Tuberculous synovitis of the knee in a 65-year-old man

Delayed Diagnosis: Tuberculous Arthritis of Right Knee Joint in a Patient with Rheumatoid Arthritis

Background

Though skeletal tuberculosis (TB) accounts about 3% of all TB cases, it occupies 10–35% of extrapulmonary TB cases. Common osteoarticular sites involved include the spine (40%), hip (25%), and knee (8%). Co-occurrence of rheumatoid arthritis (RA) and tuberculous arthritis involving peripheral joint is rarely reported in the literature. Case Presentation. We present a case of 42-year-old Sri Lankan-Sinhalese male with right knee joint pain and swelling for one-year duration. This patient had a history of long-standing RA with interstitial lung disease for which he was on multiple immunosuppressive medications including methotrexate, sulfasalazine, leflunomide, mycophenolate mofetil, and prednisolone. His knee joint aspiration fluid was positive for both acid fast bacilli (AFB) and polymerase chain reaction for TB (TB-PCR). He was started on anti-tuberculous chemotherapy.

Conclusion

TB should be considered as an important differential diagnosis for chronic mono-arthritis of knee joint with a high degree of suspicion, particularly where TB is endemic.

Primary patella tuberculosis mimicking pre-patellar bursitis: A case report and review of the literature

Introduction and importance

The Patella is very rare site for tuberculosis (TB). The knee is the third most common site for skeletal TB. The incidence of patella TB being 0.09 to 0.15%.

Case presentation

We report a case of primary tuberculous osteitis isolated from the patella. The complaint was a mixed knee pain without notion of trauma. The CT showed a large osteolysis of the upper half of the patella. The diagnosis was established on the histological study after biopsy. The patient was operated by a medial approach without arthrotomy and the pathological tissue was resected and curetted. Complementary anti-bacillary antibiotic treatment was administered for 12 months. At the last clinical control, the knee was free and painless, and we had no recurrence.

Clinical discussion

Aitken reported the first case in literature in 1933. The initial signs and symptoms are non-specific and sometimes confounded by a coincidental history of trauma. It is difficult to diagnose TB of patella in early stages because there are no constitutional symptoms. Sometimes serological parameters are inconclusive. CT scan can help if the osteolysis contained a central bone sequestration, bordered by peripheral sclerosis. Confirmation of patellar tuberculosis is made on biopsy.

Conclusion

The tuberculous localization in the patella is rare and it can pose a problem of differential diagnosis with other affections, in particular infectious and tumors. It should always be kept in mind, especially in the face of a picture of pre-patellar bursitis which progresses slowly and whose biological inflammatory syndrome is not straightforward.

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The tuberculous localization in the patella is exceptional.

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The initial signs and symptoms are non-specific and sometimes confounded by a coincidental history of trauma.

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This serological parameters are inconclusive.

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CT scan can help if the osteolysis contained a central bone sequestration, bordered by peripheral sclerosis.

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Confirmation of patellar tuberculosis is made on biopsy.

A Case of Knee Monoarthritis Caused by Mycobacterium Tuberculosis

Patient: Male, 35

Final Diagnosis: Mycobacterium tuberculosis

Symptoms: Pain • swelling

Medication: —

Clinical Procedure: —

Specialty: Rheumatology

Delay in diagnosis of generalized miliary tuberculosis with osseo-articular involvement: a case report

Introduction

Diagnosis of atypical tuberculosis is difficult. Therefore, it is important that physicians are aware of rare presentations of tuberculosis to avoid diagnostic delays.

Case presentation

We present the case of a 17-year-old Sri Lankan man who presented to our facility with an ill-defined large induration over the skin of his left buttock and thigh. A cause could not be found despite extensive investigations. He also complained of chronic knee pain, but this was not investigated further at the time due to spontaneous resolution. Three years later his knee disease flared up again, with pain, swelling and restriction of movement. A synovial biopsy was suggestive of tuberculosis. He was started on antituberculosis therapy, to which he responded well. Our patient was asymptomatic two months after completion of therapy without any subsequent flare-ups. A chest roentgenogram taken on his second presentation showed evidence of tuberculosis sequelae in his lungs. The most likely diagnosis for the buttock and thigh swelling, when considering the entire clinical picture, is a tuberculous abscess. The constellation of skin and skeletal symptoms and pulmonary tuberculosis is a rare occurrence in an immunocompetent individual, but cases have been reported.

Conclusions

This case demonstrates the different presentations and the diagnostic difficulties posed by atypical manifestations of tuberculosis. It also demonstrates the value of maintaining a high degree of suspicion in endemic areas, even in the absence of microbiological evidence.