Wrist tuberculosis-experience from eighteen cases: a retrospective study.

BACKGROUND: Wrist tuberculosis is a rare disease, which is easy to be misdiagnosed, leading to delayed treatment and poor prognosis. In this study, the clinical manifestations, diagnosis, treatment, and prognosis of 18 cases of wrist tuberculosis were analyzed retrospectively. METHODS: A retrospective study was conducted, investigating tuberculosis of the wrist, diagnosed in 18 patients from August 2013 to November 2018. Puncture biopsy confirmed the diagnosis. The study includes 11 males and 7 females, and 8 left and 10 right wrists. The average age was 53.5 ± 18.3 years and ranged from 15 to 81 years. The disease course was 1 to 42 months, with an average of 15.1 ± 11.3 months. Eighteen patients were underwent surgery and chemotherapy, 3 patients with severe bone defects were treated with wrist fusion, and 15 patients were underwent focus removal. The Gartland and Werley score, DASH score, the range of motion (ROM), grip strength, and imaging examinations were used to evaluate the postoperative recovery of the patients. RESULTS: Eighteen patients were followed up for 15 to 77 months, with an average follow up of 39.7 ± 15.3 months. The ESR and CRP levels were normal for all patients after chemotherapy. No recurrence of tuberculosis was observed in any of the patients. Among the 15 focus removals, the Gartland and Werley scores at admission, two weeks of chemotherapy, 1 month after surgery, and the last follow-up were 21.73 ± 4.33, 18.60 ± 3.16,11.27 ± 2.79, and 5.07 ± 2.28, respectively; and the DASH scores were 45.87 ± 5.58, 39.47 ± 4.72, 22.67 ± 6.54, and 6.73 ± 2.94, respectively. The range of motion (ROM) of the wrist and grip strength improved significantly when compared to those at admission. Among the three cases of wrist fusion, 2 were fixed with a steel plate and the fixation position of wrist joint was good. One case was fixed with Kirschner wire and resulted in a slightly deformed wrist joint. CONCLUSION: For patients with wrist tuberculosis, early diagnosis, preoperative and postoperative chemotherapy, thorough focus removal, and appropriate fixation of the affected limb can help restore the function of the affected wrist, reduce the recurrence rate, and improve the quality of life.

Skull base and calvarial tuberculosis presenting as chronic meningitis.

Calvarial tuberculosis is very rare accounting for 0.2-1.3% of skeletal tuberculosis. Diagnosis is also challenging in these areas due to insidious onset of presentation, low bacterial loads in these sites and unapproachable locations for sample collection. Rarely these patients may presents with features of meningitis when the adjacent meninges are involved. Here we describe a case where tubercular involvement of sphenoid, clivus, and frontal bone, who presented as chronic meningitis and diagnosis was made on the basis of radiological and histopathological findings. All the lesions almost resolved following antitubercular treatment at 5 months follow up. A high index of suspicion is needed for early diagnosis and management of this condition.

Profile of osteoarticular tuberculosis in children.

OBJECTIVE: To determine clinical profile of osteoarticular tuberculosis (TB) in children. METHODS: Cross-sectional analysis from 2007 to 2013. All patients diagnosed with bone TB, spinal TB or TB abscesses were included. RESULTS: Out of 1318 children with TB, 39 (2.96%) had osteoarticular TB, of which 16 (42%) had osteomyelitis, 8 (20.5%) had spinal involvement, 7 (17.9%) had TB synovitis, 2 (5.1%) had psoas abscess and 6 (15.4%) had abscesses. The mean age of presentation was 7.1 ± 3.5 years (range 2-14 years). Of the 33 cases in which a culture was done, 25 (64%) showed a positive culture. Drug sensitivity tests were done in 21 patients of which 10 (47.6%) tested were drug resistant, of which 4 (36.4%) were multidrug resistant (MDR), 2 (18.2%) were extensively drug resistant (XDR), 3 were pre-XDR (27.3%) and 1 was polyresistant (9.1%). Nine (23.1%) patients had TB in the past with a treatment duration of 8.3 ± 5.3 months. Contact with a TB patient had occurred in 10 (25.6%) cases. Associated pulmonary TB were seen in 6 (15.39%) and TB meningitis were seen in 1 (2.6%) patients. Surgical intervention was needed in 11 (28.2%) patients of which 5 (45.5%) underwent curettage, drainage was done in 1 (9.1%), arthrotomy in 4 (36.4%) and spinal surgery in 1 (9.1%) patient. CONCLUSION: Drug resistant osteoarticular TB is an emerging problem in children.

Tubercular involvement of the lateral malleolus and adjacent calcaneus: presentation of a rare case and review of the literature.

Osteoarticular tuberculosis (TB), despite being on the wane in the developed world, stays a problem of significance in the developing world. The issue is compounded by unusual presentations, inadequate diagnostic skills and limited understanding of its management. For foot infections, despite an increased awareness, many patients may be misdiagnosed, with associated treatment delays. A 19-year-old man presented with pain and swelling on lateral aspect of right ankle for 2 months. The patient had an undermined discharging sinus with surrounding induration and the skin adherent to the underlying bone. Patient was diagnosed as a case of ipsilateral TB lateral malleolus and calcaneus, managed with antitubercular drugs with complete resolution at 3 years of follow up. Foot and ankle TB can have atypical presentations causing delay in diagnosis. Contiguous spread of infection occurs through the synovium or the joint; however, extra-articular spread along the tendon sheaths or other soft tissues is possible, which is highlighted by the present case.

Extrapulmonary Tuberculosis: Pathophysiology and Imaging Findings.

Extrapulmonary tuberculosis (TB) represents approximately 15% of all TB infections. It is difficult to diagnose on the basis of imaging characteristics and clinical symptoms, and biopsy is required in many cases. Radiologists must be aware of the imaging findings of extrapulmonary TB to identify the condition in high-risk patients, even in the absence of active pulmonary infection. In extrapulmonary TB, the lymphatic system is most frequently affected. The presence of necrotic lymph nodes and other organ-specific imaging features increases the diagnostic probability of extrapulmonary TB. Disseminated infection and central nervous system involvement are the most frequent manifestations in immunosuppressed patients. Renal disease can occur in immunocompetent patients with very long latency periods between the primary pulmonary infection and genitourinary involvement. In several cases, gastrointestinal, solid-organ, and peritoneal TB show nonspecific imaging findings. Tuberculous spondylitis is the most frequent musculoskeletal manifestation. It is usually diagnosed late and affects multiple vertebral segments with extensive paraspinal abscess. Articular disease is the second most frequent musculoskeletal manifestation, and synovitis is its predominant imaging finding.©RSNA, 2019.

Antibiotic-impregnated articulating cement spacer maintained for 7 years in situ for two-stage primary total knee arthroplasty: a case report.

BACKGROUND: Antibiotic-impregnated articulating cement spacers can maintain interim joint motion with the potential to enhance functional status and improve patient satisfaction. Articular surfaces with cement against cement have raised concerns regarding mechanical complications and cement debris during knee motion. However, long-term clinical conditions regarding these concerns are not well addressed. CASE PRESENTATION: We report a case in which articulating cement spacers were maintained in situ for 7 years. The patient had severe left knee pain with an ankylosing knee and severe tricompartmental arthritis due to tuberculous infection. We planned to perform one- or two-stage primary total knee arthroplasty (TKA), depending on the presence of infection. Persistent osteomyelitis was found intraoperatively. The second-stage TKA was delayed on the patient's request. As the patient was satisfied with the improved knee function and pain relief after using articulating cement spacers. No symptom or sign that suggested recurrent infection or systemic toxicity was found during the 7-year follow-up. However, it seemed that the bone loss progressed insidiously. At the 7-year follow-up, a broken articulating cement spacer and medial femoral condylar fracture were found. The second-stage TKA was performed, and a considerable amount of bone loss surrounded by dense granulation tissue was observed intraoperatively. Excisional biopsy of the tissue revealed chronic foreign body reaction with infiltration of giant cells and macrophages. CONCLUSION: Although the articular spacers were maintained for 7 years without major complications, regular observation of the development and progress of bone loss was required. Surgeons should take considerable bone loss into account during conversion TKA in patients with a prolonged retention of articulating cement spacers.

Does Preserving or Restoring Lumbar Lordosis Have an Impact on Functional Outcomes in Tuberculosis of the Lumbosacral Region?

STUDY DESIGN: Single-center retrospective cohort analysis. OBJECTIVES: To analyze the impact of loss of global lumbar lordosis (GLL) on functional outcomes in tuberculosis of the lumbar and lumbosacral spine and to define strategies to restore or preserve the physiological lumbar lordosis. SUMMARY OF BACKGROUND DATA: In tuberculosis of lumbosacral spine, loss of lumbar lordosis (LL) leads to altered lumbosacral biomechanics. All available studies have assessed treatment outcomes with respect to physical well-being, neurologic improvement, bone healing, and changes in radiologic parameters. None have studied the correlation between functional outcomes and LL following treatment. We reviewed 63 patients with tuberculosis of lumbar and lumbosacral spine, with an attempt to analyze the impact of loss of GLL on functional outcomes and have defined strategies to restore the same. METHODS: We retrospectively reviewed 63 patients with lumbar and lumbosacral tuberculosis, treated conservatively (n = 33) or surgically (n = 30) from March 2007 to July 2013. Average follow-up was 43.1±7.2 months. The correlation between posttreatment GLL and the functional outcome (Oswestry Disability Index), measured at 36 months' follow-up, was analyzed. RESULTS: All patients showed good bone healing (at 8.4±1.5 months), significant improvement in neurology, VAS scores, ESR and CRP, p<0.001. Mean loss of GLL in the conservatively treated group was 6.4°±5.7°, whereas there was an average gain of 10.9°±9.9° of GLL with surgery. In all patients with minimal disability at the end of treatment, the final GLL was above 40°. In patients with severe disability and in a few with moderate disability, the posttreatment GLL was below 40°. Pearson's test showed a strong negative correlation between final posttreatment GLL and the degree of disability (r = -0.867, p<0.001). CONCLUSIONS: Early disease with minimal loss of lordosis can be managed conservatively, whereas in advanced disease with gross hypolordosis/kyphosis, posterior stabilization with or without global spinal reconstruction is essential to regain LL. The management of lumbosacral tuberculosis should aim at preserving or restoring the normal LL to achieve good functional outcomes. LEVEL OF EVIDENCE: Level III.

Tuberculosis of the Elbow Region in Pediatric Age Group - Experiences from a Single Centre.

BACKGROUND: Clinical series of tuberculosis of elbow region in children are few. The purpose of our study was to retrospectively review the presentation, healing response and functional results of 30 children. METHODS: The pretreatment disease presentation was studied from patient's case records. Serial radiographs of the patients were studied to see remineralization and healing of radiological lesions. For elbow's functional evaluation, pain, range of motion and recurrence were observed at final follow up. RESULTS: The mean patient age was 8.2 years. The mean duration of symptoms before presentation was 47 days. A discharging sinus was present in 6 patients. Multifocal presentation was found in 7 patients. The lesion was most commonly localized in proximal ulna or lower humerus. The classical 'ice cream scoop' appearance of proximal ulnar metaphysis was noted in 5 elbows. Most elbows were in Martini stage 2 (70%) at the time of presentation. All patients were treated non-operatively. Average follow up after completion of antitubercular therapy was 18.97 months. The resolution of regional osteopenia, sclerosis of lytic lesions, reappearance of bony trabeculae and decrease in size of cavities was the usual sequence of radiological healing. End average elbow flexion arc deteriorated with increasing Martini stage. 'Ice cream scoop lesions' resulted in a worse functional outcome with formation of an irregular proximal ulnar articular surface. CONCLUSIONS: Restriction of elbow range of motion, early discharging sinus formation and radiological 'ice cream scoop' appearance indicated a tubercular pathology. Late presentation with advanced disease, total joint involvement, and 'ice cream scoop appearance' resulted in decreased elbow flexion arc.

Tubercular spondylodiscitis in elderly is a more severe disease: a report of 66 consecutive patients.

PURPOSE: (1) To analyze peculiarities of presentation and prognosis of tubercular spondylodiscitis (TBS) in elderly. (2) To assess if associated co-morbidities and risks lead to poorer outcome (3) To observe if different management strategy needs to be implemented in them. METHODS: Retrospective analysis of 66 consecutive elderly TBS patients (>60 years) treated conservatively or surgically between January 2010 and July 2013 was performed. Details regarding clinical presentation (general health, ambulatory status, co-morbidities), neurological status, medical or surgical complications and outcome measurements [visual analog score, clinico-radiological evidence of healing and lumbar lordosis in lumbar (L) or lumbo-sacral (LS) or focal kyphosis in thoracic (T) or thoraco-lumbar (TL) disease] were analysed. RESULTS: Of 66 patients (mean age 67.9 years), 85% had at least one medical co-morbidity and only 45% were community ambulators. Mean delay in presentation was 132 days and lumbar disease was commonest. 35% had neuro-deficit. Most patients had stage 2 (38%) or 3 (42.4%) disease. 19 patients were conservatively managed, while others underwent surgery. Significant complications occurred in 23 patients, most common being liver dysfunction (9 patients). Five patients (8%) expired during treatment: three succumbed to multi-focal tubercular disease, while two expired secondary to medical illnesses. Mean loss of lordosis in conservatively treated (CG) L/LS disease was 8°, while lordosis was restored by 11.6° in operative group (OG). In T/TL disease, sagittal alignment correction by 12.6° was observed in OG as against 5.7° kyphotic collapse in CG patients. 92% patients were cured with no recurrences. The final VAS scores in operative and conservative groups were not significantly different (OG 1.4 ± 0.6, CG 1.9 ± 0.7). CONCLUSION: TBS in elderly differed from that in younger by having a higher co-morbidities, later presentation, higher neuro-deficit, greater mortality and increased complications. Nevertheless, in those who survived, clinico-radiological outcomes of both conservative and surgical treatments were good.

Shoulder tuberculosis in children: a report of two cases.

We report 2 children who underwent multidrug antituberculous therapy with rifampicin, isoniazid, ethambutol, and pyrazinamide followed by dedicated physiotherapy for tuberculosis of the shoulder. Both patients regained a range of motion comparable with the contralateral side after 9 to 10 months.

Multifocal tuberculous osteomyelitis: A rare presentation.

A 29 year old lady presented with vague right lower quadrant abdomen and thigh pain for the past 4 years. X-ray pelvis with both hips was remarkably normal, and MRI was suggestive of osteomyelitis in right ilium and proximal femur. Biopsy confirmed the lesion as tubercular. Isolated bone involvement by tuberculosis without a joint or pulmonary involvement is extremely rare in immunocompetent patients and has not been reported in literature so for. Tuberculosis should be suspected in patients presenting with multiple bone lesions, especially in endemic areas. Prompt surgical drainage and ATT forms the mainstay of treatment.

A rare localization of tuberculosis of the wrist: The scapholunate joint.

The tuberculosis of the hand and the wrist is a rare entity. Affecting the scapholunate joint is exceptional. It is usually diagnosed at an advanced stage of carpal destruction, due to slowly development of the symptoms. We report the case of a 58-year-old female, presenting as wrist pain for 3 months. Clinical study showed a local swelling in the left wrist, the mobility of the wrist was normal but painful at the end of motion. The diagnosis of osteoarticular tuberculosis was suspected after radiological and biological study then confirmed after histological study. Antibacillary chemotherapy during 12 months promoted healing and good outcome.

Isolated tuberculosis of the patella - report of two cases and review of the literature.

Two cases of tuberculosis of the patella presenting as an osteolytic lesion with sequestrum are described. Timely diagnosis helped in successful management of both these cases, resulting in complete resolution of symptoms with a functional knee without need for patellectomy. Clinicians must consider the possibility of diagnosis of isolated patellar tuberculosis in patients presenting with an osteolytic lesion in patella especially in areas where tuberculosis is endemic and in immunocompromised patients.

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.

[Functional outcome of tuberculous arthiritis of the knee in a male Moroccan patient]. / Regard fonctionnel sur l'arthrite tuberculeuse de genou, chez un homme d'origine marocaine.

PURPOSE: The purpose of this article is to present a case of tuberculous arthritis of the knee and discuss the importance of early diagnosis and rehabilitatin in management outcome. CASE REPORT: A 57-year-old Moroccan man with no medical history presented with a mass in the left knee associated with pain and fever. Analysis of aspirated fluid demonstrated sterile inflammatory liquid. Presumptive antibiotic therapy was ineffective. Diagnosis of tuberculous arthritis was made based on positive tuberculin skin test and interferon-release assays. Diagnosis was confirmed by arthroscopic biopsy. Physiotherapy allowed improvement in both function and analytical test findings. DISCUSSION: Tuberculous arthritis is rare occurring in only 2 to 5% of people with tuberculosis. It can be very destructive. Diagnosis is often delayed leading to joint pain, tissue damage, and functional disability (e.g. inability to walk). Since prompt treatment (antibiotics then physiotherapy) can limit complications, early diagnosis is necessary and often requires deep biopsy, except endemic zones. In the acute phase, immobilization of the extremity in a functional position is necessary. When inflammatory signs subside, physiotherapy can be undertaken in short but frequent sessions without excessive weight or resistance. CONCLUSION: The functional outcome of tuberculous arthritis depends on early multidisciplinary care involving the rheumatologist, infectious disease specialist, orthopedic surgeon and attending physician.

Comparative study on the efficacy of two-staged (posterior followed by anterior) surgical treatment using spinal instrumentation on pyogenic and tuberculotic spondylitis.

INTRODUCTION: Between 1997 and 2006, we treated 11 patients with tuberculotic spondylitis and 19 with pyogenic spondylitis using a two-staged operation (posterior spinal instrumentation, followed by anterior debridement and fusion). METHOD: We compared changes in inflammatory reactions, postoperative complications, organisms obtained during anterior debridement, neurological status, bone union, and suppression of the infection between the patients with tuberculotic and pyogenic spondylitis. PATIENTS: All patients in both groups achieved bone union and suppression of the infected sites. Decreases in C-reactive protein and erythrocyte sedimentation rate were significantly slower in the patients with tuberculotic spondylitis. Positive bacterial cultures at the second anterior debridement were obtained from 26% of patients with pyogenic spondylitis and 55% of patients with tuberculotic spondylitis. Frankel types improved in 57% of patients, but there were no differences in neurological improvement. The efficacy of the two-staged operation did not differ between the patients with pyogenic and tuberculotic spondylitis. RESULTS: Although the baselines were different, there were no significant differences in relative operating parameters, neurological improvement, or postoperative complications between the two groups. At the final follow-up, all patients finally achieved suppression of spinal infection and solid bone fusion in both groups, although the decline in inflammatory parameters was slower in the T group than in the P group.

Clinical features of tuberculous septic arthritis in Khon Kaen, Thailand: a 10-year retrospective study.

Tuberculous septic arthritis is difficult to diagnose. A retrospective analysis was done on patients over 15 years of age who attended Srinagarind Hospital, Khon Kaen, Thailand, between January 1, 1997 and December 31, 2006, whose synovial fluid culture was positive for Mycobacterium tuberculosis. The medical records of 77 patients were reviewed; one-third were in their sixth decade. Comorbid disease was found in 33 cases (42.9%), with systemic sclerosis being the most common (9 cases) followed by diabetes mellitus (5 cases) and chronic kidney disease (5 cases). Chronic monoarthritis was the most common presentation (34 cases) followed by acute monoarthritis (20 cases). More than half of the polyarticular involvements were disseminated tuberculosis. The knee was the most commonly affected joint (36.4%). Sixty percent had delayed diagnosis due to an incorrect diagnosis. Abnormal chest radiography and blood eosinophilia were found in 40 and 57.3% of cases, respectively. Synovial fluid and synovial tissue staining for acid-fast bacteria were positive in 30 and 40% of cases, respectively. A caseous granuloma was present in 57.5% of cases and non-specific synovitis in 12%. Sixty-three percent had bone erosions. Tuberculous septic arthritis should be considered in patients who present with acute or chronic monoarthritis, and who have an abnormal chest radiograph or eosinophilia. Polyarticular involvement was commonly related to having disseminated tuberculosis and may indicate systemic involvement of tuberculous infection.