Tuberculous flexor tenosynovitis of wrist and hand.

A woman in her 40s presented with a swelling over her left distal forearm and hand since 7 months, progressively increasing in size. She had history of difficulty in moving her wrist and fingers with no associated pain. She had no immune or chronic conditions except for hypothyroidism for which she was on regular medication. On examination, there was an 8×7 cm swelling on the radial side of the volar surface of her left distal forearm extending till the thenar eminence. MRI of the left upper limb was suggestive of a soft tissue swelling arising from the flexor tendon.The patient was planned for surgical excision of the swelling. Intraoperatively, there was a mass arising from the flexor tendons of flexor digitorum superficialis, flexor digitorum profundus (FDP) and flexor pollicis longus (FPL), extending distally up to the mid palm region. On incising the flexor tendon sheath, it was observed that multiple yellowish rice like granules extended across the tendons. The lesion was excised completely and sent for histopathology examination. The lax FDP of little and ring fingers were plicated following proper tension adjustment and defect in FPL was primarily repaired. Postoperatively, the patient recovered well with no local wound complications. The biopsy report was suggestive of tuberculosis. The patient completed a course of antituberculosis treatment in 6 months.

An unusual site of articular tuberculosis-A series of three conservatively managed cases.

Tuberculosis (TB) infection of the Sternoclavicular joint (SCJ) is a rare entity, with 1-2% of all osteo-articular cases reported. We report a series of three cases of TB of the SCJ, in the patients presented with swelling of SCJ. Cytology showed chronic granulomatous pathology in all three cases, with one patient having Cartridge base nucleic acid amplification test positive for TB and another one having acid fast bacilli positive on Ziehl Neelsen staining. All three were put on antitubercular treatment (ATT) that resulted in significant improvement. A high index of suspicion of TB to be maintained in cases with swellings at unusual sites especially in high burden countries like India. Similarly, gradually progressive osteoarticular swellings without systemic features should also raise suspicion of tubercular etiology, as diagnosis was delayed for about 4 months in two of our cases and about 1 year in the third case. The application of newer technologies such as CBNAAT can help in early microbiological confirmation of paucibacillary disease leading to early diagnosis and prevention of possible complications.

Tuberculosis ósea en calcáneo. Caso clínico / Bone tuberculosis in calcaneus. Clinical case

La tuberculosis extra pulmonar osteoarticular es una entidad infrecuente (16%), y aquellas de compromiso extravertebral son a su vez muy infrecuentes. Presentamos el caso clínico de un paciente masculino de 68 años de edad, con hipertensión arterial sistémica y enfermedad renal crónica, que presenta aproximadamente 1 año de evolución tórpida con dolor en retropié izquierdo, empeorando luego de infiltración con esteroide, con aumento de volumen, limitación funcional, y lesión ulcerosa con exudado purulento en cara medial. Siendo evaluado de forma clínica y con estudios de imagen por diferentes facultativos, hasta realizar toma de biopsia y cultivo óseo con diagnóstico de Tuberculosis ósea en calcáneo izquierdo. Tratado de manera quirúrgica, y actualmente cumpliendo tratamiento antituberculoso, con evolución satisfactoria recuperando movilidad articular, sin dolor y disminución del volumen de retropié(AU)

Osteoarticular extrapulmonary tuberculosis is a rare entity (16%), and those with extravertebral involvement are in turn very rare. We present the clinical case of a 68-years-old male patient with systemic arterial hypertension and chronic kidney disease, who presents approximately 1 year of torpid evolution with pain in the left hindfoot, worsening after steroid infiltration, with increased volume, limitation functional, and ulcerative lesion with purulent exudate on the medial side. He was being evaluated clinically and with imaging studies by different doctors, until taking a biopsy and bone culture with a diagnosis of Bone Tuberculosis in the left calcaneus. Surgically treated, and currently undergoing antituberculous treatment, with satisfactory evolution recovering joint mobility, without pain and decrease in rearfoot volume(AU)

[Clinical Characteristics of 68 Patients with Osteoarticular Tuberculosis].

Objective To analyze the clinical features of patients with osteoarticular tuberculosis. Method This retrospective study included a cohort of 68 osteoarticular tuberculosis patients hospitalized in Peking Union Medical College Hospital from January 2013 to December 2020.Results The patients included 42(61.8%)males and 26(38.2%)females,with a median age of 56 years.Tuberculosis pathogen was detected in 39(57.4%)patients,and 29(42.6%)patients were diagnosed by clinical manifestations.The median time from onset to diagnosis was 4 months.The most common manifestations were pain and dysfunction(86.8%),followed by fever(47.1%),weight loss(36.8%),and night sweats(13.2%).Concomitant active tuberculosis in other organs was observed in 27(39.7%)patients.Unifocal and multifocal osteoarticular tuberculosis occurred in 51(75.0%)patients and 17(25.0%)patients,respectively,which mainly attacked thoracic and lumbar spines.Tuberculosis T cell test was positive in 92.7% patients.All the bone biopsies revealed epithelioid granuloma with/without necrosis,with 75.0% positive for mycobacterial DNA,55.1% positive for mycobacterial culture,and 20% positive for acid-fast staining.The risk of developing multifocal osteoarticular tuberculosis in the patients with weight loss was 5.333 times(P=0.013)that of the patients with stable weight.Conclusions The diagnosis of osteoarticular tuberculosis is difficult and tuberculosis T cell test is an effective means.Bone biopsy is the key to diagnosis,and the PCR of mycobacterial DNA shows the highest positive derection rate.Multifocal osteoarticular tuberculosis is not rare,especially in the patients with weight loss.Thus,a comprehensive imaging evaluation is recommended to avoid missed diagnosis.

An unusual case of childhood osteoarticular tuberculosis from the Árpádian Age cemetery of Gyorszentiván-Révhegyi tag (Gyor-Moson-Sopron county, Hungary).

Ancient human remains exhibiting bony changes consistent with osteoarticular tuberculosis (OATB) indicate that the disease has afflicted mankind for millennia. Nonetheless, not many pediatric OATB cases have been published in the paleopathological literature-from Hungary, only three cases have been described up to now. In our paper, we demonstrate a child (S0603) from the Árpádian Age cemetery of Gyorszentiván-Révhegyi tag (northwestern Hungary), who represents a unique case of OATB regarding both the pattern and severity of the observed bony changes. During the macromorphological and radiological investigations, the most serious alterations were discovered in the upper thoracic spine-the development of osteolytic lesions led to severe bone loss and consequent collapse and fusion of several adjacent vertebrae. The pathological process terminated in a sharp, rigid angular kyphosis. Disruption of the normal spine curvature resulted in consequent deformation of the whole thoracic wall-it became "rugby-ball-shaped". The overall nature and pattern of the detected alterations, as well as their resemblance to those of described in previously published archaeological and modern cases from the pre-antibiotic era indicate that they are most consistent with OATB. Based on the severity and extent of the lesions, as well as on the evidence of secondary healing, S0603 suffered from TB for a long time prior to death. Besides body deformation, OATB resulted in consequent disability in daily activities, which would have required regular and significant care from others to survive. It implies that in the Árpádian Age community of Gyorszentiván-Révhegyi tag, there was a willingness to care for people in need. Detailed archaeological case studies can give us a unique insight into the natural history and different presentations of OATB. Furthermore, they can provide paleopathologists with a stronger basis for diagnosing TB and consequently, with a more sensitive means of assessing TB frequency in past populations.

Analysis of the early clinical outcomes of arthroscopic debridement in the treatment of shoulder tuberculosis.

BACKGROUND: Due to atypical clinical symptoms, it is difficult to diagnose joint tuberculosis infection, which often results in misdiagnosis and missed diagnosis. It is easy to cause joint disability. And there are few reports of using arthroscopy to diagnose and treat shoulder tuberculosis. This case series aims to introduce the clinical outcomes of arthroscopic treatment of shoulder tuberculosis. METHODS: Twenty-nine patients with shoulder tuberculosis from September 2013 to February 2019 were included (10 males, 19 females; age range from 22 to 69; the average age is 37.6 years). All patients underwent arthroscopic lesion debridement, with preoperative and postoperative regular use of isoniazid, rifampicin, pyrazinamide, and streptomycin quadruple anti-tuberculosis drugs. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded before and at the last follow-up. The shoulder function was evaluated according to the visual analogue scoring method (visual analogue scale, VAS) pain score and Constant score. RESULTS: Twenty-nine patients were followed up from 12 months to 2 years, and the average follow-up time was 15.7 months. The pathological diagnosis of all patients after surgery was shoulder tuberculosis. No serious complications were found at the last follow-up, and the incision healed well. VAS pain score, Constant score, ESR, and CRP at the last follow-up were significantly improved compared with those before treatment (P < 0.05). CONCLUSION: On the basis of the standard use of anti-tuberculosis drugs before and after surgery, shoulder arthroscopy is used to treat early and mid-term shoulder tuberculosis, which can be diagnosed by direct observation under the arthroscope and postoperative pathological examination. It has the advantages of thorough lesion removal, minimal invasiveness, rapid recovery, and reliable clinical effect.

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.

[Sternal tuberculosis: an unusual location of tuberculosis]. / Tuberculose sternale : une localisation inhabituelle de la tuberculose.

INTRODUCTION: Osteo-articular tuberculosis mainly affects the spine. Sternal localization is rare. CASE REPORT: A 43-year-old man, HIV negative and with a history of tuberculous pleurisy, was seen in a pulmonology consultation for abscesses of the chest wall. The thoracic CT scan revealed multiple antesternal and retrosternal abscesses as well as bone lesions in the sternum, ribs and vertebrae. The diagnosis of sternal tuberculosis was made by microscopy and Xpert MTB/RIF test performed on pus from the abscesses. The progress under anti-tuberculous treatment was favourable. CONCLUSION: Sternal involvement with tuberculosis is uncommon and rarely detected. The problem is mainly diagnostic. Its therapy is based on anti-tuberculous treatment.

The potential of bone disease for personal identification: a case of tuberculosis.

In the forensic anthropology practice, bone diseases are rarely considered for personal identification. In this paper, we present a forensic skeletonized case with tuberculous bone lesions, for which bone pathology may provide an indicator for positive personal identification. Antemortem hospital records were available. Postmortem CT scans of the pathologically affected bones were performed, and 3D reconstructions with Global Illumination Reconstruction software (GIR) were realized, in order to confront antemortem and postmortem data. As a result, the juxtaposition and superimposition of antemortem and postmortem images evidenced several points of correspondence in the position, anatomical contour, character, and morphological characteristics of the bone lesions, thus demonstrating through a concrete case study the potential of morphological features of bone lesions for the personal identification of unknown deceased.

Calvarial Tuberculosis Presenting with Skin Defect in an Elderly Patient.

BACKGROUND: Tuberculosis is a common disease; however, the prevalence of calvarial tuberculosis is very rare. Most cases of calvarial tuberculosis occur in young patients. We report a rare case of calvarial tuberculosis in an elderly patient. CASE DESCRIPTION: An 89-year-old woman presented with a forehead skin defect. Radiologic imaging showed bony erosion 20 × 10 mm in size with adjacent dural enhancement in the left frontal bone. The patient underwent surgical treatment. Pathology revealed chronic granulomatous inflammation with caseous necrosis, consistent with tuberculosis. Antituberculous medications were prescribed for 6 months. CONCLUSIONS: A careful assessment should be performed to obtain an appropriate diagnosis in cases of osteolytic lesions of the skull.

Examining variation in skeletal tuberculosis in a late pre-contact population from the eastern mountains of Peru.

OBJECTIVE AND MATERIALS: This research evaluates the presence and chronology of tuberculosis (TB) in the northeastern highlands of Peru (CE 800-1535) through the analysis of osseous lesions from Pre-Contact Kuelap, Chachapoyas. METHODS: We examined macroscopic lesion morphology and distribution from the skeletal series (MNI = 207). RESULTS: We determined that skeletal evidence was highly consistent with advanced multifocal and spinal tuberculosis in 13 individuals. Destructive lesions of the lower thoracic and/or lumbar vertebra bodies and sacroiliac joints are evident in most cases, but we also observed lesions within the manubriosternal, hip, and knee joints. Both adult males (n = 7) and females (n = 6) present skeletal lesions from young adult to older adults, but there is only one late adolescent. Only three individuals demonstrate similar lesion distributions. CONCLUSIONS: Variation in lesion distribution in this population-based study shows the importance of identifying extra-vertebral tuberculosis and suggests that the disease may have manifested differently than at other coastal sites. These cases confirm the presence of tuberculosis both before and after Inca occupation across this central Andean highlands region. SIGNIFICANCE: This evidence for the likely endemic presence of TB in the New World prior to European Contact furthers our understanding of the distribution of this infectious disease across the region as well as elucidating lesion distribution. LIMITATIONS: The diagnosis of tuberculosis is based on skeletal lesions and it should be confirmed by molecular analysis. FUTURE RESEARCH: Additional examination of vertebral bodies (including juvenile remains) for evidence of earlier manifestations of infection.

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.

Rice bodies in the ankle-a case of isolated tubercular tenosynovitis.

Countries with tuberculosis as an endemic disease face many challenges. Isolated tubercular tenosynovitis is a rare presentation of extrapulmonary tuberculosis and involvement of the ankle is even rare. We present a case of isolated tubercular tenosynovitis of the ankle, the diagnosis of which was suggested radiologically and confirmed by histopathology. Clinicians dealing with tuberculosis infected patients need to be aware of such rare presentations for proper diagnosis and management.

Sternoclavicular tuberculosis: an atypical imitator of refractory shoulder pain.

INTRODUCTION: Sternoclavicular joint tuberculosis is rare and has been presented in literature with few sporadic case reports or small case series. Rarity of the condition, nonspecific symptoms, difficulty to visualise the area on X-rays, and minimal clinical signs make diagnosis of sternoclavicular tuberculosis extremely difficult. Delay in diagnosis is therefore the common feature of all presented reports in literature. We here present our experience of treating 19 cases of sternoclavicular tuberculosis at our centre. MATERIALS AND METHOD: This is an observational study from 2010 to 2017 in a tertiary care referral hospital. All patients with clinical tenderness of sternoclavicular joint and shoulder joint pain of over three week duration were subjected to MRI. Patients who showed radiological lesions (radiography/MRI) were subjected to core biopsy under image guidance. A total of 26 patients had biopsy confirmed sternoclavicular tuberculosis (TB) during this period. RESULTS: All patients had improvement in shoulder function after treatment completion. Mean CSS pre-treatment was 29 which improved to mean of 8 after 18 months of ATT. Eight patients had excellent results, seven good, three fair, and one patient poor result. High initial ESR, late commencement of ATT from initial symptoms, and surgery of the involved joint were considered poor prognostic factors. DISCUSSION: Sternoclavicular tuberculosis is a rare disease with controversial etiology. Both haematogenous spread through suprascapular artery and contiguous spread through latent disease in apical lungs has been postulated. Delay in diagnosis is common to most reports in literature. Early MRI is useful in diagnosis of the lesion. The treatment for sternoclavicular joint in literature is controversial with proponents of both surgery and conservative management. CONCLUSION: Primary sternoclavicular tuberculosis is rare condition and requires a high index of suspicion for an early diagnosis. A focused sternoclavicular MRI and early biopsy may help in timely diagnosis. Early commencement of ATT has overall good clinical and functional results.

Case Report: Chest Wall Tuberculosis without Pulmonary Involvement in Three Pediatric Immunocompetent Patients.

Primary rib cage tuberculosis (TB) is an infrequent form of presentation and represents 1% of all cases of osteoarticular TB. We report three cases of children who were previously healthy and who began with swelling of the anterior surface of the rib as initial manifestation of TB. The most important clinical presentations in this series were swelling and pain, with lytic lesions and a soft tissue mass in image studies simulating oncologic pathologies. Because none of the cases had positive epidemiological contact, TB was initially not considered, so the delay in diagnosis from the onset of symptoms was 4, 1, and 2 months, respectively. The diagnosis was made through histomorphological analyses. Treatment was administered during 12, 10, and 9 months. Posttreatment studies did not show any evidence of extrapulmonary TB and until date, the patients remained without relapse or active disease. The findings in our cases illustrate that the diagnosis of chest wall TB should be suspected in all patients from endemic areas who present rib injury.

Calvarial tuberculosis: an unusual presentation of disseminated tuberculosis.

A 30-year-old man, without previous medical record, was admitted to our centre due to persistent hacking cough for the previous 2 months, accompanied by nocturnal sweating, unquantified weight loss and low-grade fever. The patient was finally diagnosed of pulmonary tuberculosis (TB). During admission, a right forehead swelling was detected, painful to palpation, fluctuating and not attached to the skin, without cutaneous alterations or neurological impairment. Surgical debridement was performed and intraoperative cultures were positive for mycobacteria TB. The patient completed 9 months of antituberculous therapy and fully recovered.

Isoniazid-loaded chitosan/carbon nanotubes microspheres promote secondary wound healing of bone tuberculosis.

Poor blood circulation makes it difficult for antitubercular drugs to achieve effective bactericidal concentration at tuberculose focus. The residual Mycobacterium tuberculosis around surgical wound would multiply, resulting in nonunion or sinus formation. Carbon nanotubes have strong tissue penetration and can cross many kinds of physiological barriers. Here, we constructed a chitosan/carbon nanotubes nanoparticles to control slow release of isoniazid. Transmission electron microscopy and nanoparticle tracking and analysis results showed that the diameter of chitosan/carbon nanotubes nanoparticles was between 150 and 250 nm. Chitosan/carbon nanotubes nanoparticles significantly prolonged the release time of isoniazid, and the release rate was more uniform, no sudden release was observed. In vitro experiments showed that chitosan/carbon nanotubes nanoparticles did not destroy biological function of isoniazid, but could reduce its cytotoxicity and inflammation. We further constructed animal model of tuberculous ulcer. The results showed that isoniazid/chitosan/carbon nanotubes nanoparticles promoted the healing of tuberculosis ulcer. Compared with isoniazid group and isoniazid/carbon nanotubes group, the area of wounds decreased by 94.6% and 89.8%, respectively. Immunohistochemistry showed that CD3+ and CD4+ T cell number decreased significantly in isoniazid/chitosan/carbon nanotubes group. In conclusion, we constructed a kind of isoniazid/chitosan/carbon nanotubes nanoparticles, which can significantly promote the healing of tuberculosis ulcer. Our study provided an effective way for the treatment of secondary wound healing of bone tuberculosis.

Performance of the deep convolutional neural network based magnetic resonance image scoring algorithm for differentiating between tuberculous and pyogenic spondylitis.

The purpose of this study was to evaluate the performance of the deep convolutional neural network (DCNN) in differentiating between tuberculous and pyogenic spondylitis on magnetic resonance (MR) imaging, compared to the performance of three skilled radiologists. This clinical retrospective study used spine MR images of 80 patients with tuberculous spondylitis and 81 patients with pyogenic spondylitis that was bacteriologically and/or histologically confirmed from January 2007 to December 2016. Supervised training and validation of the DCNN classifier was performed with four-fold cross validation on a patient-level independent split. The object detection and classification model was implemented as a DCNN and was designed to calculate the deep-learning scores of individual patients to reach a conclusion. Three musculoskeletal radiologists blindly interpreted the images. The diagnostic performances of the DCNN classifier and of the three radiologists were expressed as receiver operating characteristic (ROC) curves, and the areas under the ROC curves (AUCs) were compared using a bootstrap resampling procedure. When comparing the AUC value of the DCNN classifier (0.802) with the pooled AUC value of the three readers (0.729), there was no significant difference (P = 0.079). In differentiating between tuberculous and pyogenic spondylitis using MR images, the performance of the DCNN classifier was comparable to that of three skilled radiologists.

Tuberculous arthritis: negative Xpert MTB/RIF assay does not rule out infection!

We present a case of a 31-year-old man of Indian origin with no previous medical history who presented with an inflamed knee. Treatment for bacterial infection was unsuccessful, and needle aspiration of the left knee effusion/collection was smear and culture positive for tuberculosis (TB), despite Xpert MTB/RIF being falsely negative. The patient was commenced on quadruple therapy for TB and within 2 months had improved significantly with no clinical evidence of ongoing inflammation.