (two patients) and proximal humerus osteomyelitis, talus dome osteoarthritis, distal clavicle osteoarthritis, proximal ulna epiphysis osteoarthritis, and tibiotalar arthritis along with subtalar gland (one patient each). The clinical findings were lameness (four patients), localized pain (two patients), functional impotence, constitutional syndrome (asthenia, anorexia, and involuntary loss of>5% of total body weight) (two patients), local inflammatory signs (one patient), and fever (one patient). One patient was asymptomatic and received a diagnosis during pulmonary radiological analysis. Medical treatment with four drugs was performed in all patients; five patients required surgical treatment for abscess drainage, three of them open drainage, and two with laparoscopic drainage.

CONCLUSIONS

The final results were satisfactory, such that 71% of patients recovered joint balance but with radiological sequelae in 57,1% patients. Good prognosis, according to our results, depends on younger age and early diagnosis with early medical or surgical treatments.

Analysis of the early clinical outcomes of arthroscopic debridement in the treatment of shoulder tuberculosis

Background

Due to atypical clinical symptoms, it is difficult to diagnose joint tuberculosis infection, which often results in misdiagnosis and missed diagnosis. It is easy to cause joint disability. And there are few reports of using arthroscopy to diagnose and treat shoulder tuberculosis. This case series aims to introduce the clinical outcomes of arthroscopic treatment of shoulder tuberculosis.

Methods

Twenty-nine patients with shoulder tuberculosis from September 2013 to February 2019 were included (10 males, 19 females; age range from 22 to 69; the average age is 37.6 years). All patients underwent arthroscopic lesion debridement, with preoperative and postoperative regular use of isoniazid, rifampicin, pyrazinamide, and streptomycin quadruple anti-tuberculosis drugs. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded before and at the last follow-up. The shoulder function was evaluated according to the visual analogue scoring method (visual analogue scale, VAS) pain score and Constant score.

Results

Twenty-nine patients were followed up from 12 months to 2 years, and the average follow-up time was 15.7 months. The pathological diagnosis of all patients after surgery was shoulder tuberculosis. No serious complications were found at the last follow-up, and the incision healed well. VAS pain score, Constant score, ESR, and CRP at the last follow-up were significantly improved compared with those before treatment (P < 0.05).

Conclusion

On the basis of the standard use of anti-tuberculosis drugs before and after surgery, shoulder arthroscopy is used to treat early and mid-term shoulder tuberculosis, which can be diagnosed by direct observation under the arthroscope and postoperative pathological examination. It has the advantages of thorough lesion removal, minimal invasiveness, rapid recovery, and reliable clinical effect.

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.

Improved case detection using Xpert Mycobacterium tuberculosis/rifampicin assay in skeletal tuberculosis

Background

In India, musculoskeletal tuberculosis (TB) accounts for 10%-25% of extrapulmonary TB. Data on drug-resistant skeletal TB are lacking. At present, the diagnosis is based mainly on radiological techniques. Laboratory confirmation of skeletal TB is delayed as 6-8 weeks are required for culture results. Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay is a fully automated test which simultaneously detects MTB and RIF resistance within 3 h. Hence, this study was done to compare the yield of case detection using Xpert assay in comparison with culture in specimens received from clinically suspected skeletal TB cases.

Methods

Retrospective analysis of microscopy, culture and Xpert assay results was carried out on specimens received in laboratory from skeletal TB cases from January 2016 to December 2017.

Results

Of the 201 patients analysed, majority of the specimens were obtained from the spine (55.72%). MTB was detected in 48.68% of tissue and 24% of pus specimens. Xpert assay was detected MTB in 67 (33.33%) specimens of which 53 (47.32%) were from the spine. Culture was detected MTB in 66 (32.83%) specimens. Xpert assay was detected two specimens more than culture. One specimen was positive by only culture. RIF-resistant MTB was detected in 10 (14.92%) specimens by Xpert assay.

Conclusion

The spine is the most common site involved. Tissue specimen is better for early diagnosis. High RIF resistance in skeletal TB is an alarming situation. Ability of Xpert MTB/RIF assay for rapid and simultaneous detection of MTB and RIF resistance in comparison with culture makes it a useful diagnostic tool in skeletal TB.

[Synovial fluid cytodiagnosis]

Synovial fluid samples represent only a very small percentage of routine work in a cytology laboratory. However, its microscopic examination allows us to observe different types of cells, particles and structures that, due to their morphological characteristics, may provide relevant data for cytodiagnosis. We present certain aspects related to arthrocentesis, the relationship between the gross appearance of synovial fluid and certain pathological processes, as well as the different techniques for processing and staining the smears. Furthermore, we describe the main cytological findings in various pathological conditions of the synovial joints, such as infections (bacterial and fungal), non-infectious inflammatory type (osteoarthrosis, rheumatoid arthritis, connective tissue diseases) and tumoral, distinguishing between primary and metastatic, both solid and haematological neoplasms.

An uncommon cause of sciatic pain: tuberculous osteomyelitis of the ischial tuberosity

A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagnosis of tuberculous osteomyelitis with unknown portal entry. The patient did not report a history of a previous tuberculosis (TB) infection and her chest X-ray was negative for TB. Considering TB in the differential diagnosis of a 'bone abscess', it is of paramount importance to come to a correct diagnosis. Conventional radiographs still remain the first-line imaging modality for evaluation of skeletal symptomatology. However, biopsies or aspirates are often needed to yield the definitive diagnosis. The lack of awareness of the potential extrapulmonary involvement of TB leads to an important delay in diagnosis and treatment. Antituberculous drugs should be started at the time of biopsy and continued during 12-18 months, due to poor drug penetration into osseous and fibrous tissues.

The Classification of Long Bone Osteomyelitis: A Systemic Review of the Literature

Background: Osteomyelitis is a complex disease. Treatment involves a combination of bone resection, antimicrobials and soft-tissue coverage. There is a difficulty in unifying a classification system for long bone osteomyelitis that is generally accepted.

Objectives: In this systematic review, we aim to investigate the classification systems for long bone osteomyelitis that have been presented within the literature. By doing this, we hope to elucidate the important variables that are required when classifying osteomyelitis.

Methods: A complete search of the Medline, EMBASE, Cochrane and Ovid databases was undertaken. Following exclusion criteria, 13 classification systems for long-bone osteomyelitis were included for review.

Results: The 13 classification systems that were included for review presented seven different variables that were used for classification. Ten of them used only one main variable, two used two variables and one used seven variables. The variables included bone involvement (used in 7 classification systems), acute versus chronic infection (used in 6), aetiopathogenesis (used in 3), host status (used in 3), soft tissue (used in 2), microbiology (used in 1) and location of infected bone (used in 1). The purpose of each classification system could be grouped as either descriptive (3 classification systems), prognostic (4) or for management (4). Two of the 13 classification systems were for both prognostic and management purposes.

Conclusions: This systematic review has demonstrated a variety of variables used for classification of long bone osteomyelitis. While some variables are used to guide management and rehabilitation after surgery (e.g., bone defect, soft tissue coverage), others were postulated to provide prognostic information (e.g., host status). Finally, some variables were used for descriptive purposes only (aetiopathogenesis). In our view and from today's perspective, bone involvement, antimicrobial resistance patterns of causative micro-organisms, the need for soft-tissue coverage and host status are important variables to include in a classification system.

Tubercular dactylitis in children

Tubercular dactylitis is a rare manifestation of skeletal tuberculosis in the paediatric population. Its clinical diagnosis is often delayed as local symptoms may easily be missed in children and constitutional features such as loss of weight, loss of appetite, night sweats, evening rise of temperature and history of close contact with a patient of tuberculosis may not always be present. Parents seek treatment only when they notice significant swelling or tenderness of fingers or hand in their children. Radiology and fine-needle aspiration cytology may help in establishing an early diagnosis. Astute multidrug antitubercular therapy is curative.

Septic Arthritis of Native Joints

Septic arthritis is a rheumatologic emergency that may lead to disability or death. Prompt evacuation of the joint, either by arthrocentesis at the bedside, open or arthroscopic drainage in the operating room, or imaging-guided drainage in the radiology suite, is mandatory. Methicillin-resistant Staphylococcus aureus (MRSA) has become a major cause of septic arthritis in the United States. MRSA joint infection seems to be associated with worse outcomes. Antibiotic courses of 3 to 4 weeks in duration are usually adequate for uncomplicated bacterial arthritis. Treatment duration should be extended to 6 weeks if there is imaging evidence of accompanying osteomyelitis.

Mycobacterial Arthritis and Synovitis in Painted Reed Frogs (Hyperolius marmoratus)

Several species of atypical mycobacteria have been isolated from wild and captive amphibians. In captive anurans, cutaneous and visceral mycobacteriosis are common and can result in significant mortality, particularly when animals are immunocompromised. Mycobacterial arthritis and synovitis are reported rarely in amphibians. We describe 20 cases in painted reed frogs (Hyperolius marmoratus), which presented with cachexia, limb paresis or paralysis or 'spindly leg syndrome'. Histopathology revealed multifocal histiocytic to granulomatous synovitis affecting appendicular, rib or spinal intervertebral joints. Periarticular granulomata, granulomatous cellulitis and skeletal muscle atrophy, necrosis and degeneration were also present. In one case, granulomatous spinal osteomyelitis was recorded. Ziehl-Neelsen stains showed large numbers of acid-fast bacteria in macrophages and histiocytes. The mycobacterial isolates obtained from culture were identified as members of the Mycobacterium chelonae complex (either M. chelonae or Mycobacterium abscessus). This was confirmed by 5'-16S ribosomal ribonucleic acid (rRNA) sequencing. In 17 cases mycobacterial lesions were present only in the joints and skeleton, highlighting the importance of not ruling out mycobacterial infection on the basis of absence of cutaneous or visceral lesions.

Acute Monoarthritis of the Wrist Joint: Tuberculosis or Not?

Background Extrapulmonary tuberculosis (EPTB) is known to have many and varied presentations. However, isolated involvement of bone with tubercular infection is uncommon. The clinical features of such infections are known to mimic chronic pyogenic osteomyelitis, Brodie abscess, or tumors, but not acute monoarthritis. Case Description We describe here an unusual case of tuberculous osteomyelitis that mimicked features of acute monoarthritis of the wrist joint. Literature Review Extraspinal tuberculous osteomyelitis is rare and comprises only about 2 to 3% of all cases of osteoarticular tuberculosis, with the hip and knee joints being the most commonly involved. An extensive literature review did not show any published report of tuberculous osteomyelitis presenting as acute monoarthritis of the wrist joint. Clinical Relevance This case underlines the importance of making EPTB an important differential diagnosis even in cases with clinical features that are completely inconsistent with tubercular infections.

Pediatric and adult spinal tuberculosis: imaging and pathophysiology

The prevalence of tuberculosis (TB) has increased in developing and developed countries as a consequence of the AIDS epidemic, immigration, social deprivation, and inadequate TB control and screening programs. Spinal TB may be osseous or nonosseous. Classic findings of multiple contiguous vertebral body involvement, gibbus formation, and subligamentous spread with paravertebral abscesses are optimally evaluated with MR imaging. Nonspondylitic spinal TB is less well described in the literature, may develop in the absence of TB meningitis, and is often associated with meningovascular cord ischemia. Radiologists should be familiar with the spectrum of imaging findings, allowing early diagnosis and treatment of this serious condition.

Multifocal skeletal tuberculosis in an immunocompetent patient: a case report

Background

The occurrence of multifocal skeletal involvement in immunocompetent patients is rare, even in countries where tuberculosis is endemic. Multifocal skeletal lesions may occur as a result of hematogenous dissemination from another primary focus such as cervical lymph nodes, lungs, tonsils or gastrointestinal tract.

Case presentation

We present a 59 year-old man with a history of intermittent and disabling pain in his left knee for 2 years. The patient in this case presented with lung infection with bilateral skeletal dissemination in the knees and femurs. Immunological examination for the HIV was negative.

Conclusions

Diagnosis of this condition is not always easy because of the disease’s insidious character, and it can be confused with other diseases such as osteoarthritis, especially in middle-aged individuals.

Multifocal osteoarticular tuberculosis of the extremities in an immunocompetent young man without pulmonary disease: A case report

Osteoarticular tuberculosis (TB), an uncommon form of extrapulmonary TB, is a universal mimicker and thus represents a potential differential diagnosis of any osteolytic lesion. The present study describes a case of multifocal osteoarticular TB in an immunocompetent young man who presented with swelling and extremity pain. The patient underwent plain radiography, bone scan and magnetic resonance imaging. A diagnosis was ultimately made based on the pathology results from his second left toe. The patient responded well to anti-TB medication. The radiological findings of multifocal osteoarticular TB are described in this report. To the best of our knowledge, this is the first reported case of multifocal osteoarticular TB symmetrically affecting all the extremities.

Comparison of the clinical characteristics of Mycobacterium tuberculosis and nontuberculous mycobacteria patients with joint involvement

Nontuberculous mycobacteria (NTM) joint involvement is rare. However, the incidence of NTM disease is increasing and it is difficult to distinguish NTM from Mycobacterium tuberculosis (MTB). Here, the clinical characteristics of NTM joint involvement were compared with those of MTB. Distal joint involvement and precipitating factors were significantly more frequent for NTM joint infections. Because pathologic findings of NTM and MTB were similar, microbiological investigations are needed.

Tuberculous osteomyelitis/arthritis of the first costo-clavicular joint and sternum

A young Somali immigrant presents with a two-year history of a large, firm, painful right anterolateral chest wall sternal mass. The patient denied any history of trauma or infection at the site and did not have a fever, erythematous lesion at the site, clubbing, or lymphadenopathy. A lateral chest radiograph demonstrated a low density mass isolated to the subcutaneous soft tissue overlying the sternum, ribs and clavicle. Computed tomography (CT) with contrast demonstrated a cystic lesion in the right anterolateral chest wall deep to the pectoralis muscle. Enhanced CT of the chest demonstrated sclerosis and destruction of the rib and costochondral joint and manubrio-sternal joint narrowing. Ultrasound-guided biopsy and aspiration returned 500 cc of purulent, cloudy yellow, foul-smelling fluid. Acid-fact bacilli stain and the nucleic acid amplification test identified and confirmed Mycobacterium tuberculosis. A diagnosis of tuberculous osteomyelitis/septic arthritis was made and antibiotic coverage for tuberculosis was initiated.

Bone and joint tuberculosis

INTRODUCTION

Bone and joint tuberculosis has increased in the past two decades in relation with AIDS epidemics.

MATERIAL AND METHODS

A literature review of bone and joint tuberculosis, focusing on Pott's disease.

RESULTS

Bone and joint TB comprises a group of serious infectious diseases whose incidence has increased in the past two decades, especially in underdeveloped countries, in part due to the AIDS epidemic. Tuberculous spinal infections should be suspected in patients with an insidious, progressive history of back pain and in individuals from an endemic area, especially when the thoracic vertebrae are affected and a pattern of bone destruction with relative disc preservation and paravertebral and epidural soft tissue masses are observed. Atypical tuberculous osteoarticular manifestations involving the extraspinal skeleton, a prosthetic joint, or the trochanteric area, and nontuberculous mycobacterial infections should be considered in favorable epidemiological contexts. Surgery combined with prolonged specific antituberculous chemotherapy is mainly indicated in patients with neurological manifestations or deformities, and provides satisfactory results in most cases.

CONCLUSIONS

Spinal tuberculosis is still a relative common extra spinal manifestation of spinal tuberculosis that requires a high degree of suspicion in order to avoid neurological complications and need of surgery.

[Infectious bone diseases]

Bacterial infection of the bone is a severe disease with complications, potentially including long-term physical disability. The diagnosis and therapy of osteomyelitis include several elements: histopathology, microbiology, radiologic imagining, as well as antibiotic and surgical therapy. Histopathologists differentiate between acute osteomyelitis (infiltration of cancellous bone with neutrophil granulocytes); specific osteomyelitis (epithelioid-like granulomatous inflammation, tuberculosis, mycotic infections); primary/secondary chronic osteomyelitis (lymphocytic infiltration); and special forms of chronic osteomyelitis (varying histomorphology, Brodie abscess, SAPHO syndrome). Another important task in the histopathological diagnosis of inflammatory bone diseases is to differentiate osteomyelitis from malignant entities (sarcoma, lymphoma). Therefore, biopsy samples should be of sufficient size for safe diagnosis. Clinical information and imaging as well as interdisciplinary teamwork between radiologists, microbiologists, orthopedic surgeons and pathologists is mandatory to verify these diagnoses.

Osteomyelitis of the long bones

Long bone osteomyelitis presents a variety of challenges to the physician. The severity of the disease is staged depending upon the infection's particular features, including its etiology, pathogenesis, extent of bone involvement, duration, and host factors particular to the individual patient (infant, child, adult, or immunocompromised). Long bone osteomyelitis may be either hematogenous or caused by a contiguous spread of infection. A single pathogenic organism is almost always recovered from the bone in hematogenous osteomyelitis; Staphylococcus aureus is the most common organism isolated. A variety of multidrug-resistant organisms of bacteria continue to be a source of concern in arresting infection. The primary weapons to treat these infections are culture-specific antibiotics, aggressive debridement, muscle flaps, and bone grafts. This article offers a basic review of the classification, etiology, epidemiology, pathogenesis, and treatment of long bone osteomyelitis.

Osteoarticular manifestations of Mycobacterium tuberculosis infection

Mycobacterium tuberculosis has affected humans for much of our existence. The incidence of global tuberculosis infection continues to rise, especially in concert with HIV coinfection. Many disease processes, such as diabetes, increase the likelihood of tuberculosis infection. Tuberculosis bacteria can infect any bone, joint, tendon, or bursa; however, the most common musculoskeletal site for infection includes the spine and weight-bearing joints of the hip and knee. Many patients who present with osteoarticular tuberculosis infection will have a gradual onset of pain at the site of infection. Many patients who develop a musculoskeletal tuberculosis infection will have no evidence of a pulmonary tuberculosis infection on x-ray film and many will have very mild symptoms with the initial infection. Healthcare providers must remember that many patients who develop tuberculosis infection do not progress to active tuberculosis disease; however, the latent infection may become active with immune compromise.

A case of tuberculous arthritis following the use of etanercept

Etanercept is a tumor necrosis factor (TNF) inhibitor that has been used for the treatment of chronic inflammatory diseases including rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. Because of its immunosuppressive activity, opportunistic infections have been noted in treated patients, most notably caused by Mycobacterium tuberculosis. Tuberculosis may present in an extrapulmonary or disseminated form. Since TNF-alpha inhibitors have been used in Korea, a few cases of TNF-alpha inhibitor associated tuberculosis have been described. However, tuberculous arthritis has not been previously reported. We describe a case of tuberculous arthritis in a 57-year-old woman with rheumatoid arthritis who was treated with etanercept.

Guía de práctica clínica de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) sobre el tratamiento de la tuberculosis

The therapeutic scheme for initial pulmonary tuberculosis recommended by the SAEI is as follows: Initial phase, isoniazid, rifampin and pyrazinamide given daily for 2 months. In HIV(+) patients and immigrants from areas with a rate of primary resistance to isoniazid > 4%, ethambutol should be added until susceptibility studies are available. Second phase (continuation phase): rifampin and isoniazid, given daily or intermittently for 4 months in the general population. HIV(+) patients (< or = 200 CD4) and culture-positive patients after 2 months of treatment should receive a 7-month continuation phase. A 6-month regimen is recommended for extrapulmonary tuberculosis, with the exception of tuberculous meningitis, which should be treated for a minimum of 12 months and bone/joint tuberculosis, treated for a minimum of 9 months. Treatment regimens for multidrug resistant tuberculosis are based on expert opinion. These would include a combination of still-useful first-line drugs, injectable agents, and alternative agents, such as quinolones. Patients who present a special risk of transmitting the disease or of non-adherence should be treated with directly observed therapy.