Characteristics and Clinical Outcome of Bone and Joint Tuberculosis From 1994 to 2011: A Retrospective Register-based Study in Denmark

A ten-year experience of musculoskeletal tuberculosis at a tertiary care hospital in South India

Background

The delayed identification and management of musculoskeletal tuberculosis (MSTB) poses substantial health challenges and leads to significant morbidity. This study aimed to collate ten years of hospital data and provide valuable insights into the clinical, diagnostics, and outcomes of the patients diagnosed with MSTB.

Methods

A retrospective study was undertaken to review clinic records from 2013 to 2022 for all individuals diagnosed with MSTB in a tertiary care hospital in South India.

Results

Over a decade, 400 cases of MSTB were diagnosed, revealing 57 % males and 43 % females with a mean age of 43.2 ± 18.9 years. Spinal TB constituted 72 % of cases, with the most common involvement of thoracic vertebrae (50.9 %). Extra-spinal MSTB accounted for 28 %, prevalent more in the pediatric age group (p < 0.05). Surgical intervention was required for 80 % of spinal TB cases and 58 % of extra-spinal MSTB cases. The average follow-up duration was two years, with 73 % completing treatment. Unfortunately, seven patients died, and three experienced relapse.

Conclusion

Spinal TB is the most common type of MSTB and is predominant in young and middle-aged adults, while extra-spinal MSTB is more frequently observed in children. Where use of MRI facilitates early detection of spinal TB; histopathological and microbiological examination confirm the diagnosis. Combining anti-tubercular drugs with modern surgical approaches is essential for obtaining favorable outcomes and improving the quality of life of such patients. It is crucial to have advanced and affordable diagnostic facilities, along with increased public awareness, to reinforce tuberculosis control strategies.

Diagnostic Delay of Spinal Tuberculosis Causing Medullary Compression

We present a case of a Philippine woman in her late twenties, diagnosed with spinal tuberculosis after surgical intervention due to medullary compression. The diagnosis was preceded by four months of unexplained back pain. Differential diagnoses included ulcer, liver-gallbladder disease, musculoskeletal causes, and cancer. This case highlights the importance of considering tuberculosis as a differential diagnosis in patients from high-endemic areas to avoid diagnostic delay and the risk of disease progression.

Extrapulmonary, Chronic Septic Arthritis From Mycobacterium tuberculosis in the Ankle and Subtalar Joints

In the United States, rates of Mycobacterium tuberculosis infection have been declining for decades. Osteoarticular tuberculosis of the ankle is rarely observed. We present the case of a 65-year-old man who immigrated to the United States from India 24 years before the onset of symptoms. The patient initially reported atraumatic swelling and pain of the left ankle and foot and was treated for venous insufficiency. Later, the patient was referred to a nonsurgical orthopaedic clinic for additional workup and was found to have elevated inflammatory markers. MRI showed septic arthritis and osteomyelitis of the talus, distal tibia, and calcaneus. Joint aspiration revealed elevated white blood cell counts with predominately PMNs. The patient was then referred to an orthopaedic foot and ankle surgeon and underwent extensive irrigation and débridement. The patient was discharged on empiric antibiotics. Culture results from the original joint aspirate returned 14 days after surgery as positive for acid-fast bacillus, later identified as M tuberculosis by sequencing. Empiric antibiotics were discontinued, and the patient was started on appropriate antituberculotic therapy. This case report illustrates the challenge in the diagnosis of skeletal tuberculosis and the importance of including this condition on the differential for patients with atypical foot and ankle presentations.

Tuberculosis before and after the Black Death (1346-1353 CE) in the Hospital of St John the Evangelist in Cambridge, England

This research explores how the prevalence of tuberculosis (TB) in a medieval hospital was affected by the demographic and social changes that following the Black Death (1346-1353 CE), the initial years of the Second Plague Pandemic. To do this, skeletal remains of individuals buried at the Hospital of St John the Evangelist in Cambridge, England, that could be dated to living before (n = 77) or after (n = 55) the Black Death were assessed for evidence of TB (indicated by destructive lesions of the spine, ribs, large joints, and other recognised criteria). Overall, the odds of females having skeletal lesions caused by TB were over four times higher than males. No significant difference was detected in the prevalence rates in those who lived before and after the Black Death (7.8%, 6/77 before and 11.0%, 6/55 after). However, the odds of females having skeletal evidence of TB were over five times greater after the Black Death than they were before. These findings indicate that women may have been 1) more susceptible to TB, 2) surviving longer post-infection than men, and/or 3) that women with TB were more likely to be admitted to the Hospital especially following the Black Death. It is also possible that impairment due to TB infection may have been a contributing factor for entry into the Hospital for women but not men.

Mycobacterium tuberculosis infectious monoarthritis in a paediatric patient

Mycobacterium tuberculosis is uncommon in the USA, and when it is diagnosed, it is usually in adult patients with identifiable risk factors presenting with pulmonary manifestations of the disease. Paediatric tuberculosis is rare, and a minority of those cases can present with isolated extrapulmonary infection. When the musculoskeletal system is involved, there are often no constitutional symptoms, and it can resemble other infectious and inflammatory processes. Diagnosis is challenging, and delay leads to irreversible destructive osteoarticular changes. A prompt diagnosis requires a high index of suspicion. This report presents a case of successfully diagnosed paediatric M. tuberculosis monoarthritis of the knee to highlight these challenges.

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.

Prognostic values of geriatric nutrition risk index on elderly patients after spinal tuberculosis surgery

Background

Spinal tuberculosis (STB) is a significant public health concern, especially in elderly patients, due to its chronic and debilitating nature. Nutritional status is a critical factor affecting the prognosis of STB patients. The geriatric nutritional risk index (GNRI) has been established as a reliable predictor of adverse outcomes in various diseases, but its correlation with surgical outcomes in elderly STB patients has not been studied.

Objective

The study aimed to assess the prognostic value of the GNRI in elderly patients with STB who underwent surgery.

Methods

We conducted a retrospective analysis of medical records of elderly patients (65 years or older) diagnosed with active STB who underwent surgical treatment. Data collection included patient demographics, comorbidities, clinical history, laboratory testing, and surgical factors. GNRI was calculated using serum albumin levels and body weight. Postoperative complications were observed and recorded. The patients were followed up for at least 1 year, and their clinical cure status was assessed based on predefined criteria.

Results

A total of 91 patients were included in the study. We found that a GNRI value of <98.63 g/dL was a cutoff value for predicting unfavorable clinical prognosis in elderly STB patients undergoing surgery. Patients with a low GNRI had higher Charlson Comorbidity Index scores, were more likely to receive red blood cell transfusions, and had a higher prevalence of overall complications, particularly pneumonia. The unfavorable clinical prognosis group had lower GNRI scores compared to the favorable prognosis group. Multivariate analysis showed that lower GNRI independently predicted unfavorable clinical outcomes in elderly STB patients.

Conclusion

The study concluded that the GNRI is a valuable biomarker for predicting prognosis in elderly STB patients undergoing surgical intervention. Patients with lower GNRI scores had worse outcomes and a higher incidence of complications.

Several Potential Serum Proteomic Biomarkers for Diagnosis of Osteoarticular Tuberculosis Based on Mass Spectrometry

BACKGROUND

Osteoarticular tuberculosis is one of the extrapulmonary tuberculosis (EPTB) diseases, which is mainly caused by infection of Mycobacterium tuberculosis (MTB) in bone and joints. The limitation of current clinical test methods is leading to a high misdiagnosis rate and affecting the treatment and prognosis. This study aims to search serum biomarkers that can assist in the diagnosis of osteoarticular tuberculosis.

METHODS

Proteomics can serve as an important method in the discovery of disease biomarkers. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to analyze proteins in 90 serum samples, which were collected from June 2020 to December 2021, then evaluated by statistical analysis to screen potential biomarkers. After that, potential biomarkers were validated by ELISA and diagnostic models were also established for observation of multi-index diagnostic efficacy.

RESULTS

118 differential expressed proteins (DEPs) were obtained in serum after statistical analysis. After the diagnostic efficacy evaluation and clinical verification, inter-alpha-trypsin inhibitor heavy chain H2 (ITIH2), complement factor H-related protein 2 (CFHR2), complement factor H-related protein 3 (CFHR3) and complement factor H-related protein 5 (CFHR5) were found as potential biomarkers, with 0.7167 (95%CI: 0.5846-0.8487), 0.8600 (95%CI: 0.7701-0.9499), 0.8150 (95%CI: 0.6998-0.9302), and 0.9978 (95%CI: 0.9918-1.0040) AUC value, respectively. The remaining DEPs except CFHR5 were constructed as diagnostic models, the diagnostic model contained CFHR2 and CFHR3 had good diagnostic efficacy with 0.942 (95%CI: 0.872-0.980) AUC value compared to other models.

CONCLUSION

This study provides a reference for the discovery of serum protein markers for osteoarticular tuberculosis diagnosis, and the screened DEPs can also provide directions for subsequent pathogenesis research.

Tuberculosis Presenting as Chronic Monoarthritis: A Case Study

Mycobacterium tuberculosis infection remains a common disease in developing countries with the potential to involve the osteoarticular system. The authors report a case of knee arthritis due to tuberculosis (TB) in a 34-year-old woman. The patient presented with pain and swelling of the right knee as major complaints, without a history of respiratory symptoms. Magnetic resonance imaging (MRI) demonstrated a marked joint effusion, involving synovial tissue with cartilaginous lesion compatible with pigmented villonodular synovitis (PVNS). After several physiotherapy courses without significant relief, total knee arthroplasty was proposed. Two months after surgery and rehabilitation, symptoms did not completely resolve, with limited active range of motion. Microbial bone biopsy culture at the time of the arthroplasty revealed a TB infection. Due to the rarity and clinical nonspecificity of TB bone manifestations, early diagnosis may be challenging. Yet, attempted diagnosis and prompt pharmacological intervention are paramount to improve outcomes.

Clinical utility of tuberculosis RNA in the rapid diagnosis of bone and joint tuberculosis

OBJECTIVES

To evaluate the diagnostic accuracy of tuberculosis RNA (TB-RNA) for the rapid diagnosis of bone and joint tuberculosis (BJTB).

METHODS

We conducted a retrospective study to evaluate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) of TB-RNA and acid-fast bacillus (AFB) smear against the final clinical diagnosis.

RESULTS

A total of 268 patients were included. The overall sensitivity, specificity, PPV, NPV, and AUC of AFB smear for BJTB were 0.7%, 100.0%, 100.0%, 49.3%, and 0.50, respectively, whereas those of TB-RNA were 59.6%, 100.0%, 100.0%, 70.6%, and 0.80, respectively; for cases of confirmed (culture-positive) BJTB, these values were 82.8%, 99.4%, 99.7%, 89.2%, and 0.91, respectively.

CONCLUSIONS

The diagnostic accuracy of TB-RNA in the rapid diagnosis of BJTB was relatively good, especially in culture-positive BJTB. The use of TB-RNA could be an effective technique for the rapid diagnosis of BJTB.

Difference between the blood samples of patients with bone and joint tuberculosis and patients with tuberculosis studied using machine learning

Background

Tuberculosis (TB) is a chronic infectious disease. Bone and joint TB is a common type of extrapulmonary TB and often occurs secondary to TB infection. In this study, we aimed to find the difference in the blood examination results of patients with bone and joint TB and patients with TB by using machine learning (ML) and establish a diagnostic model to help clinicians better diagnose the disease and allow patients to receive timely treatment.

Methods

A total of 1,667 patients were finally enrolled in the study. Patients were randomly assigned to the training and validation cohorts. The training cohort included 1,268 patients: 158 patients with bone and joint TB and 1,110 patients with TB. The validation cohort included 399 patients: 48 patients with bone and joint TB and 351 patients with TB. We used three ML methods, namely logistic regression, LASSO regression, and random forest, to screen the differential variables, obtained the most representative variables by intersection to construct the prediction model, and verified the performance of the proposed prediction model in the validation group.

Results

The results revealed a great difference in the blood examination results of patients with bone and joint TB and those with TB. Infectious markers such as hs-CRP, ESR, WBC, and NEUT were increased in patients with bone and joint TB. Patients with bone and joint TB were found to have higher liver function burden and poorer nutritional status. The factors screened using ML were PDW, LYM, AST/ALT, BUN, and Na, and the nomogram diagnostic model was constructed using these five factors. In the training cohort, the area under the curve (AUC) value of the model was 0.71182, and the C value was 0.712. In the validation cohort, the AUC value of the model was 0.6435779, and the C value was 0.644.

Conclusion

We used ML methods to screen out the blood-specific factors-PDW, LYM, AST/ALT, BUN, and Na⁺-of bone and joint TB and constructed a diagnostic model to help clinicians better diagnose the disease in the future.

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.

Isolated Tuberculous Myositis: A Systematic Review and Multicenter Cases

Objective

To investigate the clinical features and associated underlying conditions of isolated tuberculous myositis (ITBM), a rare extrapulmonary tuberculosis (TB).

Methods

A systematic literature search and a multicenter survey were performed using a triangulation strategy. Data from the identified ITBM cases were extracted and analyzed to determine the underlying conditions, clinical presentations, treatments, and outcomes.

Results

Based on the systematic review, we identified 58 ITBM, including 9 pediatric, cases in the literature published from 1981 to 2021 25 (43.1%) immunocompromised and 33 (56.9%) non-immunocompromised patients. Immunocompromised cases had a significant shorter symptom duration (median 30.0 vs. 75.0 days) and a higher prevalence of multilocular involvement (20.8% vs. 0%). Among 24 immunocompromised adult patients, dermatomyositis/polymyositis (DM/PM; n=10, 41.7%) were the most common underlying diseases in adults with ITBM identified in the systematic review. Over the past 20 years, 11 Korean adults with ITBM were identified in the multicenter survey. Of 7 immunocompromised cases, two (28.6%) were DM/PM patients. TB death rate of immunocompromised patients was 0.0% and 5/23 (21.7%) in the pediatric and adult ITBM cases identified in the systematic review, respectively, and 3/7 (42.9%) in survey-identified ITBM cases.

Conclusion

ITBM has a unique clinical presentation including fever, tenderness, local swelling, overlying erythema, abscess formation and was associated with a grave outcome, especially in immunocompromised hosts. DM/PM was a highly prevalent underlying disease in both systematic review-identified and survey-identified immunocompromised ITBM patients.

Treatment of Stage I-III Hip Joint Tuberculosis With Open Surgical Debridement and Hip Spica in Children: A Retrospective Study

BACKGROUND

This study aimed to evaluate the outcome of surgical debridement combined with postoperative hip spica immobilization in the treatment of hip joint tuberculosis in children.

METHODS

This retrospective study enrolled 87 children with stage I to III hip joint tuberculosis treated surgically at our hospital from January 2010 to January 2016. All patients considering hip tuberculosis routinely received a 4-week conservative treatment first, including rest, protected weight-bearing, and 4-drugs antitubercular chemotherapy. Surgical debridement was indicated when there was no relief after this conservative protocol. Patients were divided into 2 groups according to the duration of hip spica immobilization after operation: group A (hip spica for 4 wk, 39 patients) and group B (hip spica for 6 wk, 48 patients). All patients were recommended partial weight-bearing for 7 days and then followed the same hip joint exercises program when spica was removed. Postoperative radiographs, hip dislocation or subluxation, and modified Harris hip score (MHHS) were assessed. All patients were followed up at least 5 years.

RESULTS

There were 87 patients enrolled in our study, including 34 females and 53 males, with a mean age of 7.2±2.8 years old (range: 2 to 14 y). No significant difference was observed between these 2 groups in baseline data. In group A, the mean MHHS improved from 52.1±14.7 before surgery to 87.8±8.3 at the final follow-up ( P <0.000). In group B, there was also a significant difference between the preoperative MHHS (52.7±9.4) and the final MHHS (88.6±6.5) ( P <0.000). Although there was no significant difference between these 2 groups in the final MHHS ( P =0.593), there were also no significant differences between these 2 groups in wound healing delay (3 in group A and 6 in group B, P =0.705) and pathologic subluxation (3 in group A and 1 in group B, P =0.467). The only difference between group A (79.2±8.5) and group B (75.5±7.5) was the early functional outcome assessed by using MHHS after 1 month of hip joint exercises ( P =0.032).

CONCLUSIONS

Surgical debridement combined with antitubercular chemotherapy is an effective treatment for stage I to III hip tuberculosis in children when there is no improvement after conservative treatment. Prolonged hip spica immobilization may not reduce the risk of hip subluxation after open surgical debridement but could lead to a delay in early functional recovery. Time of spica immobilization should be individualized and based on the surgeon's evaluation and the patient's condition.

Musculoskeletal tuberculosis revisited: bone and joint tuberculosis in Austria

BACKGROUND

To prevent further spread of the disease and secondary deformity, musculoskeletal tuberculosis (TB) remains a challenge in terms of early diagnosis and treatment. This study gives an overview on TB trends in Austria (pulmonary and extrapulmonary TB) (A) and analyses a retrospective series of musculoskeletal TB cases diagnosed and treated at an Austrian tertiary centre (B).

METHODS

(A) We analysed data obtained from the Austrian national TB registry to provide information on TB patients´ demographics and manifestation sites between 1995 and 2019. (B) Furthermore, we performed an observational study of all patients with a confirmed diagnosis of musculoskeletal TB who were admitted to the Department of Orthopaedics and Trauma, Medical University of Graz (2005-2019). Demographic, diagnostic, clinical and follow-up data were retrieved from the medical records.

RESULTS

(A) From 1995 to 2019, a significant linear reduction in overall Austrian tuberculosis incidence rates occurred (p < 0.001). In the period investigated, Austria recorded a total of 307 patients with musculoskeletal TB. (B) Our retrospective case-series included 17 individuals (9 males, 8 females; average follow-up 48.4 months; range 0-116). There was a biphasic age distribution with a peak in elderly native Austrians (median 69, range 63-92), and a second peak in younger patients with a migration background (median 29, range 18-39). Sites of manifestation were the spine (n = 10), peripheral joints (n = 5), and the soft tissues (n = 2). Diagnosis was based on histology (n = 13), PCR (n = 14), and culture (n = 12). Eleven patients underwent surgery (64.7%). Secondary deformities were frequent (n = 9), and more often observed in patients with spinal TB (n = 6).

CONCLUSION

Musculoskeletal TB should be considered if untypical joint infections or nonspecific bone lesions occur in younger patients with a migration background or in patients with specific risk factors.

A comparative study of a rabbit spinal tuberculosis model constructed by local direct infection via the posterior lateral approach

The present study aims to establish a method of constructing a New Zealand rabbit spinal tuberculosis model by direct local infusion of M. tuberculosis H37Rv strain into the intervertebral disc space through the posterior lateral approach. Sixty-six New Zealand rabbits were pretreated with complete Freund's adjuvant and randomly divided into 4 group: the posterolateral approach model group (Group A, 25), ventral transverse process approach model group (Group B, 25), control group (Group C, 10), and blank group (Group D, 6). In Groups A and B, the bone holes were filled with gelatin sponge after drilling, and the local area was directly infused with 0.1 ml of M. tuberculosis H37Rv strain suspension. In Group C, the gelatin sponge was filled through the posterolateral approach and the local area was infused with 0.1 ml of normal saline suspension. In Group D, No specific treatment was performed. The general conditions of the experimental rabbits in each group were compared to those of a control group; the degree of vertebral body exposure, incision length, and complications of the two methods were compared; and the tuberculosis models were evaluated by imaging, histopathology, and bacterial culture. In Group A, the lateral side of the vertebral body was well exposed, the damage was mild, and no peritoneal rupture or gastrointestinal complications were observed. In Group B, the ventral side of the vertebral body and the intervertebral disc were exposed, and abdominal complications were more likely to occur. The survival rates of the experimental rabbits at 8 weeks after surgery were 92.0% in Group A, 88.00% in Group B, 90.0% in Group C, and 100% in Group D. MRI examinations showed that in Group A, the positive rate of radiographic bone findings was 86.9% at 4 weeks after surgery and 100% at 8 weeks after surgery; in Group B, the positive rate of radiographic bone findings was 78.2% at 4 weeks after surgery and 95.4% at 8 weeks after surgery. There was no significant difference between Groups A and B in the radiographic bone findings rate detected by the same imaging method at the same time point (P > 0.05). Eight weeks after surgery, bone destruction, paravertebral abscess, and caseous necrosis occurred in the vertebral bodies of surviving rabbits in Groups A and B. The BacT/ALERT 3D rapid culture system was used to culture the pus in the lesion, and the results showed that the positive rate of tuberculosis was 52.17% in Group A and 54.54% in Group B, and the difference was not statistically significant (P > 0.05). After pretreatment with complete Freund's adjuvant, direct infusion of the H37Rv strain of M. tuberculosis into the intervertebral disc space of New Zealand rabbits via the posterolateral approach and the ventral transverse process approach can successfully establish rabbit spinal tuberculosis models.

A comparative study of one-stage posterior unilateral limited laminectomy vs. bilateral laminectomy debridement and bone grafting fusion combined with internal fixation for the treatment of aged patients with single-segment spinal tuberculosis

Study design

This is a retrospective study.

Background

To assess and compare the clinical outcomes of posterior unilateral limited laminectomy (ULL) or bilateral laminectomy (BL) debridement and bone grafting fusion combined with internal fixation among aged patients with single-segment thoracic and lumbar tuberculosis (SST/LTB).

Materials and methods

We performed a retrospective study on aged patients (age > 65 years old) with SST/LTB from January 2010 to October 2018. We reviewed 36 aged patients who were treated with BL and 31 aged patients treated with ULL. All participants had undergone and finished a three-year follow-up. The outcomes were evaluated by the improvement of neurological function, correction Cobb angle, bone fusion time, and back pain, as well as operative time, blood loss, hospital stay, and postoperative complications.

Results

The operative time, blood loss volume, and incidence of complications in group B were significantly less than those in group A (P < 0.01). The postoperative kyphotic angle in both groups was reduced significantly compared to the preoperative status (P < 0.01). The percentage of neurological improvement was 92.9% in group A and 90.9% in group B. All patients achieved solid bone fusion after surgery. At three-year follow-up, the angle loss in group B was significantly less than that in group A (P < 0.01); Furthermore, patients in group B had a lower average visual analog scale score of back pain and Oswestry Disability Index score than patients in group A (P < 0.05).

Conclusions

For aged patients with SST/LTB, ULL is a safer and more effective surgical treatment than BL.

Evaluation of host biomarkers for monitoring treatment response in spinal tuberculosis: A 12-month cohort study

BACKGROUND

Monitoring treatment response is an important precaution in spinal tuberculosis (TB), particularly when the condition was clinically diagnosed rather than bacteriologically confirmed and when drug susceptibility testing was not performed. Conventional monitoring measures have limitations and there is a need for favourable alternatives. Therefore, this study aimed to investigate changes in immune biomarkers over the course of treatment for spinal TB and to compare these responses to the conventional monitoring measure, erythrocyte sedimentation rate (ESR).

METHODS

Patients with spinal TB were recruited from a tertiary hospital in the Western Cape, South Africa, and provided blood samples at 0, 3, 6, 9 and 12 months of TB treatment. Blood samples were analysed for ESR, using standard techniques, and for 19 cytokines, using a multiplex platform. Changes in ESR and cytokine levels were investigated using a mixed model ANOVA and Least Significant Difference post-hoc testing.

RESULTS

Twenty-six patients with spinal TB were included in the study although only fifteen remained in follow-up at 12 months. Seven biomarkers changed significantly over the course of treatment (CRP, Fibrinogen, IFN-γ, Ferritin, VEGF-A, ApoA1 and NCAM, p < 0.01) with a further three showing a strong trend towards change (CCL1, CXCL9 and GDF-15, 0.05 ≥ p ≤ 0.06). Responsive biomarkers could be approximately grouped according to patterns of progressive, initial or delayed change. ESR performed similarly to CRP, Fibrinogen and IFN-γ with all showing significant decreases between 0, 6 and 12- months of treatment. Individual ESR responses were variable.

DISCUSSION

Individual ESR responses may be unreliable and support the investigation of multi-marker approaches to evaluating treatment response in spinal TB. Biomarkers of treatment response identified in the current study require validation in a larger study, which may also incorporate aspects such as evaluating biomarkers within the first week of treatment and the inclusion of a healthy control group.

Clinical Features and Outcome of Multidrug-Resistant Osteoarticular Tuberculosis: A 12-Year Case Series from France

The optimal treatment for osteoarticular infection due to multidrug-resistant tuberculosis strains (MDR-OATB) remains unclear. This study aims to evaluate the diagnosis, management and outcome of MDR-OATB in France. We present a case series of MDR-OATB patients reviewed at the French National Reference Center for Mycobacteria between 2007 and 2018. Medical history and clinical, microbiological, treatment and outcome data were collected. Twenty-three MDR-OATB cases were reported, representing 3% of all concurrent MDR-TB cases in France. Overall, 17 were male, and the median age was 32 years. Six patients were previously treated for TB, including four with first-line drugs. The most frequently affected site was the spine (n = 16). Bone and joint surgery were required in 12 patients. Twenty-one patients (91%) successfully completed the treatment with a regimen containing a mean of four drugs (range, 2-6) for a mean duration of 20 months (range, 13-27). Overall, high rates of treatment success were achieved following WHO MDR-TB treatment guidelines and individualized patient management recommendations by the French National TB Consilium. However, the optimal combination of drugs, duration of treatment and role of surgery in the management of MDR-OATB remains to be determined.

Knee tuberculosis: A misleading clinical entity (case report)

INTRODUCTION

Bone and joint infections are rare localizations of tuberculosis, and its diagnosis is challenging. The atypical clinical presentation may lead to delayed diagnosis and severe complications.

CASE PRESENTATION

We report the case of a 72-year-old female diagnosed with tuberculosis of the knee. She was complaining of progressive right knee pain and swelling without systemic signs. She was misdiagnosed as having a flare-up of osteoarthritis, which led to a delayed diagnosis and a septic subluxation of the knee. We performed a knee arthrotomy, lavage, and stabilization with an external fixator. The microbiologic tests did not isolate any germs. However, a histological examination confirmed the diagnosis by revealing a caseating granuloma surrounded by epithelioid cells. The patient treated with anti-tuberculosis therapy had a good evolution. Three months post-surgery, the external fixator was replaced with a removable knee brace.

DISCUSSION

Osteoarticular tuberculosis is often caused by the hematogenous route. The lack of specificity in clinical and radiological signs makes the diagnosis difficult, especially at the early stage, leading to delays in diagnosis and complications. Nevertheless, the recognition of predisposing factors to tuberculosis, with persisting symptoms despite treatment, should draw the intention of further investigation. The treatment of osteoarticular tuberculosis is primary medical with antituberculosis chemotherapy. However, surgical treatment is reserved for specific indications and mostly to treat complications.

CONCLUSION

The lack of specificity in clinical and radiological signs in osteoarticular tuberculosis may mislead the physician. Nevertheless, focusing on predisposing factors, especially in endemic areas, may guide diagnosis and avoid complications.

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.

Fracture of the Distal Radius by Tuberculous Osteomyelitis: A Case Report and Review of Literature

We report a 94-year-old patient with a fractured radius that was being managed conservatively. At 2 months, an abscess was observed overlying the fracture site. An MRI scan was done and samples obtained for microbiological and pathological analyses. The patient was diagnosed with tuberculous osteomyelitis. Surgical debridement of the fracture site was performed, and the bone defect was filled with bone cement impregnated with gentamicin and rifampicin. Anti-tuberculosis therapy was administered for 9 months and the patient made an uneventful recovery. Early diagnosis and correct medical treatment depend on sound evidence of tuberculous osteomyelitis. Surgical debridement is essential if abscesses are present in the bone. Level of Evidence: Level V (Therapeutic).

Novel Potential Diagnostic Serum Biomarkers of Metabolomics in Osteoarticular Tuberculosis Patients: A Preliminary Study

Osteoarticular tuberculosis is one of the extrapulmonary tuberculosis, which is mainly caused by direct infection of Mycobacterium tuberculosis or secondary infection of tuberculosis in other parts. Due to the low specificity of the current detection method, it is leading to a high misdiagnosis rate and subsequently affecting the follow-up treatment and prognosis. Metabolomics is mainly used to study the changes of the body’s metabolites in different states, so it can serve as an important means in the discovery of disease-related metabolic biomarkers and the corresponding mechanism research. Liquid chromatography tandem mass spectrometry (LC-MS/MS) was used to detect and analyze metabolites in the serum with osteoarticular tuberculosis patients, disease controls, and healthy controls to find novel metabolic biomarkers that could be used in the diagnosis of osteoarticular tuberculosis. Our results showed that 68 differential metabolites (p<0.05, fold change>1.0) were obtained in osteoarticular tuberculosis serum after statistical analysis. Then, through the evaluation of diagnostic efficacy, PC[o-16:1(9Z)/18:0], PC[20:4(8Z,11Z,14Z,17Z)/18:0], PC[18:0/22:5(4Z,7Z,10Z,13Z,16Z)], SM(d18:1/20:0), and SM[d18:1/18:1(11Z)] were found as potential biomarkers with high diagnostic efficacy. Using bioinformatics analysis, we further found that these metabolites share many lipid metabolic signaling pathways, such as choline metabolism, sphingolipid signaling, retrograde endocannabinoid signaling, and sphingolipid and glycerophospholipid metabolism; these results suggest that lipid metabolism plays an important role in the pathological process of tuberculosis. This study can provide certain reference value for the study of metabolic biomarkers of osteoarticular tuberculosis and the mechanism of lipid metabolism in osteoarticular tuberculosis and even other tuberculosis diseases.

Neglected tropical rheumatic diseases

The complexities of dealing with rheumatic diseases in tropical countries are diverse and likely due to limited health care infrastructure, lack of diagnostic and therapeutic facilities, impact of dominant prevailing diseases, and the challenges of differentiating from infectious and non-infectious disease mimics. Several tropical diseases present with musculoskeletal and rheumatic manifestations and often pose a diagnostic dilemma to rheumatologists. The diagnosis is often delayed or the disease is misdiagnosed, leading to poor patient outcomes. Endemic tropical diseases like tuberculosis and leprosy have myriad rheumatic presentations and remain important differentials to consider in patients with rheumatic manifestations. Infection with human immunodeficiency virus is a great masquerade and can mimic manifestations of multiple diseases. The role of viral infections in triggering and perpetuating autoimmunity is well known and chikungunya arthritis is a classic example of the same. This review highlights the rheumatic manifestations of tropical diseases and aims to create awareness among the caregivers. Key Points • It is crucial to be aware and identify infectious diseases presenting with rheumatic manifestations in the tropics. • Presentations akin to classic rheumatic syndromes such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus and vasculitis are common.

Candidate Biomarkers to Distinguish Spinal Tuberculosis From Mechanical Back Pain in a Tuberculosis Endemic Setting

Background

Spinal tuberculosis (TB) may have a variable, non-specific presentation including back pain with- or without- constitutional symptoms. Further tools are needed to aid early diagnosis of this potentially severe form of TB and immunological biomarkers may show potential in this regard. The aim of this study was to investigate the utility of host serum biomarkers to distinguish spinal TB from mechanical back pain.

Methods

Patients with suspected spinal TB or suspected mechanical back pain were recruited from a tertiary hospital in the Western Cape, South Africa, and provided a blood sample for biomarker analysis. Diagnosis was subsequently confirmed using bacteriological testing, advanced imaging and/or clinical evaluation, as appropriate. The concentrations of 19 host biomarkers were evaluated in serum samples using the Luminex platform. Receiver Operating Characteristic (ROC) curves and General Discriminant Analysis were used to identify biomarkers with the potential to distinguish spinal TB from mechanical back pain.

Results

Twenty-six patients with spinal TB and 17 with mechanical back pain were recruited. Seven out of 19 biomarkers were significantly different between groups, of which Fibrinogen, CRP, IFN-γ and NCAM were the individual markers with the highest discrimination utility (Area Under Curve ROC plot 0.88-0.99). A five-marker biosignature (CRP, NCAM, Ferritin, CXCL8 and GDF-15) correctly classified all study participants after leave-one-out cross-validation.

Conclusion

This study identified host serum biomarkers with the potential to diagnose spinal TB, including a five-marker biosignature. These preliminary findings require validation in larger studies.

Chronic upper back and rib pain in a healthy man: re-examining the cause

INTRODUCTION Back and rib pain is a common presentation in primary care practice. Although most cases are secondary to non-specific musculoskeletal pain, it is essential for clinicians to identify patients presenting with life-threatening pathologies. AIM This case report serves as a reminder to clinicians to reconsider their initial diagnosis when a patient's pain fails to improve, while considering life-threatening pathologies. CASE HISTORY We describe a 44-year-old man from India who presents to his general practitioner with a 2-week history of rib and upper back pain. He was initially diagnosed with non-specific musculoskeletal pain. However, after representing twice 2 months later due to persistent pain and due to the uncertainty about his condition, he was investigated with different imaging modalities. It was discovered on bone scan that he had osteolytic lesions in the right 11th rib and T2 vertebrae. As the cause of his osteolytic lesions were unclear, he was referred to different specialists. Skeletal tuberculosis was suspected when one of his specialists discovered his recent visit to India, a tuberculosis-endemic country. This reminded the specialist of the possible risks of the patient's background and its association with his symptoms. Bone biopsy of his lytic lesions revealed Mycobacterium tuberculosis, consistent with skeletal tuberculosis. DISCUSSION Revisiting the diagnosis of back and rib pain while considering other obscure and urgent pathologies is essential if a patient fails to improve clinically. Clinicians should focus on aspects of their clinical assessment to explore these pathologies, enabling earlier recognition of the disease.

Pott Disease: A Tale of Two Cases

Tuberculosis is considered one of the great masqueraders alongside syphilis and vasculitis. Pott disease is recognized as a classic manifestation of tuberculosis, yet it stands as a rare infectious syndrome in regions with low tuberculosis disease burden. To illustrate the challenges of diagnosing Pott disease in these settings, we report two cases and offer a brief overview of management recommendations for vertebral osteomyelitis caused by Mycobacterium tuberculosis. Case one concerns an 81-year-old man with a remote history of incarceration who presented with altered mental status and new pleural effusions. Case two is a 49-year-old man with well-controlled HIV who was transferred to our institution after being found to have extensive destruction of L3-L5 vertebrae and bilateral iliopsoas abscesses on outpatient imaging. These stand as illustrative examples of low and high suspicion for tuberculosis, respectively, and both cases required complex diagnostic and management decisions.

The Crucial Questions on Synovial Biopsy: When, Why, Who, What, Where, and How?

In the majority of joint diseases, changes in the organization of the synovial architecture appear early. Synovial tissue analysis might provide useful information for the diagnosis, especially in atypical and rare joint disorders, and might have a value in case of undifferentiated inflammatory arthritis, by improving disease classification. After patient selection, it is crucial to address the dialogue between the clinician and the pathologist for adequately handling the sample, allowing identifying histological patterns depending on the clinical suspicion. Moreover, synovial tissue analysis gives insight into disease progression helping patient stratification, by working as an actionable and mechanistic biomarker. Finally, it contributes to an understanding of joint disease pathogenesis holding promise for identifying new synovial biomarkers and developing new therapeutic strategies. All of the indications mentioned above are not so far from being investigated in everyday clinical practice in tertiary referral hospitals, thanks to the great feasibility and safety of old and more recent techniques such as ultrasound-guided needle biopsy and needle arthroscopy. Thus, even in rheumatology clinical practice, pathobiology might be a key component in the management and treatment decision-making process. This review aims to examine some essential and crucial points regarding why, when, where, and how to perform a synovial biopsy in clinical practice and research settings and what information you might expect after a proper patient selection.

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.

Biomarkers to predict FDG PET/CT activity after the standard duration of treatment for spinal tuberculosis: An exploratory study

OBJECTIVES

18F-Fluorodeoxyglucose (FDG) Positron Emission Tomography- Computed Tomography (PET/CT) scans can be used to assess healing following treatment for spinal tuberculosis (TB) but have limited accessibility and high cost. This study investigated the association between immune biomarkers and FDG-PET/CT activity after ≥9 months of treatment for spinal TB.

METHODS

Patients who had completed ≥9 months of treatment for spinal TB were recruited from a major hospital in the Western Cape, South Africa. Participants underwent a FDG-PET/CT scan and FDG- PET/CT activity was quantified for all spinal and extra-spinal sites. Participants also provided a blood sample, which was evaluated for 19 cytokines along with erythrocyte sedimentation rate (ESR). Correlations and multiple regression analyses were used to investigate the association between biomarkers and PET/CT measures.

RESULTS

Twenty-eight patients were recruited, of whom 24 (86%) had spinal and/or extra-spinal FDG-PET/CT activity. In the strongest multiple regression model, CXCL10/IP-10, VEGFA, IFN-γ, CRP and Factor D/Adipsin explained 52% of the variation in overall maximal FDG uptake. Conventional monitoring marker ESR showed no significant association with PET/CT measures.

CONCLUSIONS

The current findings offered encouragement that biomarkers to predict FDG-PET/CT activity may show some promise and identified candidate biomarkers for further investigation in this regard.

Role of 18F-FDG PET/CT in the Assessment of Response to Antitubercular Chemotherapy and Identification of Treatment Endpoint in Patients With Tuberculosis of the Joints: A Pilot Study

AIMS

The aim of this study was to explore the utility of 18F-FDG PET/CT in the assessment of response to antitubercular treatment (ATT) and identification of treatment endpoint.

PATIENTS AND METHODS

Forty patients (mean age, 35.3 years; 27 men) with clinically, radiologically, and histopathologically proven joint tuberculosis prospectively underwent clinical, biochemical, and PET/CT evaluation at baseline and after ~6, 12, and 18 months of ATT. Two patients were lost to follow-up, and 1 defaulted treatment. The remaining 37 were followed up until complete response (CR) was achieved. Images were visually and quantitatively (SUVmax ratio and metabolically active disease volume [MV]) evaluated by 2 experienced nuclear medicine physicians.

RESULTS

Knee (n = 18) and ankle (n = 7) were the most frequently involved sites. The median MV and SUVmax ratio at baseline were 85.10 mL and 7.21, respectively. Five patients had noncontiguous vertebral involvement, 12 had pulmonary lesions, 2 had abscesses, 6 had mediastinal, and 30 had local lymph nodal involvement. Complete response was seen in 1/39, 11/37, and 30/37 patients after 6, 12, and 18 months of ATT. Significant reductions in visual analog scale score, tenderness, joint swelling, SUVmax ratios, and MVs (Friedman test, P < 0.001) were seen after each follow-up. The median time-to-CR in skeletal lesions was significantly longer than extraskeletal lesions (591 vs 409 days; Wilcoxon signed-rank test, P < 0.001). Time-to-CR in joint lesions positively correlated with MV at first follow-up (Pearson = 0.452, P = 0.005) and negatively correlated with percentage change in MV (first follow-up from baseline) (Pearson = -0.620, P < 0.001). ROC analysis yielded a cutoff of ≤71% reduction in MV at first follow-up (80.8% sensitivity, 81.8% specificity) to predict extension of ATT beyond 12 months. Using ROC analysis at second follow-up, a cutoff of ≤12.67 mL (for CR) was derived and was validated in patients at the third follow-up, with an accuracy of 84.4%. Patients with CR in PET/CT maintained disease-free state during a mean follow-up of 271 days.

CONCLUSIONS

18F-FDG PET/CT is an excellent tool in estimating total disease burden, assessing response to ATT and identification of treatment endpoint in joint tuberculosis.

Arthroscopic Ankle Arthrodesis for End-Stage Tuberculosis of the Ankle: A 2-Year Follow-Up

Surgical treatment for end-stage ankle joint tuberculosis (TB) has rarely been reported. This study followed cases treated by arthroscopic arthrodesis for ankle joint TB to evaluate its efficacy and safety in the clinic. Patients who underwent arthroscopic ankle arthrodesis for ankle joint TB between April 11, 2010, and December 31, 2016, were followed. Their diagnoses were confirmed by bacterial culture or pathological examination. During arthroscopy, tissue samples were first obtained to further confirm the diagnosis. Then the necrotic tissue, hyperplasia of synovial tissue, and exfoliated cartilage were removed. Ankle joint arthrodesis was performed if the area of articular cartilage damage was >2 cm². Continued nutritional support and standardized anti-TB drug treatment were given after surgery. Follow-up measurements included visual analogue scale score, American Orthopaedic Foot and Ankle Society score, erythrocyte sedimentation rate, and radiographic imaging. All 9 patients in this study, with an average age of 54 (range 37 to 68) years, were followed. The mean follow-up duration was 55.44 ± 31.15 (range 24 to 96) months. There were significant differences in the visual analogue scale scores, American Orthopaedic Foot and Ankle Society scores, and erythrocyte sedimentation rate between before treatment and 18 months postoperatively (p < .05). All patients (100%) showed union at 18 ± 4 weeks. Arthroscopic treatment for ankle joint TB has the advantages of minor trauma and low complications. It can be used to accurately obtain samples from specific areas of TB for further diagnosis. According to the degree of articular cartilage damage, the surgeon can determine whether to perform arthrodesis. Thorough debridement of necrotic tissue and residual articular cartilage on the fusion surface can improve the rate of ankle fusion.

Concordance and Discordance of Orthopedicians with Revised National Tuberculosis Control Program with Reference to Musculoskeletal Tuberculosis: A Qualitative Inquiry

BACKGROUND

Musculoskeletal tuberculosis (TB) continues to share the major burden of extrapulmonary TB. This burden up to some extent may be attributed to the implementation gap which is reasonably broadest at the level of the immediate point of care. As an orthopedic physician is an important stakeholder at this juncture, it is imperative to recognize their experiences, perceptions, and anticipations to fill this gap. This qualitative inquiry tries to explore these attributes in the context of the recent development at the policy level in Revised National Tuberculosis Control Program.

METHODOLOGY

Type of Study Qualitative inquiry with framework approach.

SETTINGS

Orthopedic surgeons working in different work settings.

SAMPLING METHOD

Purposive sampling. An iterative topic guide for an in-depth interview was prepared by reviewing the literature and expert opinions. The questions were contextual, diagnostic, evaluative, and strategic. This study adopted a framework approach as the issue was near to evaluative and strategic policy research. The recorded interviews were transcribed and coded into axial and serial codes. A framework matrix was created and thematic mapping was done to understand the phenomena and to offer the solution framework.

RESULTS

The investigators detected an element of unawareness of the current context coupled with the perceived previous stringency of the program. This is in conjunction with already multifaceted diagnostic and prognostic complexity. This leads to mutual dissociation and skepticism.

CONCLUSION

This qualitative inquiry explored an element of dissociation between programmatic objectives and individualistic concerns of the caregivers. An integrated ecosystem which may take care of synergistic reciprocation among the two is imperative for successful implementation.

Bone and joint tuberculosis in patients undergoing dialysis: clinical features, risk factors, and outcomes in 17 patients

OBJECTIVE

This study was performed to investigate the clinical features, risk factors, and outcomes of bone and joint tuberculosis in patients undergoing dialysis.

METHODS

We systematically reviewed the medical records of 17 patients with bone and joint tuberculosis undergoing dialysis who were admitted to our hospital from January 2009 to January 2019.

RESULTS

Seventeen patients with bone and joint tuberculosis undergoing dialysis were identified in this retrospective study, and 13 patients were undergoing hemodialysis. The mean age of the 17 patients was 61.3 years (range, 32-82 years), and 10 (58.9%) patients were male. Most of the patients had a low CD4+ cell count and low hemoglobin and albumin levels. Surgery was performed in 6 patients (35.3%), and 13 of the 17 patients (76.4%) were cured. Three patients had bone or spine sequelae, mainly because of a delayed diagnosis, and one patient died of heart failure.

CONCLUSION

These findings indicate that older age, a low CD4+ cell count, and low hemoglobin and albumin levels are possible risk factors for bone and spine tuberculosis in patients undergoing dialysis. If diagnosed early, most patients should have a good outcome after anti-tubercular therapy with or without surgery.

Treatment of Bone and Joint Tuberculosis in France: A Multicentre Retrospective Study

Background: Nine percent of all cases of tuberculosis are bone and joint tuberculosis (BJTB). BJTB occurs in two main forms: spinal (STB) and extraspinal (ESTB). The aim of this study was to compare STB with ESTB in terms of diagnosis, treatment and outcomes. Methods: We collected demographic, clinical, microbiological, treatment duration and outcome data for patients with BJTB in a retrospective multicentre study over a 17-year period. Results: Of the 116 patients included in the study, 69 (59.5%) had STB and 47 (40.5%) had ESTB. The median age was higher in the ESTB group. There were significantly more foreign-born patients in the STB group. The median time for diagnosis was longer for ESTB (6 months) than STB (4 months) (p = 0.017). Magnetic resonance imaging was highly reliable for the diagnosis. Direct examination and histology allowed the diagnosis to be made in more than 80% of cases. The median treatment duration of 12 months, regardless of the type of BJTB, was longer than recommended. A favourable outcome was achieved in 91.9% of cases. Conclusion: The management of BJTB remains challenging. An earlier diagnosis should be more effective, reducing the total duration of treatment and leading to better tolerance.

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.

Minimally invasive surgery for paravertebral or psoas abscess with spinal tuberculosis - a long-term retrospective study of 106 cases

Background

Minimally invasive surgery (MIS) is a common treatment option for paravertebral or psoas abscesses (PAs) in patients with spinal tuberculosis (ST). However, its efficacy remains controversial. The aim of the study was to evaluate the efficacy of MIS for PA with ST combined with anti-tuberculous chemotherapy.

Methods

A total of 106 consecutive patients who underwent MIS for ST with PA from January 2002 to Oct 2012 were reviewed. The MIS involved computed tomography (CT)-guided percutaneous catheter drainage and percutaneous catheter infusion chemotherapy. Clinical outcomes were evaluated based on the changes observed on preoperative and postoperative physical examination, inflammatory marker testing, and magnetic resonance imaging (MRI).

Results

The mean follow-up period was 7.21 ± 3.15 years. All surgeries were successfully completed under CT-guidance without intraoperative complications and all patients experienced immediate relief of their symptoms, which included fever and back pain. The preoperatively elevated erythrocyte sedimentation rate and C-reactive protein values returned to normal at a mean period of 3 months postoperatively. Solid bony union was observed in 106 patients and no abscesses were found on MRI examination.

Conclusion

MIS carries advantages in terms of less invasiveness, precise drainage, and enhanced local drug concentration. While the technique has not been fully characterized and clinically prove, its use in addition to conservative chemotherapy and open debridement and instrumental fixation may be recommended for patients with ST and PA.

Changes in the medical burden of pyogenic and tuberculous spondylitis between 2007 and 2016: A nationwide cohort study

BACKGROUND

This nationwide study aimed to compare the medical burdens of pyogenic spondylitis (PS) and tuberculous spondylitis (TS) between 2007 and 2016 in Korea.

METHODS

We used a national database managed by the National Health Insurance Service (NHIS) with data from the years 2007 and 2016. A total of 9655 newly diagnosed patients with PS or TS were correspondingly enrolled in the PS or TS group. Chi square test analyses were used to compare the PS and TS groups.

RESULTS

The overall incidence of infectious spondylitis during the study period was 9655 persons. The PS and TS groups consisted of 7305 and 2350 cases, respectively. Individual medical costs in the PS group (USD 10,049 ± 94 vs. USD 16,672 ± 17,729, P < 0.001) and the TS group (USD 4882 ± 6869 vs. USD 8531 ± 10,709, P < 0.001) both increased. The total medical cost for the PS group increased significantly between 2007 and 2016 in Korea (USD 24,428,560 vs. USD 81,044,196, P < 0.001). In contrast, the total medical cost for the TS group decreased between 2007 and 2016 in Korea (USD 8,573,038 vs. USD 4,879,520, P < 0.001).

CONCLUSION

This nationwide study shows that the total medical cost of PS has increased and that the total medical cost of TS has decreased between 2007 and 2016 in Korea.

Spinal blastomycosis: unusual musculoskeletal presentation with literature review

We report a case of a 41-year-old male who presented to our institution with a large groin mass. CT, MRI and PET imaging was performed and was concerning for a soft tissue abscess likely originating in the lumbar spine. Differential considerations included infection, with atypical infections such as tuberculosis strongly considered. Biopsy revealed fungal elements preliminarily reported as consistent with Cryptococcus neoformans but later revealed to be Blastomyces dermatitidis. The patient responded positively following the introduction of appropriate treatment. This case illustrates the imaging similarities between spinal blastomycosis, spinal tuberculosis, and other fungal infections as well as the need for biopsy to differentiate.

Use of Ultra-Deep Sequencing in a Patient with Tuberculous Coxitis Shows Its Limitations in Extrapulmonary Tuberculosis Diagnostics: A Case Report

Unbiased metagenomic next-generation sequencing (mNGS) has been widely applied in clinical microbiology for infectious disease diagnostics. Some successful applications in central nervous system infections and respiratory tract infections have proved it to be a promising tool for pathogen detection. Here, mNGS was used to confirm the infectious etiology in a case of tuberculous coxitis, which is a common type of extrapulmonary tuberculosis (TB). A 77-year-old Asian male presented with hip pain and fever was diagnosed with smear- and culture-negative tuberculous coxitis based on the evidence of imaging and interferon-γ release assay. At the same time as the anti-TB therapy started, the patient underwent joint clearance surgery. Whole blood and synovial fluid sampled from surgery were kept for bacteriological confirmation using mNGS with high sequencing depth. However, only two paired-end reads from synovial fluid samples were identified as Mycobacterium tuberculosis. Before leaving hospital, the patient was still receiving anti-TB treatment and began to recover. Considering the obvious escalation of the cost and analysis time as the depth of sequencing increases, although we got a positive result here, the scarce number of reads obtained through ultra-deep sequencing indicates its limitations in extrapulmonary tuberculosis.

Extrapulmonary Tuberculosis in Denmark From 2009 to 2014; Characteristics and Predictors for Treatment Outcome

Background

Extrapulmonary tuberculosis (EPTB) represents an increasing percentage of tuberculosis (TB) cases in Europe. However, strategies on TB prevention and successful treatment outcomes primarily target pulmonary TB. In this nationwide study, we present characteristics of EPTB, treatment outcomes, and predictors for unfavorable treatment outcomes.

Methods

All patients diagnosed with EPTB from 2009 to 2014 were included. Logistic regression analyses were used to identify risk factors for unfavorable outcome. The following definitions were used: unfavorable outcome: the sum of treatment failed, lost to follow-up, and not evaluated; patient delay: time from TB-related symptom onset until first hospital contact related to TB; doctor delay: time from first TB-related contact in the health care system to start of TB treatment.

Results

A total of 450 EPTB cases were notified, which represented 21.1% of all TB cases in Denmark. Immigrants accounted for 82.9%. Lymph nodes were the most common site of EPTB (55.4%) followed by pleural TB (13.4%). Patient delay was significantly longer among immigrants than Danes (60 vs 30 days; P < .01), whereas doctor delay was significantly longer among Danes (38.5 vs 28 days; P < .01). Treatment completion rates were high and reached 90.9% in 2014. Male gender (odds ratio [OR], 5.18; 95% confidence interval [CI], 1.79–15.04) and age 0–24 years (OR, 16.39; 95% CI, 2.02–132.64) were significantly associated with unfavorable outcome.

Conclusions

EPTB represented a significant number of all TB cases and was predominantly seen among younger immigrants in Denmark. To maintain high treatment completion rates, increased focus on male gender and young age is needed.

Contribution of Computed Tomography Scan to the Diagnosis of Spinal Tuberculosis in 14 Cases in Assaba, Mauritania

Background

The incidence of tuberculosis has increased in recent years in both developed and developing countries.

Objective

This retrospective study aimed to review all cases of spinal tuberculosis diagnosed at the Department of Internal Medicine and Infectious Diseases in Kiffa Regional Hospital and assess the role of computed tomography (CT) scan in establishing definite diagnosis.

Patients and Methods

Data were collected from clinical records of patients admitted to the hospital for rachialgia between August 2016 and July 2018.

Results

Fourteen (12.2%) adults with spinal tuberculosis were found among 115 patients with all forms of tuberculosis during the study period. The mean (± standard deviation) age of our patients was 47.5 ± 22.0 years old with male:female (8/6) sex ratio of 1.3. The mean duration of evolution of the disease was 15 months. The presenting signs and symptoms included rachialgia in most patients (93%), associated with segmental spinal stiffness (50%) and/or neurological complications (50%). Diagnosis was established on the basis of clinical history, clinical examination, standard vertebral column radiography, and CT scan. Vertebral imaging showed a clear predominance of lumbar lesions (57%), followed by dorsal (36%) and cervical (7%) involvement. The evolution under treatment was favorable, with the exception of two cases of medullary compression.

Conclusion

Spinal tuberculosis is the most common form of osteoarticular tuberculosis. It affects predominantly lumbar and dorsal vertebrae. In the absence of histological confirmation, the presence of back pain associated with major radiological signs of spondylosis disc disease seems to justify the use of CT scan to confirm the diagnosis of this pathology.

Arthroscopic management for early-stage tuberculosis of the ankle

Background

Due to atypical clinical presentation, wide use of antibiotics, and lack of specificity in diagnosis, diagnosis of tubercular (TB) infection in joints is increasingly difficult, and misdiagnosis is common. The use of arthroscopy for the diagnosis and treatment of early-stage ankle TB has rarely been reported. This case series intended to present the clinical outcomes of arthroscopic management for early-stage ankle TB.

Methods

Fifteen patients with chronic synovitis of the ankle and suspicious cause of early-stage ankle TB underwent arthroscopic treatment from April 1, 2010, to March 31, 2016. These cases all failed to confirm diagnosis of TB by ankle arthrocentesis. They included seven males and eight females with an average age of 37.5 (8 to 70) in the study. Among them, five cases had history of pulmonary tuberculosis, and six had history of trauma. The procedure included synovial membrane biopsy and debridement. The diagnosis was confirmed by pathologic examination and culture. The treatment was combined with systemic anti-tuberculous drugs. Follow-up measurements included VAS score, AOFAS score, ESR, CRP, and MRI.

Results

After arthroscopic management, 13 cases confirmed TB by pathologic examination and culture, and two cases still remained clinically suspected TB; the rate of confirmed case was 87%. The incision healed well in all cases, and no serious complications were observed. There were significant differences in VAS scores, AOFAS scores, ESR, and CRP between before and after treatment (P < 0.01). Joint swelling disappeared or was relieved after 2 months in most patients. Ankle swelling and pain in one patient was improved after changing anti-tuberculous drugs. MRI suggested that all patients had effusion in the articular cavity, accompanied by bone edema of the distal tibia and talus before the treatment. After the surgery, the effusion was significantly reduced, and the signal of bone edema almost disappeared. No recurrent TB was found during the follow-ups.

Conclusion

Arthroscopic management for early-stage ankle TB is minimally invasive, safe, and reliable. It can easily obtain samples from specific area of TB for further confirmation of the diagnosis, while the debridement can also assist in local disease control. For cases of highly suspicious joint TB, arthroscopic biopsy and debridement after transient anti-TB treatment is recommended.

Level of evidence

Level IV, therapeutic case series

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1048-y) contains supplementary material, which is available to authorized users.

Mycobacterial Musculoskeletal Infections

Although less common as causes of musculoskeletal infection than pyogenic bacteria, both Mycobacterium tuberculosis and nontuberculous mycobacteria can infect bones and joints. Although tuberculous arthritis and osteomyelitis have been recognized for millennia, infections caused by nontuberculous mycobacteria are being identified more often, likely because of a more susceptible host population and improvements in diagnostic capabilities. Despite advances in modern medicine, mycobacterial infections of the musculoskeletal system remain particularly challenging to diagnose and manage. This article discusses clinical manifestations of musculoskeletal infections caused by Mycobacterium tuberculosis and nontuberculous mycobacteria. Pathogenesis, unique risk factors, and diagnostic and therapeutic approaches are reviewed.