Tuberculous osteomyelitis of the cuboid: a report of four cases

Unveiling foot tuberculosis as an under-recognized source of foot pain

PURPOSE

Foot tuberculosis is a rare form of osteoarticular tuberculosis, accounting for less than 1% of cases. It presents unique diagnostic challenges due to its nonspecific clinical features and overlapping symptoms with other conditions. This study aimed to investigate the clinical presentation, radiographic findings, and prognosis of foot tuberculosis, with the goal of improving early recognition and appropriate intervention.

METHODS

A prospective study was conducted between November 2016 and July 2021, involving 39 patients diagnosed with foot tuberculosis. Clinical examinations, laboratory tests, X-rays, and MRI evaluations were performed to aid in the diagnosis. Biopsy was conducted on patients with radiological lesions. Patients were treated with an 18-month course of antitubercular therapy (ATT). Foot Function Index (FFI) scores were recorded before and after treatment. Statistical analysis was conducted to assess factors impacting prognosis.

RESULTS

Unilateral foot involvement was observed in all patients, with a male predominance (61.5%) and a mean age of 31.3 years. The most common symptoms were pain and edema, with sinus tracts present in 17.9% of patients. Radiographic findings showed cystic and sclerotic lesions, with the "spina ventosa" appearance primarily affecting the metatarsal bones. MRI played a valuable role in early detection. Histopathological examination confirmed tuberculosis in all cases, and acid-fast bacilli were found in 23% of patients. Most patients (79.4%) responded well to ATT without requiring surgery. Factors such as high initial ESR, delayed ATT initiation, multiple lesions, and tarsal involvement were associated with unfavourable outcomes.

CONCLUSION

Foot tuberculosis presents with nonspecific symptoms, leading to misdiagnosis and delays in appropriate treatment. Clinical examination, radiographic evaluation, and biopsy are essential for accurate diagnosis. Early initiation of ATT is crucial for favourable outcomes. Factors such as high initial ESR, delayed treatment initiation, multiple lesions, and tarsal involvement negatively impact prognosis. This study highlights the importance of recognizing foot tuberculosis and provides insights into its clinical presentation, radiographic features, and treatment outcomes, facilitating timely intervention and improved patient management.

Unveiling Neglected Pin-Site Tuberculosis: An Uncommon Encounter Due to Surgical Distal-End Radius Fracture Management With K-Wires

In this case report, a 29-year-old man underwent surgery to treat a fracture to the left distal end of his radius using closed reduction and K-wire fixation. The patient was advised to follow up in the outpatient department after six weeks for cast and K-wire removal. Still, the patient failed to do so and was doing alternate day dressing of the K-wires. After six months he slipped and fell from his cot while sleeping, sustaining an injury to the left wrist. Initially, he developed a swelling over the wrist, which suddenly increased in size and ruptured. Thick white caseous material was leaking out from the wounds. The patient underwent debridement and K-wire removal. An intraoperative sample was sent for a bacterial culture sensitivity test, histological analysis, and cartridge-based nucleic acid amplification test (CB-NAAT/GeneXpert). Postoperatively, anti-tuberculous treatment was started. The patient fully recovered from tuberculosis and had a complete range of movements after treatment.

Tubercular Osteomyelitis of Cuboid

INTRODUCTION

Tuberculosis (TB) affection of foot appears to be a rare clinical entity and accounts for <10% and 0.1-0.3% of osteoarticular and extrapulmonary TB, respectively. In TB foot, tarsal joints and calcaneum are more commonly affected followed by talus, distal end of first metatarsal, navicular, cuneiforms, and cuboid bones.

CASE REPORT

A 24-year-old female presented with pain and swelling over dorsum of the left foot from the past 8 months. On examination, there was a diffuse round shaped, solitary swelling measuring about 3.5 cm × 2.5 cm (approx.) with its surface smooth, non-pulsatile, non-fluctuant, non-transilluminant, non-compressible, and non-reducible present over dorsum of the left foot. Radiographic investigations revealed osteolytic lesion over the base of 3rd, 4th, and 5th metatarsals, middle and lateral cuneiforms and cuboid bones along with soft tissue swelling and diffuse transient osteopenia. Under spinal anesthesia, trucut biopsy of the mass revealed paucibacillary type of TB in histopathological examination. The patient was provided with ATT drugs in the form of intensive phase drugs (HRZE) daily for 4 months and continuation phase drugs (HRE) daily for 10 months according to the weight of the patient. The patient was followed up with erythrocyte sedimentation rate and C-reactive protein every 2 months once. The patient achieved a normal range of movements in the midtarsal joints except for the painful terminal range of movements. The patient was still under our follow-up.

CONCLUSION

The cuboid is the second most involved tarsal bone. The diagnosis is not always frankly evident, and a high index of suspicion has to be maintained. Surgical intervention should be limited to biopsy only as multidrug chemotherapy alone is sufficient to achieve complete healing.

Tuberculosis of the Cuboid in a 16-Month-Old Child: A Case Report

CASE

A 16-month-old male child presented with swelling over the dorsolateral aspect of the right foot associated with limp and no other constitutional symptoms. Tenderness and swelling were noted over the dorsolateral aspect, and radiographs revealed an eccentric lytic expansile lesion in the right cuboid. Biopsy of the lesion revealed necrotizing granulomas, and molecular testing later documented tuberculosis. The child received antitubercular medications and was relieved of symptoms in 6 weeks. Complete healing was observed after 12 months.

CONCLUSION

In developing countries, a high index of suspicion helps in the early diagnosis and appropriate management of tubercular osteomyelitis in children.

Case Series and Review of the Literature of Mycobacterium chelonae Infections of the Lower Extremities

Mycobacterium chelonae infections involving the lower extremities are rare clinical entities that present a diagnostic challenge given its diverse clinical presentations ranging from superficial (e.g., cellulitis, painful vesicular lesions) to deep (e.g., tenosynovitis) infections. We present 1 cases of M chelonae infections of the feet diagnosed 6 to 12 months after initial symptoms representing the difficulty of diagnosing this condition. Both cases were successfully managed with aggressive surgical debridement and long durations of antibiotic therapy with long-term care. A comprehensive review of the literature of M chelonae infections of the lower extremities was performed to provide summary data on the presenting symptoms, examination findings, predisposing conditions, and management approaches of this rare, but emerging clinical entity. Our cases and comprehensive review serve to raise awareness of atypical mycobacterial infections, including M chelonae, and advocate for the early consideration of mycobacterial cultures in the diagnostic workup of chronic lower extremity infections especially in the setting of poor initial response to standard antibacterial therapies.

Two stage surgical treatment of cuboid osteomyelitis. A case report and review of the literature

Isolated osteomyelitis of the cuboid bone is an extremely rare condition. A 32 year old man was evaluated for a painful and swollen right foot after a penetrating trauma and the presence of a sinus in the lateral aspect the midfoot. MRI findings were consistent with the presence of cuboid osteomyelitis. The patient underwent a two stage procedure which included partial excision of the cuboid bone, the use of a cemented spacer for lateral column length preservation, followed by arthrodesis of the calcaneocuboid joint with a tricortical autologous bone graft harvested from the ilium and preservation of the cuboid-metatarsal joints. At 4 years follow up, the patient is asymptomatic. Diagnosis of isolated cuboid osteomyelitis requires high clinical suspicion and a two stage procedure is an effective approach for symptomatic patients who do not respond to conservative treatment. LEVEL OF CLINICAL EVIDENCE: IV.

Tuberculosis of Calcaneus - A Case Report and Review of Literature

Introduction

Osteoarticular tuberculosis (TB) constitutes 1-3 % of cases and about 10% of osteoarticular TB affects the foot and ankle. In foot, TB calcaneus is the most commonly affected bone.

Case Report

A 21-year-old male presented with pain, swelling in the right heel for 5 months and difficulty in walking for 2 months. Plain X-ray (axial) view of calcaneus showed a lytic lesion in calcaneus. Biopsy was done under local anaesthesia and histologic examination revealed a characteristic granuloma, caseous necrosis, and Langhans giant cells which confirmed our diagnosis. The patient was treated with anti-TB chemotherapy for 12 months. Radiographs at 18 months follow-up showed a healed lesion. At present, the patient is comfortable with no complaints.

Discussion and Conclusion

TB calcaneus is rare condition and a high index of clinical suspicion along with imaging studies helps in diagnosis. Conservative management with anti-TB chemotherapy for adequate duration helps in complete resolution of the infection with good functional results.

Tuberculosis of the Left Wrist Joint and Spine

The incidence of wrist tuberculosis is rare. Clinical features and radiographs are not conclusive in the beginning, happen to delay the achievement of the diagnosis, and thus result in poor treatment. We present a case report of wrist tuberculosis that had delayed diagnosis. Hence, the initiation of antituberculous treatment was delayed, as the initial investigations were not conclusive of tuberculous infection. The patient was treated surgically multiple times before tuberculosis was diagnosed. Antituberculous chemotherapy was started for the patient for one year until she became afebrile and infective markers returned to normal. However, the patient developed left wrist stiffness due to arthrofibrosis and bony destruction of the wrist joint.

Synovial tuberculosis of the hand: An ancient disease in an unusual localisation

Background

Tuberculosis is the most prevalent infectious disease in the world. It is mainly caused by Mycobacterium tuberculosis. Osteoarticular tuberculosis represents 1%-3%. Tenosynovitis is the most common form of the disease in the hand.

Aims

The aim of this study is to present an update of synovial tuberculosis.

Materials and Methods

The authors present a literature review, the clinical and surgical management and case reports.

Results

The outcomes were satisfactory and were not report complications.

Conclusions

Early diagnosis, surgical transection of the transverse carpal ligament, debridement and complete excision of the infected synovium may be required, along with antituberculosis drugs. Knowledge of this disease in the hand can provide a better diagnosis and outcome.

Diagnosis and treatment of tuberculosis of the foot and ankle-A literature review

Foot osteoarticular tuberculosis is uncommon. Late diagnosis and sub-optimal management can lead to significant morbidity, deformity and even death. Preservation of life, limb and function can be achieved with prompt diagnosis and treatment. In 1882, Robert Koch published his discovery of mycobacterium tuberculosis as the causative agent of tuberculosis (TB), and showed the disease was infectious rather than inherited. Over two centuries later, TB remains one of the top 10 causes of death worldwide. Whilst in 90% of cases TB infects the respiratory system, in 10% it is extrapulmonary and can infect the skeletal, nervous, lymphatic and genitourinary systems. The spine is the most frequently affected site in the musculoskeletal system and this is known as Pott's disease. The foot and ankle is affected in only 0.13% cases of extrapulmonary TB. A high index of suspicion is thus required. This infrequency in incidence, heterogeneity of its presentation along with the difficulty in early diagnosis often causes significant delays in its treatment and hence results in a considerable disability. The medical treatment is well established but the role of surgery, its usefulness and its correct timing remain controversial. The main diagnostic issues include imaging being non-specific. Plain radiographs remain the first line imaging modality. MRI and CT scans provide greater detail and capture the disease at an earlier stage. Microbiological testing has low sensitivity and specificity becasue TB lesions are paucibacillary. Bone biopsy is of significant diagnostic value as it not only allows histological examination to detect granulomas but enables sensitivity and resistance testing of anti-tuberculous therapy (ATT). Issues relating to treatment include timing, duration, combination of chemotherapy and the challenge of multi drug resistant tuberculosis MDR-TB. The selection and timing of appropriate surgical techniques and optimal duration of follow-up are further points to consider. In this article we aim to review the literature on diagnosis and treatment of foot and ankle TB.

Role of Surgery in Management of Osteo-Articular Tuberculosis of the Foot and Ankle

Background:

Tuberculosis of the foot and ankle still remains to be a significant problem, especially in the developing countries, and with an increase in incidence in immunosuppressed patients. Treatment is mainly medical using multidrug chemotherapy; surgical interventions range from biopsy, synovectomy and debridement, to joint preserving procedures like distraction in early cases, and arthrodesis of hindfoot joints and the ankle in advanced disease with joint destruction.

Surgical Options: All procedures should be done after initiating appropriate medical management. The ankle is the commonest joint needing intervention, followed by the subtalar and talo-navicular joint. Forefoot TB limited to the bone rarely needs surgical intervention except when the infective focus is threatening to invade a joint. Articular disease can spread rapidly, so early diagnosis and treatment can influence the outcome. Surgical interventions may need to be modified in the presence of sinuses and active disease; fusions need compression, and implants have to be chosen wisely. External fixators are the commonest devices used for compression in active disease, but intramedullary nails better stabilize pantalar arthrodesis. Arthroscopy has become a valuable tool for visualizing the ankle and hindfoot joints, and is an excellent adjunct for arthrodesis by minimally invasive methods.

Conclusion:

Although Osteoarticular Tb involving the foot and ankle is largely managed with chemotherapy, specific indications for surgical intervention exist. Timely done procedures could limit joint destruction, or prevent spread to adjacent joints. Fusions are the commonest procedure for sequelae of disease or for correcting residual deformity.

Tuberculosis around the tarsal navicular: A rare entity

Osteoarticular TB around the tarsal navicular is a chronic, uncommon condition affecting the midfoot, which causes significant morbidity to the patient. Tuberculosis around the tarsal navicular is rarely described in the literature. A series of three cases - two involving the talo-navicular joint and one involving the naviculo-cuneiform joint is described. Biopsy was used in all the cases for achieving diagnosis. All patients had good to fair outcome following medical management with anti-tubercular therapy. Due to the pauci-bacillary nature of the disease, a positive culture of the disease is not always possible. The diagnosis depends on a positive histopathology finding. Once an early diagnosis is achieved, antitubercular therapy is usually the mainstay. Clinical awareness of the rare presentations of this disease can help in early detection, adequate treatment and good to fair outcomes. Due to the destruction of the midfoot joints, some patients report difficulty in walking on uneven surfaces and barefoot, for which triple arthrodesis may be offered.

Painful Lytic Lesions of the Foot: A Case Report

The presence of lytic lesions in the bones of foot raises a number of diagnostic possibilities ranging from infection, inflammatory pathology to neoplastic conditions. Although the radiological picture is not pathognomonic of any pathology, clinical history and histopathological examination can help to clinch the diagnosis. We present a case of multiple lytic lesions of the foot and discuss possible differential diagnoses. The patient was diagnosed as a case of madura foot and the lesions responded to surgical debridement and anti-fungal treatment with a good functional outcome. Madura foot is an uncommon, chronic granulomatous fungal or bacterial infection with a predilection in people who walk barefoot. Although known for a specific geographical distribution, madura foot should be kept as a possible diagnosis in patients presenting with lytic lesions of the foot due to population emigration across the world.

Isolated tuberculous osteomyelitis of the talonavicular joint without pulmonary involvement-a rare case report

Tuberculosis is one of the leading causes of death worldwide amongst curable diseases. It is estimated that one-third of the world's population has been diagnosed with tuberculosis infection [1]. The prevalence is on the rise with an estimated 9.4 million new cases per year worldwide [1]. Tuberculosis most commonly presents with pulmonary involvement. However, approximately 23-30% of patients found to be infected with tuberculosis have extrapulmonary symptoms [2]. Of those, only 1-3% have been found to have osseous disease. Skeletal involvement with a primary focus of tuberculosis usually affects major weight-bearing joints such as the hip and knee. Tuberculosis infections of the foot and ankle are very rare, accounting for 1% of all tuberculosis infections [2-4]. Difficulties arise in the timing of diagnosis, patient compliance of therapy and awareness of the less obvious presenting symptoms. Musculoskeletal tuberculosis, although rare, can be a problem. Its uncommon site, non-specific presenting symptoms and its ability to mimic numerous disorders make it more difficult to formulate a definitive diagnosis and, in turn, leads to therapeutic delays [5-7]. It is for this reason that we report this case in an effort to promote awareness.

Multifocal bilateral metatarsal tuberculosis: a rare presentation

Tuberculosis, or phthisis (consumption) as it was popularly known in the Greek era, has been endemic in Southeast Asia and Sub-Saharan Africa; however, the human immunodeficiency virus epidemic has seen the re-emergence of this disease in the areas in which it was not very commonly reported. With this, the need for understanding and treatment of rare presentations of tuberculosis has become of paramount importance to achieve the World Health Organization millennium goal of a "reversal of incidence by 2015." Foot involvement has been reported in 0.1% to 0.3% of extrapulmonary cases. Multifocal lesions have an incidence of <10% in osteoarticular tuberculosis. Bilateral feet involvement in multifocal tuberculosis has not yet been reported in either children or adults in published studies. We report a case of tuberculosis with lesions in the bilateral metatarsals, the occurrence of which is very rare. The diagnosis was mainly histopathologic owing to the paucibacillary nature of the disease. Early identification and treatment with antitubercular drugs will normally result in a good cosmetic and functional result.

Tuberculosis of the Cuboid: A Case Report and Review of the Literature

Tuberculosis (TB) remains a major global health problem. According to a recent World Health Organization report, it ranks as the second leading cause of death from an infectious disease worldwide. According to the "UK Health Protection Agency Tuberculosis in the UK: 2012 Report," 8963 cases were reported in the United Kingdom in 2011. London had the greatest proportion of cases in the United Kingdom and the greatest rate of disease. TB affecting the foot is rare, affecting about 10% of all skeletal TB cases. However, owing to the current patterns of global immigration, with significant volumes of people migrating out of endemic countries, it has become a disease that physicians and surgeons in developed countries should be more aware of in today's practice. To the best of our knowledge, we present the first adult case of TB of the cuboid in the United Kingdom and the first adult case documented outside of India. We present the case details and the results of a thorough review of the literature. TB of the foot and ankle poses a diagnostic challenge because of the propensity of TB to mimic other pathologic entities radiologically. Tissue diagnosis and antitubercular medication is the mainstay of diagnosis and treatment, respectively.

Isolated tuberculosis of the talonavicular joint in a child

Tuberculosis of small bones of foot is a diagnostic dilemma particularly when it is isolated. We report a rare case of isolated tuberculosis of navicular bone in 1a 11-year-old girl that was differently traded for a long time before final diagnosis.

Tuberculosis of the foot: An osteolytic variety

BACKGROUND

Foot involvement in osteoarticular tuberculosis is uncommon and isolated bony involvement of foot bones with an osteolytic defect is even more rare; diagnostic and therapeutic delays can occur, worsening the prognosis. We present a retrospective series of osteolytic variety of foot tuberculosis.

MATERIALS AND METHODS

We present 24 osteolytic variety of foot tuberculosis (Eleven calcaneus, four cuboid, two cunieforms, one talus, three metatarsals, three phalanges) out of 92 foot TB cases collected over last 20 years. There were 16 adults and eight children. Tissue diagnosis was established in 23 of 24 cases based on PCR AFB staining, culture, and histopathology. Surgical intervention was reserved for patients with either a juxtaarticular focus threatening to involve a joint or an impending collapse of a midfoot bone with cystic destruction.

RESULTS

Fifteen cases had an osteolytic lesion on the radiographs resembling a space-occupying lesion, five had patchy osteolysis, while four showed coke like sequestra; one patient had a lesion in two bones. Antitubercular chemotherapy after biopsy was sufficient to heal the lesion in 19 cases, while in five cases surgical debridement needed to be done. The lesions healed eventually. At an average followup of 8.3 years, (range 2-15 years) there were no recurrences and all patients were free from pain, with no restriction of movements. Six patients complained of occasional pain during walking on uneven ground.

CONCLUSION

When tuberculous pathology is limited to the bone, the prognosis is better than in articular disease, as there is less deformity, and hence, less residual pain and disability.

Tuberculosis infection of the talonavicular joint

Isolated tuberculosis osteomyelitis affecting the foot is extremely rare. Symptoms are nonspecific and haematological investigations are often unhelpful making diagnosis difficult. We report the case of a 41-year-old female who presented with a 7-month history of a painful hindfoot following a minor ankle sprain. Inflammatory markers were mildly raised and initial radiographs showed only some mild narrowing of the talonavicular joint. MRI scanning suggested osteomyelitis centred over the talonavicular joint. Open biopsy confirmed areas of caseous necrosis but no acid-fast bacilli were seen. The final diagnosis was confirmed with culture of mycobacterium tuberculosis. A good recovery was seen following debridement and commencement of anti-tuberculosis chemotherapy. Unless an awareness of this condition exists, the diagnosis and therefore the appropriate treatment can often be delayed which may lead to significant consequences for the patient.

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.

Tuberculous osteomyelitis of the midfoot in the absence of a pulmonary lesion: a case report

A 57-year-old Somalian woman presented to the podiatry clinic in 2001, 9 years after immigrating to the United States, with a complaint of right foot pain overlying the Lisfranc joint after a twisting injury. Radiographs and CT scans showed no signs of fracture. One year later, the patient presented with painful, swollen soft tissues mass overlying the previous injury area. MRI revealed heterogeneous masses with underlying bony erosions. Soft tissue biopsy revealed a granulomatous lesion, suspect for Mycobacterium. A subsequent bone biopsy produced an acid-fast bacillus by DNA-RNA probe consistent with Mycobacterium species. The patient had a positive Mantoux test, but a negative chest X-ray, displaying no constitutive symptoms of fatigue or weight loss associated with most cases of tuberculosis. She was treated with anti-tuberculin medications for 9 months and conservative management of the bony lesions with a complete resolution of symptoms.

Isolated medial cuneiform tuberculosis: a case report

Skeletal involvement in extrapulmonary tuberculosis is extremely rare, and foot involvement accounts for less than 10% of osteoarticular tuberculosis. Tuberculosis osteomyelitis of the foot can also mimic a wide range of pathology. As a result, this condition is often misdiagnosed, or the true nature of the lesion is identified late in the diagnostic process. This article reports a case of tuberculosis in the medial cuneiform of a 3-year-old girl. Initially misdiagnosed as osteochondrosis, the patient returned 2 years later with a draining sinus on the medial aspect of the left midfoot. New radiographs showed a cystic lesion in the substance of the medial cuneiform. A diagnosis of tuberculosis was established after biopsy and histopathological examination of operative specimen. Antituberculosis treatment was implemented and continued for 16 months. At that time, clinical signs of infection had ceased.

Tuberculosis of the foot and ankle

Tuberculosis of the foot and ankle is an uncommon presentation of skeletal tuberculosis. The uncommon site, lack of awareness, and ability to mimic other disorders clinically and on radiographs, leads to diagnostic and therapeutic delays. In the early stages and when the disease is limited to bone, medical treatment leads to excellent healing and limited residual disabilities. Joint involvement occurs because of spread from a periarticular bony focus, and in the midfoot, the disease may spread to involve all the interconnected joints, leading to a stiff foot and residual deformities. Of 74 cases reviewed, the calcaneus was involved most commonly, followed by infection of the midtarsal, Lisfranc joints, and ankle. The most common radiologic finding is that of osteoporosis, which may be intense: cancellous bone involvement may present as a cystic lesion with or without sequestrum. Computed tomography scans and magnetic resonance imaging are helpful examinations. Because the disease is paucibacillary, a positive acid fast bacilli culture is rare and the diagnosis usually is confirmed by obtaining granulomatous tissue on biopsy. The treatment basically is medical, with surgical intervention being reserved for patients with intractable disease or as a salvage procedure for patients with deformed hindfoot joints.