Mycobacterial Musculoskeletal Infections

Nontuberculous Mycobacterial Flexor Tenosynovitis of the Wrist and Hand

Nontuberculous mycobacteria (NTM) are uncommon causes of cutaneous and musculoskeletal infections. Here, we present an immunocompromised patient with persistent swelling in the left hand, wrist, and distal forearm. MRI findings revealed flexor tenosynovitis with synovial hypertrophy of the left hand and wrist and loculated fluid containing rice bodies along the distal flexor digitorum muscles in the volar aspect of the left wrist. The patient underwent flexor tenosynovectomy, and histological examination of the excised tenosynovium and mass revealed noncaseating granulomas. Mycobacterium intracellulare was identified in microbiological cultures. Antimycobacterial therapy was administered postoperatively to manage the infection. This report underscores the significance of maintaining a high index of suspicion for NTM infection when assessing chronic hand swelling, particularly in individuals with compromised immune systems.

Nontuberculous mycobacteriosis oligoarthritis of the right hand misdiagnosed as rheumatoid arthritis: A case report

Infection with Mycobacterium marinum has several different clinical presentations. Most commonly, it appears as a solitary papulonodular lesion on an extremity. A rare presentation of osteoarticular M. marinum involving multiple small joints and tenosynovitis of the hand, which was misdiagnosed as rheumatoid arthritis, is reported. The patient was initially treated for seronegative rheumatoid arthritis but failed to respond to methotrexate. Magnetic resonance imaging showed arthritis and tenosynovitis. Subsequently, synovial biopsy led to histological and microbiological diagnosis. Antimycobacterial treatment should be started promptly in such cases. The combined use of rifampicin, ethambutol, and clarithromycin appears to be effective, and debridement is indicated in patients with deep-seated infections.

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.

Prosthetic joint infection caused by an imipenem-resistant Mycobacterium senegalense

Periprosthetic joint infection (PJI) remains one of the most common complications of total knee arthroplasty. Although mainly caused by Staphylococcus aureus and other Gram-positive microorganisms, occasionally, commensal or environmental bacteria are reported as causative agents of these infections. The present work aimed to report a case of PJI caused by an imipenem-resistant Mycobacterium senegalense strain. A bacterial strain isolated from the culture of intraoperative samples was observed by optical microscopy after Gram and Ziehl-Neelsen staining. The species identification was performed by mass spectrometry analysis and partial sequencing of the heat shock protein 65 (hsp65) gene. The antimicrobial profile of the clinical isolate was determined according to the Clinical and Laboratory Standards Institute. Mass spectrometry and gene sequencing analysis identified the bacterial isolate as Mycobacterium fortuitum complex and M. senegalense, respectively. The isolated was found exhibiting an imipenem-resistant profile. The accurate and timely identification, as well as investigation of the antimicrobial susceptibility profile, of fast-growing nontuberculous mycobacteria species are crucial for establishing the prompt and correct treatment of the infection, particularly in cases of patients at greater risk for opportunistic and severe infections.

Clinical course in patients with chronic undifferentiated arthritis of the elbow after arthroscopic synovectomy

BACKGROUND

Surgical treatment can be considered for patients with undifferentiated arthritis (UA) limited to the elbow joint. The purpose of this study was to analyze the clinical outcomes of arthroscopic synovectomy.

METHODS

Nineteen patients who underwent arthroscopic synovectomy for chronic UA of the elbow between 2006 and 2019 were enrolled in this study. One patient was excluded because of evidence of tuberculosis in the biopsy. Chronic UA of the elbow was defined as (1) localized synovitis diagnosed by magnetic resonance imaging, (2) no specific cause, and (3) no response to conservative treatment for >3 months. We compared baseline characteristics and clinical outcomes between the remission and disease progression groups.

RESULTS

Postoperatively, synovitis was controlled in 13 patients. In 5 patients, the symptoms disappeared after surgery without any medical treatment. Four patients discontinued disease-modifying antirheumatic drugs. Nine patients were classified as in remission. The disease progression group had a longer symptom duration, elevated rheumatoid markers, and higher Larsen grading. However, the difference was not statistically significant.

CONCLUSIONS

Arthroscopic synovectomy achieved remission in approximately 47% of patients with chronic UA of the elbow. Although arthroscopic synovectomy did not prevent RA, it can be considered for rapid resolution of synovitis and diagnostic purposes.

Bone and joint tuberculosis in paediatrics: a 13-year retrospective study

Introduction. Bone and joint tuberculosis (BJTB) is rare in developed countries, particularly in the paediatric population.Hypothesis/Gap Statement. The clinical features and sequelae of paediatric BJTB in Europe are not well characterized and should be assessed to achieve a better approach.Aim. To assess the management and outcomes of paediatric BJTB.Methodology. Longitudinal observational study of all paediatric patients (0-17 years old) diagnosed with BJTB between 2008 to 2020 in a tertiary-care hospital.Results. We identified 18 patients with BJTB, with a median age of 10 years (IQR 6-14.8), 66.7 % male. Most (72 %) were diagnosed after 2015 and were foreign-born (88.9 %), mainly from Portuguese-speaking African countries, and none had HIV. The most common symptoms were pain (77.8 %), fever (50 %) and bone deformity (44.4 %). Spinal TB (STB) affected 13 (72.2 %) and extra-spinal TB (ESTB) 9 (50 %) patients, and 4 (27.7 %) had both conditions. Diagnostic positive procedures included positive nucleic acid amplification technique (NAAT) (44.4 %), Mycobacterium tuberculosis isolation (44.4 %) and compatible histology (33.3 %). All completed antituberculous drugs for a median of 12 months (IQR 12-13) and nine (50 %) had surgery. Overall, acute complications occurred in 16 (88.9 %) patients - 11/13 (84.6 %) with STB and 5/5 (100 %) with ESTB - and included abscesses, spinal compression, spine deformity and pathological fractures. Sequelae were still present at the 12-month follow-up in seven cases (46.7 %), and were more common in foreign-born patients sent to Portugal to receive medical treatment (66.7 vs 20 %).Conclusions. Paediatric BJTB is difficult to diagnose and has high morbidity, requiring long-term follow-up. Over the last decade, foreign-born TB seems to be increasing, with still longer treatment courses and more acute complications and sequelae.

Radiographic Findings of Inflammatory Arthritis and Mimics in the Hands

Clinical presentation could be challenging in patients with arthralgia, and imaging plays an important role in the evaluation of these patients to make the diagnosis or narrow the differential diagnosis. Radiography of the hands is a commonly available imaging modality that can provide crucial information with regard to the pattern and pathology of the involved joints. It is important that radiologists and rheumatologists are familiar with the imaging findings of different rheumatic diseases to make the diagnosis in the early stages of disease to initiate treatment.

Musculoskeletal Tuberculosis: New Insights on Diagnosis Strategy and Treatment

BACKGROUND/ OBJECTIVE

Skeletal tuberculosis (TB) is rare. We aimed to report on diagnostic strategy and treatment of skeletal TB.

METHODS

In this multidisciplinary single-center medical records review study, all adult patients admitted between January 2009 and December 2019 with microbiologically proven skeletal TB were included. Demographic, medical history, laboratory, imaging, pathologic findings, treatment, and follow-up data were extracted from medical records.

RESULTS

Among 184 patients identified with TB, 21 (16 women, 42 years [27, 48 years]) had skeletal involvement. Skeletal TB included spondylitis (n = 11), lytic bone lesions (n = 7), sacroiliitis (n = 5), arthritis (n = 3), osteitis (n = 2), and diffuse muscle abscesses without bone lesion (n = 1). Lytic lesions involved both axial and peripheral skeleton at multiple sites in most cases. 18F-fluorodeoxyglucose positron emission tomography was performed in 13 patients and helped to detect multifocal asymptomatic lesions and to target biopsy. All patients were treated with anti-TB therapy for 7 to 18 months. Fifteen patients (71.4%) received steroids as an adjunct therapy. Eleven patients needed an orthopedic immobilization corset, and 3 patients underwent surgery. All patients clinically improved under treatment, but 2 relapsed over a median follow-up of 24 months (12-30 months). No patient died or suffered long-term disabilities.

CONCLUSION

Our study emphasizes the diversity of skeletal involvement in TB. 18F-fluorodeoxyglucose positron emission tomography scanner at diagnosis is key to assess the extension of skeletal involvement and guide extraskeletal biopsy. Neurological complications might be prevented by adding corticosteroids to anti-TB therapy.

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.

Application of Metagenomic Next-Generation Sequencing in Mycobacterium tuberculosis Infection

The fight against Mycobacterium tuberculosis (MTB) has been going on for thousands of years, while it still poses a threat to human health. In addition to routine detections, metagenomic next-generation sequencing (mNGS) has begun to show presence as a comprehensive and hypothesis-free test. It can not only detect MTB without isolating specific pathogens but also suggest the co-infection pathogens or underlying tumor simultaneously, which is of benefit to assist in comprehensive clinical diagnosis. It also shows the potential to detect multiple drug resistance sites for precise treatment. However, considering the cost performance compared with conventional assays (especially Xpert MTB/RIF), mNGS seems to be overqualified for patients with mild and typical symptoms. Technology optimization of sequencing and analyzing should be conducted to improve the positive rate and broaden the applicable fields.

A refractory tenosynovitis of the wrist: a case report

Background

Mycobacterium malmoense is a species of slow-growing nontuberculous mycobacteria. It causes mostly pulmonary infections or lymphadenitis in children, but is increasingly encountered in isolated tenosynovitis in adults. Diagnosis is often delayed because of the rarity of the condition and the difficulty of culturing the bacteria.

Case presentation

We report on a rare association of seronegative polyarthritis with infectious nontuberculous mycobacteria tenosynovitis. A 65-year-old Caucasian female was referred to our clinic because of persisting tenosynovitis of the finger flexor tendons of her right hand, despite two previous synovectomies. She also reported bilateral shoulder and left wrist pain. Paraclinical investigations showed slightly elevated inflammatory parameters. Ultrasound showed synovitis of metacarpophalangeal joints of the right hand and right knee, and a bilateral subacromial bursitis. Hand magnetic resonance imaging also revealed an erosive carpal synovitis. Bacteriological analysis of the second tenosynovectomy specimen showed no growths in aerobic and anaerobic cultures. An additional synovial fluid analysis of the wrist joint was negative for mycobacteria and crystals. Seronegative polyarthritis was suspected, but the initiated immunosuppressive treatment with prednisolone and methotrexate resulted in no clinical improvement of the tenosynovitis. Yet the other joints responded well, and the inflammatory parameters normalized. The immunosuppression was later stopped because of side effects. Due to massive worsening of the tenosynovitis, a third synovectomy was performed. Mycobacterium malmoense was identified on biopsy, leading to the diagnosis of infectious tenosynovitis. At this point, we started an antituberculous therapy, with incomplete response. A combination of antimicrobial and immunosuppressive treatment finally led to the desired clinical improvement.

Conclusion

The treatment of nontuberculous mycobacteria tenosynovitis is not well established, but combining antibiotics with surgical debridement is probably the most adequate approach. Our case highlights the importance of having a high clinical suspicion of an atypical infection in patients with inflammatory tenosynovitis not responding to usual care.

Non-tuberculous Mycobacterial Infection of the Musculoskeletal System Detected at Two Tertiary Medical Centres in Henan, China, 2016-2020

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal system is rare but poses a grave threat to public health. These infections yield non-specific symptoms that remain undetected until the development of the later stages of the disease. In this study, we performed a retrospective review of 25 cases of musculoskeletal NTM infection at two tertiary medical centres over a 5-year period to determine the clinical features and improve the current clinical diagnosis and treatment. The most common mycobacterial species detected were Mycobacterium fortuitum in eleven patients, Mycobacterium abscessus in eight patients, Mycobacterium houstonense in three patients, Mycobacterium avium in two patients, and Mycobacterium smegmatis in one patient. The sites of infection included the limbs and joints, most commonly the knee (ten patients) and foot (six patients). The median duration from the onset of symptoms to diagnosis was 2.5 months (0.8-13.5 months). Deep sinus tracts extending to the surgical site were observed in 60% of the patients (15/25), and granulomatous inflammation and granulomatous inflammation with necrosis occurred in 60% of the patients (15/25). All patients underwent surgical treatment for infection control, and all patients, except one, received antimycobacterial therapy based on drug sensitivity assays. The median duration of the antimicrobial chemotherapy was 5 months (range: 3-20 months). At the final follow-up, 24 patients presented with absence of recurrence and one patient succumbed owing to heart failure after debridement. Our findings highlight the importance of vigilance and improvements in the diagnostic methods for musculoskeletal NTM infection. Aggressive surgical treatment and antimycobacterial drug treatment can help achieve satisfactory results.

Retrospective Analysis of 10 Cases of Disseminated Nontuberculous Mycobacterial Disease with Osteolytic Lesions

Purpose

Disseminated nontuberculous mycobacterial (DNTM) infection can involve multiple organs, including the lungs, skin and soft tissues and lymph nodes. However, NTM infection leading to osteolysis has been rarely reported. Here, we analyzed the clinical features, osteolytic mechanisms, treatment and prognosis of patients with DNTM disease with osteolytic lesions.

Patients and Methods

This retrospective study was conducted between January 1, 2011, and December 31, 2020, at the First Affiliated Hospital of Guangxi Medical University and the Fourth People’s Hospital of Nanning City. Patients who had culture and/or histopathological proof of DNTM disease with osteolytic lesions were included.

Results

Ten HIV-negative patients with DNTM disease with osteolytic lesions were enrolled. Five of these patients had underlying diseases. Seven and three of the patients were positive and negative for anti-interferon-γ autoantibodies (AIGAs), respectively. The AIGA positivity rate was 70% (7/10). Ostealgia and anemia were the most common symptoms, followed by fever, emaciation, cough, expectoration, anorexia, subcutaneous abscesses and lymphadenopathy. Leukocyte and neutrophil counts were increased. The most common sites were the vertebrae, sternum, clavicle and ribs, although the femur, ilium, humerus, and scapula were also involved. Radiography and computed tomography (CT) showed moth-eaten or irregular destruction of bone, bone defects, pathological fracture, periosteal proliferation and surrounding abscesses. Emission CT (ECT) bone scans showed significantly increased uptake in many skeletal regions. Positron emission tomography(PET)/CT showed metabolic activity in multiple bones. All patients received anti-nontuberculous therapy, and five underwent surgery. Two died during treatment.

Conclusion

DNTM infection of bone and leading to osteolysis usually occurs in patients with AIGA-positive antibodies. DNTM disease with osteolysis is characterized by increased leukocytes and neutrophil counts, focal suppurative granulomas, and multiple areas with moth-eaten or irregular destruction of bone with increased radioactive concentrations. Early diagnosis and timely, effective combination anti-NTM therapy can improve the prognosis.

Septic Arthritis of the Right Wrist Due to Mycobacterium avium Complex in an Immunocompetent Patient

Septic arthritis due to Mycobacterium avium complex (MAC) is extremely rare. While MAC infection is classically associated with HIV/AIDS and immunosuppressed states, it may occur in immunocompetent individuals. We report a case of MAC septic arthritis of a native wrist joint in an immunocompetent host. The diagnosis of septic arthritis due to MAC is commonly delayed and initially misdiagnosed, warranting a high level of suspicion to make an accurate and timely diagnosis. Suspecting the diagnosis when there are atypical features present in the clinical history may be crucial in identifying affected patients.

A diffuse granulomatous inflammation secondary to a trauma of hand: a case report

Granulomatous inflammation is rare in the musculoskeletal system and difficult to diagnose. Here we describe a case of a 62-year-old woman with a history of being stabbed by a fishbone presented with a soreness, swelling, and limitation of movement of her right palm and wrist for 4 months. Surgery was done and the histopathology of specimens demonstrated granulomatous lesion, which was negative for acid-fast bacilli. This case demonstrates the diagnosis of granulomatous tenosynovitis on MRI, ultrasound, and surgical examination under anesthesia.

Evaluation of patients admitted with musculoskeletal tuberculosis: sixteen years' experience from a single center in Turkey

Background

The aim of our study was to describe musculoskeletal system tuberculosis (TB) as a single-center experience.

Methods

This is a retrospective observational study conducted at a TB Dispensary in the east Mediterranean part of Turkey between 2004 and 2020. The clinical and demographic characteristics including age, gender, involvement location and duration of illness, presenting complaint, local examination findings, treatment outcome were retrieved and analyzed from the case files. Statistical analyses were performed using SPSS Statistics version 17.0 (IBM). The normality of data analysed by using Kolmogorov-Smirnov. The descriptive statistics were reported as mean ± standard deviation, medians, and ranges (min-max).

Results

Overall, 31 patients (3.2 % of all TB cases) with a mean age of 44.2 ± 16.7 years had musculoskeletal tuberculosis. The mean duration of treatment was 12.9 ± 5.5 months. Of the 31 patients, six (19.4 %) had concomitant pulmonary TB. One of the patients was in the pediatrics age group, and two of them were in the geriatric group. The most affected area was the vertebra. The most common complaint of the patients was back pain and seen in 22 patients (70.9 %).

Conclusions

The physicians should be suspicious about the diagnosis of musculoskeletal TB disease. If the diagnosis and treatment are delayed, spinal damage and other consequences might be incurable.

Septic arthritis of native joints due to Mycobacterium avium complex: A systematic review of case reports

INTRODUCTION

While MAC native joint septic arthritis is historically considered a rare entity, the number of reported cases have increased in recent decades. However, no comprehensive review of this topic has been conducted.

OBJECTIVES

To conduct a systematic review of cases of MAC native joint septic arthritis reported in the literature and summarize the presentations, baseline characteristics, risk factors, diagnosis, treatment, and treatment outcomes.

METHODS

A systematic review was conducted by performing an extensive literature search through Medline, Google Scholar, and Web of Science, starting from their inception. Screening of articles, assessment of eligibility, and data synthesis from eligible articles were independently performed by two reviewers with input from a third reviewer to achieve consensus. Inclusion criteria to determine eligibility included articles in English, case reports/case series, adult patients who presented with MAC/MA/MI septic arthritis of a native joint. Statistical analyses were performed using Statistical Package for the Social Sciences.

RESULTS

Thirty-three cases of MAC native joint septic arthritis were reported since 1976. MAC septic arthritis affects immunocompetent and immunocompromised patients, most frequently as a monoarthritis involving the knees and wrist. MAC septic arthritis may present in the context of disseminated MAC infection and primary MAC septic arthritis. The average time to diagnosis from onset of symptoms was 20 months, where the majority of cases were initially misdiagnosed. Although arthrocentesis can be used to make the diagnosis, a synovial biopsy is necessary in many cases to confirm the diagnosis. A combination of surgery and antimycobacterial drug treatment has the highest chance of achieving complete resolution.

CONCLUSION

The diagnosis of septic arthritis of native joints due to MAC can be challenging and/or delayed. A high level of suspicion is needed in high-risk patients and also when atypical presentations occur. Therefore, understanding the presentation, risk factors, and pitfalls in diagnosing MAC septic arthritis are essential. MAC septic arthritis literature is scarce, necessitating further research of this rare condition to increase awareness, diagnostic accuracy and determine the optimal treatment strategy to improve patient outcomes.

Approach to the diagnosis and treatment of non-tuberculous mycobacterial disease

Non-tuberculous mycobacteria (NTM) is a collective name given to a group of more than 190 species of Mycobacterium. The clinical presentation for most NTM infections is non-specific, often resulting in delayed diagnosis. Further complicating matters is that NTM organisms can be difficult to isolate. Medications used to treat NTM infection can be difficult for patients to tolerate, and prolonged courses of anti-mycobacterial therapy are often required for adequate suppression or eradication. Herein, we review different NTM syndromes, appropriate diagnostic tests, and treatment regimens.

Recurrent Nontuberculous Mycobacterial Tenosynovitis

Background: Nontuberculous mycobacteria are an uncommon pathogen for musculoskeletal infection and are difficult to treat because of delays in diagnosis, prolonged treatment requiring both antimycobacterial therapy and surgical debridement, and high rates of resistance to antimycobacterial therapy.

Case Report: We report the case of an 88-year-old male with recurrent Mycobacterium avium complex tenosynovitis despite receiving multiple courses of pharmacologic therapy and surgical debridement.

Conclusion: Nontuberculous mycobacterial musculoskeletal infections can be difficult to diagnose and equally difficult to treat. A combination of antimycobacterial therapy and surgical debridement is often required; however, the rate of treatment failure remains high, particularly with rapidly growing mycobacteria such as Mycobacterium avium.

Tuberculosis Septic Arthritis of the Elbow: A Case Report and Literature Review

Tuberculosis (TB) infections of the musculoskeletal system are rare. A 77-year-old female with chronic left elbow pain for five months was treated by irrigation and debridement of the elbow for a presumed diagnosis of septic arthritis. Her pain and wound condition did not improve, and she was referred to our institution. Plain radiograph and magnetic resonance imaging (MRI) revealed an osteolytic lesion with joint effusion and severe destruction of the elbow joint. We suspected an atypical infection of the elbow due to the chronicity, negative culture results and severe osteoarticular destruction. An open arthrotomy with irrigation and debridement was performed, and the joint was stabilized with a pin and immobilized. A tissue acid-fast bacillus (AFB) stain was positive and Mycobacterium tuberculosis culture and polymerase chain reaction (PCR) were also positive. Anti-TB drugs were started for a planned 12-month course, but she developed an adverse drug reaction from the standard regimen and had to be switched to a second-line regimen. The stitches were removed at two weeks and the wound eventually healed. The elbow was immobilized in a posterior slab for six weeks then the pin was removed. At the last follow-up visit seven months after the initial surgery, she had improved, with only mild pain on elbow motion. Her range of motion was 110 degrees of flexion and extension lag of 30 degrees.

TB of the elbow is a rare condition. The presentation is insidious and varies, and can be confused with other elbow conditions. Delayed diagnosis can lead to severe joint destruction and poor outcome. The physician should always suspect a TB elbow in cases of chronic elbow pain with synovitis, especially in areas endemic for TB. Joint fluid aspiration and MRI are the most reliable investigations for diagnosis. Anti-TB drugs are the mainstay of treatment. Appropriate surgical interventions such as drainage, synovectomy and reconstructive procedures will often be required. Collaboration between the orthopedist and an infectious specialist is essential for optimal treatment planning.

Mycobacterium bovis BCG osteoarticular infection complicating immune therapy for bladder cancer: a case report

Osteoarticular infection with Mycobacterium bovis (M. bovis) is a rare complication of bladder cancer treatment with intravesical Bacillus Calmette–Guèrin (BCG). We describe a case of disseminated Mycobacterium bovis BCG infection masquerading as a chronic prosthetic joint infection in a patient with several risk factors for progressive mycobacterial infection.

Infectious Tenosynovitis of the Tibialis Anterior Due to Mycobacterium chelonae After Intravenous Heroin Injection

Mycobacterium chelonae is a ubiquitous Gram-positive, acid-fast, non-spore-forming bacterium commonly encountered in nature associated with aquatic animals, soil, and water, including tap water. Nontuberculous mycobacterial tenosynovitis infections caused by M. chelonae in the lower extremity are uncommon, leading to a paucity of literature documenting the diagnosis and treatment of such cases. This report is of a 65-year-old male patient who was found to have an M. chelonae infection along the tibialis anterior tendon after injecting himself with heroin into the dorsal foot veins. This review covers the diagnosis and treatment as well as a case report on the outcome of infectious tenosynovitis of the tibialis anterior associated with M. chelonae. To date, this is the only reported case of tibialis anterior infectious tenosynovitis caused by M. chelonae after intravenous heroin injection.

Tuberculous tenosynovitis of the Flexor Tendons of the hand and wrist: A case report and mini-review

Tuberculous tenosynovitis of hand and wrist is a rare disease but it is found sometimes, especially in TB-endemic areas. The clinical presentation is not specific, however, most patients present with painless swelling at the wrist and hand with limited range of motion, and nerve compression symptoms have been reported. The diagnosis of this conditions can be made from histopathology. Antituberculosis drugs are the mainstay treatment while surgery is controversial.

Case presentation

We present the case of an 83-year-old Thai woman with no history of exposure to tuberculosis. She presented with swelling and mild pain at her right wrist and the fifth finger of her right hand for 3 months. Ultrasonography revealed tenosynovitis in the right hand and wrist. Mycobacterium tuberculosis was confirmed with tissue diagnosis after an open biopsy. 2-months regimens containing Isoniazid, Rifampicin, Pyrazinamide and Ethambutol/6-months of isoniazid and rifampicin treatment was successful without complications. We follower her up for 1 year, at which time she had returned to do normal daily activities. Her final DASH score was 10.8.

Conclusion

Tuberculous tenosynovitis is rare, but still occasionally encountered, especially in TB-endemic areas. The challenge is that this condition is difficult to diagnose due to its clinically insidious onset and the presentation is not obviously specific. Laboratory analysis, imaging (MRI, ultrasonography) and microbiology are useful to help reach a diagnosis, but finally confirmation is from histopathology. The treatment mainstay is medical, but surgery may be required if conservative treatment fails or in late stages of the disease.

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Chronic painless swelling of the hand and wrist in TB endemic area should include TB tenosynovitis.

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Tissue pathology is the mainstays for diagnosis.

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The treatment mainstay is an anti-tuberculosis drugs regimen.

Extraspinal articular tuberculosis: An 11-year retrospective study of demographic features and clinical outcomes in East London

OBJECTIVES

To describe demographic features, clinical outcomes and diagnostic delay amongst patients with extra-spinal articular tuberculosis (TB) in a low-incidence setting.

METHODS

Cases of TB treated at our institution between 2004 and 2014 were identified via the London TB register (LTBR). Demographic features of extra-spinal articular TB cases were compared to controls with TB at all other sites. For articular cases (excluding individuals <16 years or with spinal TB without peripheral joint involvement) clinical data were retrospectively collected.

RESULTS

6,146 TB patients were identified over the study period; 146 (2.4%) cases had extra-spinal articular infection. There was no difference in median age between extra-spinal articular TB cases and controls with TB at other sites (31 vs 32 years, p = 0.57). Articular cases were more likely to be male (70.6% vs 59.5%, p = 0.007), Bangladeshi (28.7% vs 18.0%) or Pakistani (24.0% vs 16.1%) and were less likely to be Black-African (9.5% vs 19.8%) (p < 0.001). 93 cases were included in the case series; 85 (88.5%) were migrants and 83 (89.2%) were South Asian. Knee and elbow joints were affected in 22 (23.7%) and 18 (19.4%) cases respectively. The median durations of pre-healthcare and healthcare associated delay were 16 and 6 weeks respectively. Where mycobacterial culture was performed, 57/75 (76%) were positive for Mycobacterium tuberculosis. 86 (92.5%) cases received standard quadruple therapy for a median of 6 months (IQR 6-9). Recurrence of TB infection occurred in 4 (4.3%) cases and there were no TB related deaths. Seven (7.6%) cases required surgical intervention.

CONCLUSIONS

Extra-spinal articular TB more commonly affected men and people of South Asian ethnicity. Significant diagnostic delays were identified, including avoidable healthcare-associated delays.

Does the Effectiveness and Mechanical Strength of Kanamycin-Loaded Bone Cement in Musculoskeletal Tuberculosis Compare to Vancomycin-Loaded Bone Cement

BACKGROUND

Antibiotic-loaded bone cement (ALBC) is used to deliver antimycobacterial agents into the focal lesion of musculoskeletal tuberculosis. Although kanamycin is currently used as an antimycobacterial agent for the treatment of multidrug-resistant tuberculosis, there is no information about its suitability in ALBC.

METHODS

An in vitro experiment was conducted with cylindrical shape of 40 g of bone cement with 1, 2, and 3 g of kanamycin. Eluate (1 mL) was extracted from each specimen to measure the level of elution and antimycobacterial activity on days 1, 4, 7, 14, and 30. The quantity of kanamycin in eluates was evaluated by a liquid chromatography-mass spectrometry system, and the antimycobacterial activity of eluates against Mycobacterium tuberculosis H37Rv was calculated by comparing the minimal inhibitory concentration. The ultimate compression strength was conducted using a material testing system machine (Instron 3366; Instron, Norwood, MA) before and after elution.

RESULTS

Eluates from ALBC containing 2 and 3 g of kanamycin had effective antimycobacterial activity for 30 days, whereas eluates from ALBC containing 1 g of kanamycin were partially active until day 30. The pre-eluted compression strength of kanamycin-loaded cement and vancomycin-loaded cement was weaker as they contained a larger amount of antibiotics. There was no statistical difference between the strength of all kanamycin regimens and 1 g of vancomycin in the ultimate compression test. After 30 days of elution, the strength of all kanamycin-loaded cement and vancomycin-loaded cement cylinders was significantly lower than that of initial specimens (P < .05).

CONCLUSION

The antimycobacterial activity of ALBC containing more than 2 g of kanamycin was effective during a 30-day period. The ultimate compression strength of bone cement loaded with 1-3 g of kanamycin was comparable with 1 g of vancomycin while maintaining effective elution until day 30.

Mycobacterium senegalense Osteomyelitis of the Distal Tibia: A Case Report

Mycobacterium senegalense infection is rare. We present the third documented case of M. senegalense infection and the first to involve the musculoskeletal system. A 55-year old immunocompetent male developed chronic osteomyelitis of the ankle and required antibiotic spacers, an Ilizarov external fixator and multiple antibiotic regimens to eradicate the infection.

Prepatellar Bursal Infection Caused by Mycobacterium tuberculosis with an In Situ Total Knee Arthroplasty: A Case Report and Comprehensive Literature Review

Prepatellar bursal infection is a rare occurrence. The incidence of tuberculosis, including musculoskeletal type, is increasing. We present a case of isolated prepatellar bursal swelling associated with a discharging sinus; the condition developed in an elderly patient 4 years after total knee arthroplasty. Aspiration of the bursa revealed acid-fast bacilli on Ziehl–Neelsen staining, typical of Mycobacterium tuberculosis; this was confirmed later on culture. The patient was successfully treated with a 6-month course of antituberculous chemotherapy. To the best of our knowledge, only two previous cases of tuberculous prepatellar bursal infection have been reported in English literature. Our case illustrates the importance of considering tuberculous prepatellar bursal infection in the differential diagnosis of anterior knee swelling. All physicians treating patients with musculoskeletal disease should be aware of the possibility of this diagnosis and maintain a high index of suspicion; this is especially true in areas where tuberculosis is still endemic and in high-risk patients, such as the elderly.

Nontuberculous mycobacterial infections of the lower extremities: A 15-year experience

Objectives

Nontuberculous mycobacterial infection (NTMI), which is increasing in prevalence, is challenging to diagnose and manage despite the availability of capable laboratories because of subtle and nonspecific clinical findings and nonstandardized treatment guidelines. We aimed to present our experience with lower-extremity NTMI and to compare clinical characteristics and treatment outcomes between immunocompetent and immunocompromised patients.

Methods

To determine clinical presentations and outcomes, we reviewed electronic health records of all patients with lower-extremity NTMI treated and followed up at our institution from January 2002 through December 2017.

Results

Twenty-four patients were included in this study. Mean (SD) age was 58 (19) years. Eighteen patients (75%) were men; 13 (54%) were immunocompetent; and 9 (37%) had bone and joint involvement. No significant differences existed between immunocompetent and immunocompromised patients, except immunocompetent patients had significantly more infections at the hip, thigh, and toe. Bone and joint infection required significantly longer treatment time than skin and soft-tissue infection.

Conclusions

Regardless of immune status, patients with lower-extremity NTMI had similar characteristics, treatments, and outcomes. However, immunosuppression can be a major risk factor in the development of disseminated NTMI and associated complications. Acid-fast bacilli culture is strongly recommended for evaluation of delayed or nonhealing lesions. Aggressive medical and surgical management can be associated with good clinical outcomes.

Treatment of Extrapulmonary Nontuberculous Mycobacterial Diseases

Nontuberculous mycobacteria (NTM) diseases mainly manifest as pulmonary illnesses, but 20 -30% of NTM isolates originate from extrapulmonary diseases. These diseases cause a variety of clinical syndromes, including skin and soft-tissue infections, musculoskeletal infections, lymphadenitis, and disseminated disease. In skin and soft-tissue infections, musculoskeletal infections, prolonged treatment with combinations of antibiotics is effective in the treatment of NTM diseases, with surgery as an important complementary tool. The recommended duration of therapy for skin and soft-tissue infection is usually 2 – 4 months for mild disease and 6 months for severe disease, while treatment of musculoskeletal NTM disease usually requires at least 6 - 12 months. Management options of NTM lymphadenitis include surgical intervention, medical therapy, or observation. Treatment of disseminated NTM disease generally requires 6 to 12 months after immune restoration. However, despite a considerable increase in knowledge about NTM diseases, determining optimal treatment approaches remains a complex and challenging task.

Tuberculous arthritis: negative Xpert MTB/RIF assay does not rule out infection!

We present a case of a 31-year-old man of Indian origin with no previous medical history who presented with an inflamed knee. Treatment for bacterial infection was unsuccessful, and needle aspiration of the left knee effusion/collection was smear and culture positive for tuberculosis (TB), despite Xpert MTB/RIF being falsely negative. The patient was commenced on quadruple therapy for TB and within 2 months had improved significantly with no clinical evidence of ongoing inflammation.