Isolated medial cuneiform tuberculosis: a case report

Tuberculosis presenting as arthritis of the ankle: A case report

Tuberculosis presenting as monoarticular involvement in immunocompetent patients is rare. Here, we report a Sri Lankan patient presenting with ankle swelling due to tuberculosis with no other extrapulmonary or pulmonary involvement. Magnetic resonance imaging showed destruction of articular cartilage of the ankle joint with chronic inflammation of the subtalar joint. The diagnosis was confirmed by synovial tissue culture which was positive for Mycobacterium tuberculosis. The patient recovered uneventfully with anti-tuberculosis treatment. Therefore, a high degree of suspicion is necessary to diagnose extrapulmonary tuberculosis when patients are presenting with atypical monoarthritis.

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.

Miliary tuberculosis and acquired immunodeficiency syndrome - 'a cursed duet'

Tuberculous osteomyelitis is rare and usually involves the vertebrae but is seldom found in the foot. The uncommon site and ability to mimic other disorders clinically and radiographically leads to diagnostic and therapeutic delays. We report a case of a 40-year-old man who initially presented to his podiatrist with intermittent pain and swelling of his right ankle and foot that lasted for a year. He also started to exhibit significant weight loss and unexplained fevers and was subsequently hospitalized for cellulitis of his right foot. On further workup, patient was found to have miliary tuberculosis (TB) and acquired immunodeficiency syndrome (AIDS). Patient was treated with anti-TB therapy for 9 months and highly active anti-retroviral therapy. Our patient presented with ongoing chronic right foot and ankle pain that was proven to be secondary to TB osteomyelitis of cuneiform bones of the right ankle in the setting of AIDS. The patient's clinical presentation was unusual due to symptom duration and lack of systemic characteristics. Like our case, reported incidence of osteomyelitis of bone/joint in extrapulmonary TB is estimated to be 10%, and out of all bones/joint TB cases, only 1% are found to be in the foot.

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.

Mycobacterium chelonae-abscessus Complex Infection After Flatfoot Reconstruction

Mycobacterium infections involving tuberculosis in the foot are rare but cases are readily available in published studies. Atypical or nontuberculosis mycobacterium foot infections are rare, especially those involving the soft tissue and bone, and have been infrequently reported. To date, no case reports involving atypical mycobacterium infection after elective foot surgery have been reported. We present the case of a 49-year-old female who underwent flatfoot reconstruction, with a resultant Mycobacterium chelonae-abscessus infection and osteomyelitis postoperatively. The patient ultimately underwent hardware removal with multiple debridements. The patient was treated ultimately with a 6-week course of intravenous antibiotics and 5 months of oral antibiotics for the mycobacterium infection and osteomyelitis. At the last follow-up examination, the patient remained healed with a satisfactory outcome. We also provide a literature review of mycobacterium infections in the foot.

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.

Foot and ankle tuberculosis: case series and literature review

Foot and ankle tuberculosis (TB) is a rare presentation of skeletal TB. The uncommon site along with low index of clinical suspicion in the western world leads to delays in the diagnosis and treatment. This can make joint sparing procedures less successful, especially in the midfoot where the joints can often be interconnected. Plain radiographs have low sensitivity and specificity and cross sectional imaging in the form of MRI or CT is more reliable. Treatment involves the use of multiple anti-tuberculous drugs in the first instance, followed by surgery to address any symptomatic deformity and/or secondary degenerative changes. We present our experience on the management of this rare problem and review the literature on the clinical presentation, diagnosis, imaging modalities and treatment.

Ankle arthrodesis in tubercular arthritis using anterior bridge plating: a report of 2 cases

Ankle arthrodesis is a common procedure for tubercular arthritis in India. However, attaining fusion in osteoporotic bones is difficult to achieve by both external and internal fixation methods described in the literature. We report two cases for ankle arthrodesis using an anterior approach to the ankle and internal fixation with a bridging anteriorly placed AO L/AO T plate. Both ankles were fused. The surgical technique is simple, easily reproducible and gives excellent results.

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.

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.

[Tarsal osteoarthritis: a rare localisation of tuberculosis]

We report the case of a 39-year-old woman with an uneventful medical history who presented an inflammatory left foot with no notion of trauma or fever. The plain x-ray and magnetic resonance imaging demonstrated talonavicular and subtalar osteoarthritis. A surgical biopsy with excision of inflammatory and necrotic tissue and removal of a fistular tract was performed. Histology revealed the presence of granulomas with caseous central necrosis suggesting tuberculosis of the bone. The diagnosis was confirmed when bacteriology samples grew Mycobacterium tuberculosis. Antituberculosis drugs were administered for twelve months. At 24 months, the patient presents a painful stiff rear foot after the development of secondary talonavicular degeneration. This case illustrates a particular clinical presentation of tuberculosis. This diagnosis should be considered in the presence of atypical bony lesions with a chronic course. Early diagnosis enables proper therapeutic management. Useful diagnostic imaging techniques include plain x-rays, computed tomography, and magnetic resonance imaging. Certain diagnosis is based on bacteriological and histological examinations.