Multifocal musculoskeletal cystic tuberculosis without systemic manifestations

Multifocal osteoarticular tuberculosis in children

PURPOSE

To review records of 16 children with multifocal osteoarticular tuberculosis.

METHODS

Records of 7 girls and 9 boys aged one to 14 (mean, 6) years with multifocal osteoarticular tuberculosis were reviewed. Haematological tests and radiographs of the chest, whole spine, pelvis, knees, elbows, hands, and feet were taken. The diagnosis was confirmed histologically. Patients were treated with standard 4-drug antitubercular chemotherapy (isoniazid, rifampicin, ethambutol, pyrazinamide) for 2 months, followed by a 2-drug regimen (isoniazid and rifampicin) for 10 months. Supportive treatment (deworming and nutritional advice) was also provided.

RESULTS

All 16 patients were immunocompetent. Pain and swelling around the lesions were the main symptoms; fever was not common (2 cases only). No patient reported weight loss or night sweats. The mean number of bony lesions was 3.4 (range, 2-15) per patient. Appendicular (hands and feet) involvement was more common than axial (spinal) involvement. Radiological appearances of the lesions were cystic, irregular, lytic, and with or without sequestrum/ periosteal reaction. Some lesions were asymptomatic and detected incidentally on radiographs. Only one patient had active chest lesions. Five patients had spinal involvement but no neurological deficit. No patient underwent any surgical intervention, except for diagnostic biopsy. The mean follow-up period was 18 (range, 6-24) months. All patients showed complete healing within one year of chemotherapy. There were residual deformities and restriction of joint movement in patients with advanced articular and axial osteoarticular involvement.

CONCLUSION

Children with multifocal osteoarticular tuberculosis were usually immunocompetent. Appendicular involvement was common, but concomitant chest involvement was uncommon. Standard multidrug antitubercular therapy and nutritional supplementation achieved good outcome.

Tuberculous osteomyelitis of the scapula masquerading as metastasis

Tuberculosis (TB) of the scapula is an unusual presentation of musculoskeletal tuberculosis. In an endemic area, this rare presentation may become more frequent. The indolent nature of tuberculous bone and joint disease often leads to delayed or missed diagnosis. It is not uncommon for this disease to mimic malignancy. Therefore, the prompt recognition of distinguishing features is vital for correct diagnosis. In particular, imaging is a key tool in helping to make the diagnosis, through the recognition of certain key radiological patterns. However, as there are no pathognomonic imaging findings, the diagnosis rests on histopathological and microbiological confirmation. We report a case of tuberculous osteomyelitis of the scapula. This entity has not received much attention in literature. Pure tuberculous osteomyelitis involving flat membranous bone, as depicted in this report, is rare. Our patient also had an ovarian malignancy, which had decreased our index of suspicion. We therefore present this case as tuberculosis masquerading a cystic scapular metastases.

Chest wall tuberculosis: a review of CT appearances

Tuberculous abscesses of the chest wall, though uncommon are not infrequently encountered in countries endemic to the disease. This pictorial review of 14 patients highlights the varied appearance of tuberculosis (TB) of the chest wall on CT. The patients ranged in age from 9 to 55 years (a mean of 25 years) with a preponderance of chest wall lesions in young adults and in females (male to female ratio of 2:5). Cases in which there was no involvement of the chest wall other than of the spine have been excluded. In all cases CT demonstrated peripherally enhancing chest wall collections some of which were accompanied by changes in adjacent bone. Enlargement of intrathoracic lymph nodes with comparatively lesser involvement of lung parenchyma and pleura was also seen.