Tuberculosis of the elbow in children

Tuberculosis of the Elbow Joint in an Indian Boy: A Rare Entity With a Diagnostic Challenge

Tuberculosis of the bones and joints is an infrequently reported entity. Isolated involvement of the elbow joint is exceedingly rare, even in endemic countries. The diagnosis is an arduous task, especially if it presents in younger age groups. Herein, a case of tuberculosis of the right elbow joint in a seven-year-old Indian child is presented. The diagnosis was challenging due to the vague clinical features and rarity of the disease, but he was diagnosed after a detailed clinical examination along with a radiometric assessment. He was initiated on the appropriate chemotherapy.

Post-tuberculosis sequelae in children and adolescents: a systematic review

In 2020, an estimated total of 155 million people had survived tuberculosis. Among this number, a sizable proportion have considerable post-tuberculosis morbidity, as shown for the adult population. This systematic review aims to identify the spectrum and prevalence of post-tuberculosis sequelae in children and adolescents. Four databases were systematically searched from database inception to Feb 7, 2022, for literature on post-treatment outcomes of tuberculosis acquired during childhood. Of the 4613 identified publications, 71 studies were included in this systematic review. Studies on cohorts with comparably rare (most of which were extrapulmonary) tuberculosis presentations, such as spinal tuberculosis and tuberculous meningitis were over-represented; however, no study assessed long-term sequelae in a cohort with an average childhood tuberculosis spectrum. The descriptive analysis includes long-term outcomes of 3529 paediatric patients 1 month to 36 years after confirmed (47%) or clinical (53%) tuberculosis. In a considerable proportion of children, a broad spectrum of post-tuberculosis sequelae were identified, ranging from radiological residua after pulmonary tuberculosis, to disabling deformities after musculoskeletal and cutaneous tuberculosis, to somatic and psychosocial impairment after tuberculous meningitis. A better understanding and comprehensive assessment of post-tuberculosis sequelae in children are needed to improve tuberculosis care beyond antituberculous treatment.

Current concepts in the diagnosis and management of tuberculosis of the elbow joint

Elbow is an uncommon joint to be affected by Mycobacterium tuberculosis infection. It is involved in approximately 1-5% of all cases with musculoskeletal tuberculosis (TB). Early diagnosis of TB of the elbow joint can be easily missed due to an indolent natural history, delay in presentation, and varied clinical features. Delay in diagnosis can lead to irreversible osteoarticular destruction and loss of joint function. Careful clinical assessment, adequate imaging, microbiological, and/or histopathological confirmation of Mycobacterium tuberculosis infection is essential for early diagnosis of TB of the elbow joint. Judicious and early administration of anti-tubercular therapy can lead to preservation of the joint and a satisfactory functional outcome. Surgical intervention may be needed in later stages of the disease to achieve control of the infection, correction of deformity, instability, and restoration of function.

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.

Tuberculosis of the Elbow Region in Pediatric Age Group - Experiences from a Single Centre

BACKGROUND

Clinical series of tuberculosis of elbow region in children are few. The purpose of our study was to retrospectively review the presentation, healing response and functional results of 30 children.

METHODS

The pretreatment disease presentation was studied from patient's case records. Serial radiographs of the patients were studied to see remineralization and healing of radiological lesions. For elbow's functional evaluation, pain, range of motion and recurrence were observed at final follow up.

RESULTS

The mean patient age was 8.2 years. The mean duration of symptoms before presentation was 47 days. A discharging sinus was present in 6 patients. Multifocal presentation was found in 7 patients. The lesion was most commonly localized in proximal ulna or lower humerus. The classical 'ice cream scoop' appearance of proximal ulnar metaphysis was noted in 5 elbows. Most elbows were in Martini stage 2 (70%) at the time of presentation. All patients were treated non-operatively. Average follow up after completion of antitubercular therapy was 18.97 months. The resolution of regional osteopenia, sclerosis of lytic lesions, reappearance of bony trabeculae and decrease in size of cavities was the usual sequence of radiological healing. End average elbow flexion arc deteriorated with increasing Martini stage. 'Ice cream scoop lesions' resulted in a worse functional outcome with formation of an irregular proximal ulnar articular surface.

CONCLUSIONS

Restriction of elbow range of motion, early discharging sinus formation and radiological 'ice cream scoop' appearance indicated a tubercular pathology. Late presentation with advanced disease, total joint involvement, and 'ice cream scoop appearance' resulted in decreased elbow flexion arc.

Epidemiology of Musculoskeletal Tuberculosis in an Area with High Disease Prevalence

Study Design

Retrospective observational study.

Purpose

The aim of this study was to assess the distribution of age and site of infection in patients with musculoskeletal tuberculosis (TB) and determine the number of TB/human immunodeficiency virus (HIV) coinfections as well as the incidence of multidrugresistant (MDR) TB.

Overview of Literature

Of all TB cases, 1%–3% show skeletal system involvement and 30% are HIV coinfected. Although the reported distribution of skeletal TB is majorly in the spine, followed by the hip, knee, and foot/ankle, the epidemiology of extrapulmonary TB and especially musculoskeletal TB remains largely unknown, particularly in areas with a high prevalence of the disease.

Methods

This is a retrospective study of a consecutive series of patients admitted to a tertiary care facility in an area with the highest prevalence of TB worldwide. TB was confirmed on tissue biopsy with polymerase chain reaction testing (Xpert for Mycobacterium tuberculosis and rifampicin resistance), culturing, or histological analysis. Data were analyzed regarding demographic information, location of the disease, HIV coinfections, and drug resistance.

Results

In all, 125 patients (44 children; 35%) with a mean age of 27 years (range, 1–78 years) were included. Age peaks were observed at 5, 25, and 65 years. Spinal disease was evident in 98 patients (78%). There were 66 HIV-negative (53%) and 29 (23%) HIVpositive patients, and in 30 (24%), the HIV status was unknown. Five patients (4%) showed MDR TB.

Conclusions

The age distribution was trimodal, spinal disease was predominant, MDR TB rate in our cohort was high, and a large portion of TB patients in our hospital were HIV coinfected. Hence, spinal services with sufficient access to operating facilities are required for tertiary care facilities in areas with a high TB prevalence.

Diagnostic Accuracy of the Xpert MTB/RIF Assay for Extrapulmonary Tuberculosis in Children With Musculoskeletal Infections

BACKGROUND

Xpert MTB/RIF (Xpert) is useful for the diagnosis of extrapulmonary tuberculosis (TB) in adults, but there is limited evidence on its usefulness in children. We aimed to investigate the accuracy of Xpert for the diagnosis of extrapulmonary TB in children with musculoskeletal infections.

METHODS

The diagnostic accuracy of Xpert was compared with a reference standard of culture or histopathology in children hospitalized with suspected osteoarticular TB in Cape Town, South Africa from June 2013 to May 2015.

RESULTS

One hundred and nine samples of 102 patients (60 male; 58.8%) with a median age of 5.6 years (interquartile range: 2.2-8.7) were included. There were 23 samples with confirmed TB by culture or histology (21.1%); histology was positive in all of these, while culture was positive in 14 samples (12.8%). Xpert was positive in 17 samples (15.6%), providing a sensitivity of 73.9% (95% confidence interval: 51.6-89.8) and specificity of 100% (95% confidence interval: 95.7-100). Xpert was positive at a mean of 0.8 days (0.46-1.4) compared with 21 days (19-30) for culture, P < 0.001. Multidrug-resistant TB was detected on culture in a single sample that was negative on Xpert testing.

CONCLUSIONS

Xpert confirmed extrapulmonary TB of bone and joints more accurately and faster than culture and should be used as a first-line test. Histology remains a useful test for musculoskeletal TB in children.

Magnetic resonance imaging findings in tubercular arthritis of elbow

OBJECTIVE

To evaluate magnetic resonance imaging (MRI) features of tubercular involvement of elbow joint.

METHODS

Fourteen patients with tubercular arthritis of elbow were evaluated. The following findings were recorded on MRI (n=12): bones involved; erosions, intraosseous abscesses, synovial thickening, and effusion; hypointensity within the thickened synovium on T2-weighted images; and periarticular soft tissue changes.

RESULTS

The common abnormalities on MRI were synovial thickening and bone erosions (n=12), soft tissue (n=9)/intraosseous (n=5) abscesses, and T2 hypointensity within the thickened synovium (n=5).

CONCLUSIONS

A diagnosis of elbow tuberculosis should be considered if there is a combination of findings involving bone and soft tissue.

Tuberculosis of the elbow: A clinicoradiological analysis

BACKGROUND

The incidence of Tuberculosis (TB) of elbow is 2-5% of all skeletal locations. Most reports of TB elbow have focused attention on the diagnosis. The management options and classification has been missing. We present a retrospective clinicoradiological analysis of 38 cases (40 elbows) of TB of elbow joint.

MATERIALS AND METHODS

The patients presented with pain, swelling and loss of motion. Two cases had bilateral involvement. The average delay between onset of symptoms and presentation was 8 months. The elbows were classified according to modified Martini's radiological classification, which distinguishes between osseous lesions close to joint line (e.g. coronoid, condyles) and lesions away from the joint line (e.g. epicondyles, olecranon). We modified the classification to subdivide into para-articular bony lesions that had invaded the joint and those that were threatening to invade joint. All patients received antitubercular chemotherapy and immobilization in above-elbow plaster slab for 4-8 weeks. Twenty patients underwent surgical interventions (synovectomy, intraarticular debridement).

RESULTS

The average followup period was 5.3 years (range 1.5-14.2 years). The range of movement at final followup averaged 107° for stage 2, 90° for stage 3A, 47° for stage 3B and 32° for stage 4. Range of supination and pronation was less satisfactory as compared to flexion and extension and all elbows with bony involvement had less than 90° arc of supination and pronation.

CONCLUSION

Surgical intervention could appreciably alter the outcome especially in patients with extra-articular involvement close to the joint. We have classified this subgroup separately.

Tuberculosis of the elbow joint in children: a review of ten patients who were managed nonoperatively

BACKGROUND

There is scarce information regarding osteoarticular tuberculosis of the elbow in children, even in countries where tuberculosis is endemic. We report our experience with ten patients who were managed nonoperatively.

METHODS

We retrospectively assessed ten children with elbow tuberculosis with regard to their presentation, diagnosis, management, response to standard antitubercular drugs, and outcome at the completion of antitubercular therapy. All patients were managed nonoperatively with splinting for as long as six weeks, followed by mobilization along with multidrug antitubercular medication for twelve months.

RESULTS

Swelling of the elbow that did not respond to initial treatment was the most common cause for referral to our clinic. The proximal ulnar metaphysis was most commonly involved. The average duration of follow-up was twenty-six months. The average time for healing of draining sinuses was twelve weeks (range, four to fourteen weeks). Lytic lesions, including coke-like sequestrum, healed radiographically at an average of 7.4 months (range, six to nine months). Range of motion improved with treatment, but some motion restriction always persisted, depending on the extent of joint destruction.

CONCLUSIONS

In the Indian subcontinent, the presentation of elbow tuberculosis is usually exudative with abscess formation, and the disease is fairly advanced at the time of diagnosis. An "ice cream scoop" appearance of the proximal part of the ulna in children should raise suspicion for tuberculosis. Elbow tuberculosis in children can be treated adequately with use of nonoperative means, regardless of the extent of osseous destruction, with a good outcome.