Tuberculosis of the metacarpals and phalanges of the hand

Pediatric Multidrug-Resistant Disseminated Tuberculosis Presenting as Small Finger Tuberculous Osteomyelitis: A Case Report

CASE

We report a case in the United States of a 12-year-old girl with multidrug-resistant tuberculous (MDR-TB) osteomyelitis of the hand managed with surgical debridement and second-line anti-TB therapy. The disease course was complicated by dissemination and multifocal progression.

CONCLUSION

Despite early intervention, multidrug resistance makes TB treatment challenging and facilitated progression to disseminated disease in this case. We review the difficulties in diagnosis and treatment of pediatric MDR-TB.

Tuberculosis of hand and wrist: Varied clinical presentation and functional outcome by surgical intervention in 13 cases

A prospective study of 13 cases with tuberculosis of hand and wrist was presented with mean age of patients being 42.7 years (range 18 months to 84 years). Pain, swelling and difficulty in movement of adjacent joints were the most common presenting complaints. The discharging sinus, abscess & nerve compression were also observed in some cases. Out of 13 cases, bone involvement was seen in one case, joint involvement in five cases, soft tissue involvement in five cases and two cases had both soft tissue and joint involvement. All patients had undergone operative intervention for confirmation of diagnosis and improvement in function. Surgeries like open biopsy, debridement and tenosynovectomy were performed. Depending upon drug sensitivity on culture and histopathology report, standard anti-tuberculous treatment (ATT) was commenced under supervision of Infection Disease expert. Hand function was evaluated by modified Green and O'Brian score. The mean score was 58.84 (35-70) before any intervention and it improved to 89.23 (60-100) at 6 months follow up after surgical intervention and ATT. In conclusion, surgery may help for early functional recovery and for encouraging patient to use their hand for activities of daily living.

Mycobacterial Infections of the Hand

BACKGROUND

Hand infections caused by mycobacteria are relatively uncommon compared to infections caused by other pathogens; therefore, much of the available literature consists of case reports and limited case series. Broadly categorized into tuberculous and nontuberculous mycobacterial (NTM) infections, both tuberculous and NTM infections are typically insidious with long incubation periods and with the ability to remain dormant for prolonged periods.

METHODS

We reviewed the most current literature on the epidemiology, presentations, treatment methods, and resistance patterns of mycobacterial infections of the hand focusing on the indications and outcomes of nonoperative as well as operative interventions.

RESULTS

The worldwide burden of tuberculosis remains high and while the overall rate of new diagnosis drug resistant tuberculosis has been on the decline some regions of the world have demonstrated staggeringly high resistance rates to first-line tuberculosis therapies. Signs and symptoms of mycobacterial hand infection are typically inconsistent, and highly dependent on the specific structures of the hand that are affected; therefore, these infections may mimic other infections of the hand like tenosynovitis, joint space infections, and cutaneous infections. The main stay of treatment remains antimycobacterial therapies including but not limited to rifampin, isoniazid, pyrazinamide, and ethambutol.

CONCLUSIONS

The complications associated with mycobacterial hand infections can be significant. Prompt evaluation, including a thorough history to evaluate for potential exposures to infectious sources, followed by appropriate antibiotic choice and duration, with surgical management as needed, is key to reducing the chance that patients experience lasting effects of the infection.

Clinical features and treatment outcome of wrist tuberculosis in adult- a retrospective study of 84 consecutive cases with minimum of 2 years follow up

Background

Wrist tuberculosis (TB) is a rare disease that may result in residual deformity, pain, or stiffness even after proper antitubercular chemotherapy (ATT) and surgical intervention. The aim of our study is to present clinical features and functional outcomes of wrist TB in a consecutive series of 84 adult patients with a minimum of 2 years of follow-up.

Methods

Clinical features and treatment outcomes of 84 consecutive adult patients with wrist TB from January 2003 to June 2018 including 45 men and 39 women, with a mean age of 46.8 years (18–84) were retrospectively analyzed. Data were collected on participants’ demographic details. The primary outcome measures were QuickDASH score, grip strength, Visual Analogue Scale (VAS), and PRWHE. Secondary outcomes include health-related quality of life was evaluated using the EuroQol five-dimension five-level (EQ-5D-5L), assessment and postoperative complications of patients who underwent operation were also recorded.

Results

All 84 patients with an average follow-up of 50.8 (24–105) months. The mean duration of symptoms before treatment was 10.5 months (2–21). There were 27 patients with bony and 57 with primarily soft-tissue involvement based on preoperative evaluation of plain radiographs and MRI. There were 33 patients treated with ATT and 51 patients were treated with surgery followed by ATT. Among them, 13 patients (15.5%) underwent incision and decompression, 14 patients (16.7%) underwent wrist synovectomy, 13 patients (15.5%) underwent wrist joint fusion by plate fixation, and 11 patients (13.1%) underwent wrist joint fusion by external fixation. At the last clinical visit, the QuickDASH, and PRWHE scores of all patients decreased significantly, the VAS improved from 5.9 to 1.4, EQ-5D-5L utility index improved from 0.36 to 0.88, EQ-VAS improved from 40.2 to 89.1. All patients indicated good wrist recovery at the last follow-up, and the treatment achieved satisfactory clinical outcomes.

Conclusion

The onset of wrist TB is insidious; early diagnosis, good patient compliance, and surgery combined with ATT are crucial steps for treatment of wrist TB, and also essential for the patient's postoperative recovery. Wrist arthrodesis has achieved satisfactory results in the treatment of severe wrist TB.

Outcome of Neglected Versus Treated Tuberculous Dactylitis in the Same Patient - A case report

Introduction

Skeletal tuberculosis is a rare form of extrapulmonary Mycobacterium tuberculosis infection. When tubular bones are affected, it is called tuberculous dactylitis (TD). This rare entity can be seen in the hand or foot and has been mentioned in a handful of case reports.

Case Report

A 56-year-old female patient presented to our clinic for left hand middle finger swelling and pain of 1-year duration. Her medical history was relevant for 15 years history of progressive 4th and 5th fingers malformations that were attributed to “sarcoidosis,” and for which she was treated with anti-inflammatory and low dose steroids therapy. At our clinic, physical examination was consistent with a swelling of the base of the middle finger associated with tenderness and decreased range of motion. Radiographs of the hand showed a lytic lesion involving the distal half of the first phalanx, along with blurred limits of the bone surfaces involved. An magnetic resonance imaging was ordered and showed hyper-intense signal of the first phalanx, along with subcutaneous enclosed collections on both sides of the phalanx. Surgical debridement with open biopsy and culture was done. Pathology results showed caseating granulomas, and cultures confirmed the diagnosis of TD. A computed tomography scan of the chest was done postoperatively; where few calcified nodules were noted. She also received a 9-months course of anti-tuberculous drugs and had complete cure by 9 months postoperatively.

Conclusion

TD of the hand is a very rare entity of the spectrum of extrapulmonary M. tuberculosis infection. Clinicians should have a high index of suspicion concerning this pathology not to delay the diagnosis, which could lead to permanent deformity. Early diagnosis and treatment can significantly improve outcomes.

Tuberculous Dactylitis in Adult - A Case Report and Review of Literature

Introduction:

Tubercular dactylitis is an uncommon form of musculoskeletal tuberculosis (TB), especially after the age of 5 years without any risk factors.

Case Report:

A case of 49-year-old male presented with pain, swelling, and discharging sinus of proximal phalanx of third digit of the right hand with no constitutional symptoms for 2 years, with multiple failed treatment in form of antibiotic therapy. There were no risk factors such as immunodeficiency or any co-morbidities. The plain radiograph was suggestive of increased bone density with mild periosteal reaction; magnetic resonance imaging was suggestive of tubercular osteomyelitis. A biopsy was performed, the gene expert of the sample revealed TB with no drug resistance. The patient was managed with anti-tubercular drugs with complete resolution of clinical and radiological symptoms at 1-year follow-up.

Conclusion:

TB should be considered a differential in patients with chronic soft-tissue or skeletal lesions even in the absence of the usual risk factors because with treatment it still carries a good prognosis.

Advances in the molecular detection of tuberculosis in pre-contact Andean South America

Andean paleopathological research has significantly enhanced knowledge about the geographical distribution and evolution of tuberculosis (TB) in pre-Columbian South America. In this paper, we review the history and progress of research on ancient tuberculosis (TB) in the Andean region, focusing on the strengths and limitations of current approaches for the molecular detection of ancient pathogens, with special attention to TB. As a case study, we describe a molecular screening approach for the detection of ancient Mycobacterium tuberculosis in individuals from Late Intermediate Period (1000-1400 CE) contexts at the site of Huari, Peru. We evaluate 34 commingled human vertebrae and combine morphological assessments of pathology with high throughput sequencing and a non-selective approach to ancient pathogen DNA screening. Our method enabled the simultaneous detection of ancient M. tuberculosis DNA and an evaluation of the environmental microbial composition of each sample. Our results show that despite the dominance of environmental DNA, molecular signatures of M. tuberculosis were identified in eight vertebrae, six of which had no observable skeletal pathology classically associated tuberculosis infection. This screening approach will assist in the identification of candidate samples for downstream genomic analyses. The method permits higher resolution disease identification in cases where pathology may be absent, or where the archaeological context may necessitate a broad differential diagnosis based on morphology alone.

Bilateral Tubercular Dactylitis: Unusual presentation of an usual disease

INTRODUCTION

Bilateral Tubercular Dactylitis (TD) is an unusual presentation of tuberculosis and only handful numbers of cases are reported in the literature. Hence, very little is known about its clinical presentation, statistic, radiological features and its outcome.

METHODS

We have included seven male and two female patients of mean age 7.2 years, of the proven cases of bilateral TD by histopathological or microbiological or PCR analysis from core biopsy. Radiological features were recorded from plain radiograph. All patients were given Antitubercular drugs according to WHO 2010 recommendation (four drugs for 3-5 months, three drugs for next 3-5 months and finally two drugs for 6-8 months). Debridement was done whenever required.

RESULTS

Of total 26 lesions, the most common presentation was swelling with or without mild pain. Discharging sinus was present in four lesions. There were six phalanges, 18 metacarpal and two metatarsals. Radiographically, the most common type of lesion was soft tissue swelling followed by lytic lesion. Histopathologically tuberculosis was proven in 10 (55.6%) lesions, bacteria isolated in 5 (27.8%) lesions and PCR was done in 8 lesions and was positive in all. All lesions healed after giving ATT except one which developed psudo-arthrosis and one patient developed coronal plane deformity that was corrected by JESS.

CONCLUSION

A clinician should always suspect tuberculosis while dealing with a pathology of hand and feet even if it is bilateral. Suspected case can be diagnosed by histopathological, microbiological or PCR analysis and it can be treated by ATT with a good functional outcome.

Tuberculosis of lunate as an isolated intraosseous osteolytic lesion in an adult: a diagnostic challenge

In an endemic zone of tuberculosis (TB), osseous involvement is a relatively common presentation. Spine and long bones are the the most common nidus of TB. Smaller bones and joints are relatively less involved. Thorough clinical examination and history of typical constitutional symptoms like weight loss, fever and loss of appetite are the diagnostic aids for initiating early treatment. Wrist and hand involvement is a rare occurrence and often presents atypically without any obvious symptoms or signs. This results in delayed diagnosis and worse outcome. TB of lunate without articular involvement is a very rare subset and we present such an isolated case of TB involving the lunate, without any typical symptoms, with the patient complaining of vague pain without any restriction of joint mobility. TB was diagnosed with the aid of radiology, haematology and histopathology. 18 months of multidrug antitubercular treatment was given, to which the patient responded well.

Extra-Spinal Osteoarticular Tuberculosis: A Retrospective Analysis of 103 Cases

Introduction. Many studies in the literature deals with epidemiology, diagnosis and management of spinal tuberculosis but there is scant amount of such data for extraspinal osteoarticular TB. Material and methods. Demographic patient data like age, sex, bone and joint involved, side involved, duration of symptoms was noted. All suspected cases of extra-spinal musculoskeletal TB with positive acid-fast bacilli (AFB) staining or positive cartridge based nucleic acid amplification test (CBNAAT) or histopathological evidence of granulomatous infection and minimum 1 year follow up after completion of 12-month ATT were included in the study. Outcome evaluation was done on the basis of residual pain, range of motion of joint along with deformity of the affected part, if any. Results. A total of 103 patients (55 males, 48 females) were analyzed. The mean duration of treatment was 14.2±2.8 months. The mean age of the patients at presentation was 30.5±18.5 years. The most common site affected was the ankle joint followed by hip and knee. 95 cases (92.2%) were diagnosed by histopathological examination of synovial tissue or material obtained from core biopsy. 90 cases (87.3%) were treated conservatively on oral drugs only while 13 cases (12.7%) were treated operatively. Outcome after completion of ATT were graded as good in 46 (46.9%), fair and poor each in 26 patients (26.5%). Conclusion. Extraspinal osteoarticular TB can be managed effectively by 12-month ATT if diagnosed early. Some cases with advanced arthritis can be salvaged with implant arthroplasty or arthrodesis under cover of ATT.

Tuberculous osteomyelitis of the wrist presenting as a monoarthritis syndrome

Osteoarticular tuberculosis is the third most frequent location of tuberculosis after the lung and lymph nodes, accounting for approximately 10%-20% of all cases of extrapulmonary disease. Tuberculosis of the hand and wrist is the rarest osteoarticular location after the shoulder. The authors report the case of a 50-year-old woman without medical history who was diagnosed with isolated tuberculosis of the wrist presenting as monarthritis. The diagnosis was confirmed by histopathological and microbiological examination. Late stages of osteomyelitis are even rarer without any predisposing factors such as immunosuppression. This case underlines the importance of including tuberculosis in the differential diagnosis of monoarthritic syndromes to prevent delayed initiation of therapy and consequent complications and bone damage.

Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: Is Tenosynovectomy Imperative?

The treatment of flexor tenosynovitis in the hand and wrist due to tuberculosis is controversial. Although some authors recommend the antituberculous chemotherapy, the others recommend the surgical treatment. In this article, 12 patients with synovial tuberculosis of the flexor aspect of the hand and the wrist were evaluated with respect to diagnosis and treatment modalities. None of the patients had a history of tuberculosis, concomitant disease, immunosuppressive drug use, drug abuse, and human immunodefficiency virus positivity. A chest x-ray and family screening were performed in all of the cases, none had evidence of tuberculosis in the lung. The biopsy, histopathological examination, acid-fast bacillus staining, and BACTEC tuberculosis culture were performed. Antituberculous chemotherapy was initiated in patients diagnosed with tuberculosis by either histological or microbiological examinations. The patients did not undergo any further surgery after biopsy procedures. The lesions regressed totally in all patients after 3 months of treatment. Carpal tunnel syndrome symptoms and signs recruited at five months of treatment. In patients with flexor tuberculosis tenosynovitis, it is possible to achieve good results by applying only medical therapy after a biopsy, and without the need for further surgery.

Osteoraticular Tuberculosis-Brief Review of Clinical Morphological and Therapeutic Profiles

Osteoarticular tuberculosis (OATB) is a rare form of tuberculosis (TB) whose incidence rose significantly nowadays especially in the underdeveloped countries. The main risk factors predisposing to this new challenge for the medical system are the Human Immunodeficiency Virus (HIV) epidemic, the migration from TB endemic areas and the development of drug and multidrug-resistant strains of Mycobacterium tuberculosis (Mt). The disease affects both genders and any age group although the distribution depending on gender is controversial and that depending on age has a bimodal pattern. In most cases the initial focus is elsewhere in the organism and the most frequent pathway of dissemination is lympho-haematogenous. The clinical picture includes local symptoms as pain, tenderness and limitation of motion, with some particularities depending on the segment of the osteoarticular system involved, sometimes accompanying systemic symptoms specific for TB and other specific clinical signs as cold abscesses and sinuses. The radiographic features are not specific, CT demonstrates abnormalities earlier than plain radiography and MRI is superior to plain radiographs in showing the extent of extraskeletal involvement. Both CT and MRI can be used in patient follow-up to evaluate responses to therapy. TBhas been reported in all bones of the body, the various sites including the spine (most often involved) and extraspinal sites (arthritis, osteomyelitis and tenosynovitis and bursitis). Two basic types of disease patterns could be present: the granular type (most often in adults) and the caseous exudative type (most often in children) one of which being predominant. The algorithm of diagnosis includes several steps of which detection of Mt is the gold standard. The actual treatment is primarily medical, consisting of antituberculosis chemotherapy (ATT), surgical interventions being warranted only for selected cases. It is essential that clinicians know and refresh their knowledge about manifestations of OATB.

Multifocal Tubercular Dactylitis: A Rare Presentation of Skeletal Tuberculosis in an Adult

Tubercular dactylitis is an uncommon form of osteo-articular tuberculosis seen in children. Multifocal involvement, simultaneously involving hands and feet is extremely uncommon. Here we report an adult patient with tubercular dactylitis involving multiple digits of both hands and second digit of right foot in absence of any risk factors like immunodeficiency or any debilitating condition. The patient was successfully treated with anti-tubercular drugs for six months. Mycobacterium tuberculosis infection of bones and joints can present in an unusual way but early diagnosis and treatment caries a good prognosis.

Diffuse phalangeal signal abnormality on magnetic resonance imaging: phalangeal microgeodic disease

BACKGROUND

Phalangeal microgeodic disease is a rare and benign self-limited condition involving the phalanges, often in the setting of cold exposure, with characteristic MR imaging abnormalities. Radiographic case descriptions are predominantly from Asia and Europe, with only seven cases using MR to characterize phalangeal microgeodic disease.

OBJECTIVE

In this study we describe the MR imaging appearance of unusual and striking phalangeal signal abnormality compatible with phalangeal microgeodic disease at our institution in North America.

MATERIALS AND METHODS

We retrospectively reviewed cases presenting at our institution with unusual or unexplained phalangeal signal abnormalities between 2001 and 2014. We reviewed the MR imaging appearances in conjunction with radiographs and any other available imaging investigations.

RESULTS

Of 189 examinations reviewed during the study period, 8 imaging studies in 6 patients met the study inclusion criteria. Signal abnormality was present in 57 of 112 phalanges (51%), frequently involving the distal phalanges (70%, 28 of 40), followed by the middle phalanges (56%, 18 of 32) and the proximal phalanges (28%, 11 of 40). The pattern of involvement was most commonly diaphysis (38%), followed by metaphysis (32%) and epiphysis (30%). The extent of MR signal abnormality was greater than that suspected based on clinical presentation or on radiographs.

CONCLUSION

The presence of unexplained diffuse characteristic marrow involvement of multiple painful phalanges on MR images, often in the setting of cold exposure, should raise the possibility of phalangeal microgeodic disease. Consideration of this diagnosis based on MR findings would lead to a more conservative management and avoid unnecessary invasive diagnostic procedures.

Isolated Tuberculosis of Capitate and Triquetrum

Musculoskeletal system is involved in about 20% of the patients diagnosed with tuberculosis. Although musculoskeletal tuberculosis generally affects spine and large joints (hip and knee), hand involvement of the tuberculosis is seen in 10% of the patients with musculoskeletal involvement and also isolated tuberculosis of hand or wrist is much rarer. In the following report, we discuss the case of a 23-year-old male patient who was diagnosed with isolated tuberculosis of the capitate and triquetrum bone. The patient presented with a nonhealing sinus on the left wrist joint. Imaging revealed lytic lesions of the capitate and triquetrum. The diagnosis of tuberculosis was confirmed by histopathological examination on the bone specimen obtained from the debridement and curettage. Antituberculosis therapy was started postoperatively and 1 month later, healing of the sinus was observed. There was no sign of reactivation seen at follow-up 22 months after treatment.

Tuberculous Dactylitis : Case Presentation and Functional outcome

Introduction:

Skeletal tuberculosis involving the small bones is less common than pulmonary tuberculosis. Tuberculous dactylitis involves the short tubular bones of the hands and feet more commonly in children. The bones of the hands are the one’s more frequently affected than bones of the feet, with the proximal phalanx of the index and middle fingers as the commonest sites for infection. Spread to the skeletal system occurs during the initial infection via the lympho-haematogenous route. The radiographic features of cystic expansion have led to the name “Spina Ventosa” for tuberculous dactylitis of the short bones. We report a case of tuberculous dactylitis in the right little finger.

Case Presentation:

We describe a 36-year-old woman, who presented with a 12-month history of painless swelling of her right little finger associated with fever and night sweats. Her history was remarkable for persistent productive cough. On examination, her investigation reports and radiographs correlated with the symptoms of tuberculosis, suggestive of tuberculous arthritis. Magnetic resonance imaging of the hand was suggestive of osteomyelitis. Histopathological examination revealed chronic granulomatous inflammation that was consistent with osteomyelitis of the bone due to tuberculosis. However, acid-fast bacilli were not identified.

Full course of anti-tuberculosis regimen was commenced. Monthly follow-up and radiographic examinations revealed improvement of the patient under this treatment. She also achieved a good functional outcome.

Conclusion:

Tuberculosis should be considered in patients with unusual soft tissue or skeletal lesions in order to make an early diagnosis and to achieve a good functional outcome. Although tuberculosis of the hand has a varied presentation, the majority of lesions respond to conservative treatment, as anti-tuberculosis chemotherapy is the cornerstone in the management of skeletal tuberculosis.

Multifocal Tubercular Dactilytis of Feet with Tubercular Ulcers

Tuberculosis is a common disease in developing countries like India, affecting all age groups. Pulmonary tuberculosis is the most common manifestation of the disease but the disease may affect almost any part of the body. Among cases presenting with skeletal tuberculosis, tuberculosis of the spine, commonly known as Pott's spine, is the most common. Tuberculosis of the short and tubular bones of hands and feet is called tubercular dactilytis. It is a very rare presentation of the disease, usually affecting the small bones of the hand in children younger than 6 years. Tubercular dactilytis, particularly involving the small tubular bones of the foot, is extremely rare.

Excision Arthroplasty for First CMC Joint Tuberculous Osteomyelitis

INTRODUCTION

Tuberculous involvement of metacarpals and phalanges is a rare presentation of extrapulmonary tuberculosis in adult. Tuberculous infection of the metacarpals, metatarsal and phalanges of hands and feet is known as tubercular dactylitis.

CASE REPORT

A 65 years old female with history of pain and swelling at 1st metacarpal of left hand, since 3 months which gradual in onset and progressive in nature associated with multiple cervical swellings. While radiographs showed a pathological fracture of the 1st carpo-metacarpal joint (CMCJ) with soft tissue swelling, MRI revealed a large heterogenous lesion at the carpo-metacarpal joint of the thumb with bony erosions of the trapezium and 1st metacarpal base on T2W-STIR images. The lesion was extending upto the palmar aspect of the hand and displacing flexor pollicis longus tendon medially. During surgery, there was caseous material seen which was debrided and the fractured fragment was excised and sent for biopsy. The CMCJ was found to be unstable and a kirschner wire was used to stabilize the 1st CMCJ and immobilized in a POP splint. The biopsy of the fragment revealed tuberculous osteomyeltis. On follow-up the K-wire had backed out partially at the end of 5 weeks which was then removed and range of motion was started. At end of 1 year follow up the patient had little restriction of movement as compared to the opposite hand with no pain and hindrance in daily activity.

CONCLUSION

The swelling subsided once Anti-Tubercular Treatment was started. The cervical lymphadenopathy also resolved over a period of 1 month.

Long-term follow-up results of foot and ankle tuberculosis in Turkey

The incidence of tuberculosis has been increasing, especially in the past 2 decades. Skeletal tuberculosis is very rare compared with the frequency of the pulmonary form. In the present study, we have shared our long-term experience with foot and ankle tuberculosis, providing information about the different aspects of the disease. A total of 70 patients with foot and ankle tuberculosis, treated from 1983 to 2005, were evaluated. The mean patient age was 34.4 (range 7 to 85) years at the diagnosis. The mean interval between the first symptoms and the diagnosis was 26.4 months (range 1 month to 15 years). The mean follow-up period was 21.7 (range 8 to 30) years. The infection affected both the joint and the bones in 29 patients, only the joints in 13, only the bones in 22, and the soft tissues alone in the remaining 6 patients. The most common joint location was the tibiotalar joint. The talus was the most commonly infiltrated bone. All patients underwent biopsy, and 28 patients underwent additional surgical procedures. In 18 patients (25.7%), 1 to 4 recurrences developed during the follow-up period. In the last follow-up visits, either severe destruction of the bones or end-stage arthrosis was evident in 39 patients (55.7%), especially in those with osseous tuberculosis. Foot and ankle tuberculosis is very rare. The diagnosis of the disease will often be late owing to the lack of pathognomonic findings. A histopathologic evaluation should not be omitted in cases with suspicion. The incidence of residual deformity or end-stage arthrosis has been high in the long term; however, the patients will usually be without any symptoms.

Tuberculous dactylitis (spina ventosa) with concomitant ipsilateral axillary scrofuloderma in an immunocompetent child: A rare presentation of skeletal tuberculosis

Tuberculous dactylitis is a distinctly uncommon, yet well recognized form of tuberculosis involving the small bones of the hand or foot. It occurs in young children in endemic areas under 5 years of age. Tuberculosis of the short tubular bones like phalanges, metacarpals or metatarsals is quite uncommon beyond 6 years of age, once the epiphyseal centers are well established. The radiographic features of cystic expansion have led to the name “Spina Ventosa” for tuberculous dactylitis of the short bones. Scrofuloderma is a mycobacterial infection affecting children and young adults, representing direct extension of tuberculosis into the skin from underlying structures e.g. lymph nodes. An 8-year-old malnourished girl had multiple axillary ulcers with lymphadenopathy. Tuberculous dactylitis with ipsilateral axillary scrofuloderma was suspected on clinical and radiological grounds. The suspicion was confirmed by histology and bacteriology. The patient responded to antitubercular drugs with progressive healing of the lesions without surgery. Concomitant presence of these dual lesions suggesting active disseminated tuberculosis in immune-competent child over 6 years is very rare and hardly reported.

Unusual presentation of isolated metacarpal tuberculosis

Metacarpal tuberculosis is a rare presentation of the disease; it represents only 1% of all bone sites. The following report documents the case of a 28-year-old female who sought a consultation for a painful right hand following an injury. Radiographs showed a fracture of the distal fifth metacarpal through a lytic lesion. Histology of a biopsy specimen revealed granulomas with caseous necrosis, specific to tuberculosis. The patient experienced a complete recovery with anti-tubercular treatment. This case of an unusual presentation of isolated metacarpal tuberculosis was reported with the intention of highlighting the rarity of this location. It is therefore imperative to bear in mind the possibility of such atypical presentations of tuberculosis when making a rapid and correct diagnosis and prescribing adequate treatment.

Tuberculous extensor tenosynovitis of the hand

Tuberculous tenosynovitis is a rare manifestation of extrapulmonary tuberculosis (Tb), especially if solely the dorsal hand compartment is affected. In this report, we present the medical history of an immuno-competent 32-year-old man presented with a painful swelling of the right dorsal wrist. Initial inflammation onset had occurred 6 months before he consulted our service, resulting in consultation of several physicians and extensive diagnostic procedures without gaining a specific diagnosis. Finally, after extensive diagnostic tests, a tenosynovectomy was performed and tuberculosis-induced extensor tenosynovitis was detected. The diagnosis was established by positive histology, repeated specific PCR and T-SPOT.TB. Tuberculous tenosynovitis can easily be overlooked as a cause of chronic tenosynovitis particularly in immunocompetent young people lacking any risk factors.

Tubercular Dactylitis:

Tubercular Dactylitis is a rare extra-pulmonary presentation in adults with more than 85% of cases presenting children below 6 years old.

Tuberculous Tenosynovitis of the Hand: A Case Series

Tuberculous Tenosynovitis of the hand usually presents late because of its non-specific nature that starts insidiously and becomes indolent. Although most of the tuberculous tenosynovitis reported has been the primary focus of the disease, tuberculous tenosynovitis of the hand can be the presenting feature of multiple foci skeletal tuberculosis. In this case series we report three cases of tuberculous tenosynovitis with three different presentations; the definitive diagnosis being made by biopsy and tissue culture. Combined early surgical intervention and chemotherapy was the definitive treatment although the courses of treatment and outcomes differed.

[Pseudo-tumor digital tuberculosis: A case report and review of the literature]

We report a case of a 66-year-old woman, who was treated for a circumferential tumefaction of the middle phalanx of the third finger, evolving for one year. The excision-biopsy of the phalanx led to the diagnosis of an osseous tuberculosis. Through this exceptional case, the authors made a review of the literature on the clinical, radiological and evolutionary aspects of the digital osseous tuberculosis.

Tubercular dactylitis and multifocal osteoarticular tuberculosis--two rare cases of extrapulmonary tuberculosis

Involvement of small bones of hand and feet leading to tuberculous dactylitis involvement is a rare presentation of extrapulmonary tuberculosis. Even rarer is the association of tuberculous dactylitis with multifocal skeletal involvement, even in countries like ours, where tuberculosis is endemic. The authors report two cases, one of tuberculous dactylitis in a 55-year-old male and another of multifocal skeletal tuberculosis in a 4-year-old male. Both the patients were effectively treated with antitubercular drugs.

Tubercular osteomyelitis of the second metatarsal: a case report

A number of studies have described the osteoarticular involvement of tuberculosis, but very few cases of tubercular osteomyelitis of the foot have been reported. We describe a case of spina ventosa affecting the second metatarsal, with a review of the literature and description of the clinical manifestations, diagnostic images, and treatment of skeletal tuberculosis.

Tuberculosis of the hand

There has been recent interest in tuberculosis of the hand because of a rising incidence owing to increasing numbers of immigration, an aging population, and immunosuppressed people including affected patients with human immunodeficiency virus. In this article, we review the epidemiology, bacteriology, pathophysiology, diagnosis, and principles of treatment of tuberculosis of the hand. The second part of the report emphasizes the classification of hand tuberculosis (cutaneous lesions, tenosynovitis, bursitis, osteomyelitis, arthritis, and tuberculous hypersensitivity reactions) along with the classic presentations of each of these hand lesions.

Tubercular osteomyelitis of metacarpals and phalanges in children

The purpose of the series is to describe the management of tubercular osteomyelitis of metacarpals and phalanges in 11 children (range, 3-12 years) and to retrospectively analyse the relationship between radiological staging and clinical outcome following treatment. The available literature on the clinical and radiological manifestations of tubercular osteomyelitis of the hand (excluding wrist) was also reviewed. Follow-up averaged 17.7 months following completion of treatment. The different radiological descriptions of the condition could be grouped into three stages: Stage 1 (stage of soft tissue swelling and no bony changes), Stage 2 (stage of bony expansion) and Stage 3 (stage of destruction). The previously described different radiological entities of tubercular osteomyelitis of metacarpals and phalanges appear to be a sequential manifestation of the disease spectrum. Healing with non-operative treatment is excellent provided the diagnosis is made when tuberculosis presents with soft tissue swelling alone and before bony destruction occurs.

[Tuberculosis of the hand and wrist: different aspects of 30 cases]

Tuberculosis of the hand and wrist is a rare entity. We report 30 cases of tuberculosis of the hand and wrist, including ten cases of wrist osteoarthritis, ten cases of tenosynovitis, four cases of metacarpophalangeal and interphalangeal osteoarthritis and six cases of metacarpal and phalangeal osteitis. The histological study after surgical biopsy revealed caseating giant cell granulomas with epitheloid cells confirming the diagnosis. Antibacillary chemotherapy promoted healing and good outcome in our patients. The aim of our work is to analyze the epidemiological, diagnostic, therapeutic and evolutionary aspects of this disease through a series of 30 cases.

[Pseudotumoral tuberculosis of bone. About a metacarpal case report]

Metacarpal tuberculosis is a very rare form of the disease; it represents 1% of all bone sites. The diagnosis is often difficult because of the non-specific nature of the clinical examination and X-rays. Specialised morphological investigations are a capital contribution, but histology is diagnostic. Specific chemotherapy, combined with a bony debridement, generally allows desiccation of the bacilli in the lesions and the fixation of bone lesions. We report a case with the intention of pointing out the rarity of this location, the difficulty of diagnosis that may be encountered, and to highlight the severity of bone lesions that are mainly due to their late diagnosis.

Tuberculous dactylitis pseudotumor of an adult thumb: a case report

Tuberculous dactylitis is an uncommon condition which is particularly difficult to differentiate from other lesions, particularly tumors. We report the case of a 56-year-old, healthy, left-handed person who consulted for progressive painful swelling of 8-month duration in the right thumb, which had developed after direct trauma. The plain radiograph of the thumb revealed extensive destruction of the proximal phalanx associated with pathological fracture. Magnetic resonance imaging (MRI) showed replacement of the affected phalanx with prominent soft tissue mass with extension outside the bone margins. The diagnosis of tuberculous dactylitis was based on histological characteristics and positive acid fast bacilli using Ziehl-Neelsen stain. Surgical debridement and anti-tuberculous chemotherapy eradicated the infection. Seven years post treatment, the patient had good function of the thumb with no significant disability interfering with his daily activity.

Tuberculosis of the hand: clinical presentation and functional outcome in 32 patients

A prospective series of 32 cases with tuberculosis of the hand and wrist is presented. The mean age of the patients was 23.9 years (3 to 65), 12 had bony disease and 20 primarily soft-tissue involvement. The metacarpal of the little finger was the most commonly involved bone. Pain and swelling were the usual presenting features and discharging sinuses were seen in three cases. All patients were given anti-tubercular chemotherapy with four drugs. Operative treatment in the form of open or arthroscopic debridement, or incision and drainage of abscesses, was performed in those cases where no response was seen after eight weeks of ATT. Hand function was evaluated by the modified score of Green and O'Brien. The mean was 58.3 (25 to 80) before treatment and 90.5 (80 to 95) at the end. The mean follow-up was for 22.4 months (6 to 43). Conservative treatment was successful in 24 patients (75%). Eight who did not respond to chemotherapy within eight weeks required surgery. Although tuberculosis of hand has a varied presentation, the majority of lesions respond to conservative treatment.

[Shoulder pain revealing tuberculosis of the humerus]

Tuberculous spondylitis is the most common form of musculoskeletal tuberculosis. However, extraspinal manifestations have been described with tuberculosis of the wrist, femur, foot or shoulder, as in the patient presented. Because of an often-indolent clinical presentation, the diagnosis is delayed and antituberculous treatment is not able to prevent serious bone destruction.

[Tuberculosis dactylis: a case report]

INTRODUCTION

Tuberculosis dactylis is exceptional. We report one case in an 11 years old girl.

OBSERVATION

N.D., 11 years old, was admitted for a right hand second finger tumour evolving since six months and linked to a trauma. Clinical examination founded a painful fusiform of the right second finger with limited movements of the finger. The hand radiography showed a second phalange osteitis of the finger without periosteitis reaction. The sedimentation rate was accelerated to 130 mm at the first hour. The intracutaneous reaction with tuberculin was positive to 19 mm. In her preceding, her mother would have suffered from pulmonary tuberculosis two years before incompletely treated during eight months. Histological examination showed a caseous necrosis and an epithelial giant cellular follicle. A twelve months antituberculosis polychimiotherapy permitted a healing without sequelae.

DISCUSSION

Tuberculosis dactylis has to be evoked with epidemiological, clinical, radiological and immunological arguments. The antituberculosis treatment permitted to do the retrospective diagnosis and to get a healing.

Isolated metacarpal bone tuberculosis-a case report

SUMMARY

Tuberculous involvement of the metacarpals and phalanges is a rare presentation of extrapulmonary tuberculosis in adult. Here is a case of tubercular dactylitis in a 27 year old female presenting as discharging sinus over proximal part of third metacarpalbone of left hand.

Subphrenic abscess and recurring focal lesions due to tuberculosis in a patient with IgA deficiency

Subdiaphragmatic abscess has not yet been reported as a manifestation of tuberculosis. We report an IgA deficient patient with recurrent episodes of unusual extrapulmonary manifestations of tuberculosis including subdiaphragmatic abscesses and metacarpophalangeal osteomyelitis that was improved each time with antituberculosis drugs. There was not any resistance to the drugs used against mycobacterium despite repeated courses of antituberculosis regimens. In such recurrent cases, one should rule out any immunodeficiency states.

Tuberculosis of the shoulder joint

OBJECTIVES

Skeletal tuberculosis is less common than the pulmonary form. The involvement of the shoulder joint is infrequent. We report our experience treating tuberculosis of the shoulder in 11 patients.

METHODS

There were seven men and four women, ranging in age from 19 to 55 years (average 28.09 years). The duration of their complaints at presentation ranged from 3 to 24 months. The most common presentation was pain, which was seen in 10 joints. All of the patients had mild to moderate restriction of motion of the shoulder. On laboratory examination, the erythrocyte sedimentation rate was increased mildly. No patient had an active tuberculosis lesion or history of pulmonary disease. The diagnosis was based on the clinical picture and radiographic features, and was confirmed by open biopsy. The diagnosis was not confirmed by biopsy in one patient, but the family history and clinical and radiological features were highly suggestive of tuberculosis. Surgical debridement was done in two patients and open biopsy in eight patients in order to obtain samples for pathology. Arthrodesis was done in only one patient. In all patients, treatment began with a four-drug regimen for 2 months, followed by a two-drug regimen for 10 months.

RESULTS

The mean follow-up period after the end of treatment was 28.72 months (range, 22-52 months). At the time of the last visit, all the lesions had healed without recurrence. Five cases had a painless, mobile shoulder, while three had mildly restricted shoulder motion without pain, and three had residual limitation of motion of the affected shoulder.

CONCLUSIONS

Tuberculosis of the shoulder can be difficult to diagnose in the early stages. If not diagnosed early, bony tuberculosis may reduce the quality of life. Therefore, tuberculosis should be suspected in cases of long-standing pain in the shoulder. It is necessary to keep tuberculosis in the differential diagnosis of several osseous pathologies. Arthrodesis should be reserved only for lesions that fail to heal after adequate chemotherapy and rehabilitation.

Disseminated tuberculosis presenting with finger swelling in a patient with tuberculous osteomyelitis: a case report

BACKGROUND

Extrapulmonary manifestations of tuberculosis have become increasingly important in the era of HIV/AIDS.

CASE PRESENTATION

We describe a case of tuberculosis (TB) dactylitis in a patient with AIDS who originated from the Ivory Coast. The diagnosis was established by direct visualization of acid-fast bacilli on joint fluid and bone biopsy of the proximal phalanx. Imaging of the chest revealed multiple bilateral nodules. Confirmation of the diagnosis was made by isolation of Mycobacterium tuberculosis from sputum and bone cultures.

CONCLUSION

Tuberculosis should be considered in patients with unusual soft tissue or skeletal lesions, especially when an immunosuppressive condition is present. Ziehl-Neelsen staining and culture of tissue obtained via surgical biopsy offer the most direct approach to diagnosis.