Epidemiology of skeletal tuberculosis in Beijing, China: a 10-year retrospective analysis of data.

Skeletal tuberculosis (STB) is one of the most common forms of extrapulmonary tuberculosis; however, limited epidemiological data are available on this public health concern worldwide, especially in developing countries. The aims of this study were to analyze the epidemiological characteristics of STB cases and to identify risk factors associated with drug resistance among STB cases in China. We included STB inpatients at Beijing Chest Hospital from January 2009 through December 2018. The multiple demographic and clinical variables of patients were collected from the hospital's electronic patient record. In total, 3086 STB patients were hospitalized in Beijing Chest Hospital. Of these cases, 1988 (64.4%) were spinal TB cases, 991 (32.1%) were joint TB cases, and 107 (3.5%) were concurrent spinal-joint TB cases. The most frequent localization of the infections in joints included the knee (21.5%), hip (17.9%), and elbow (10.3%). For spinal TB, lumbar, thoracic, and cervical spinal TB were present in 51.7%, 40.6%, and 4.4% of cases, respectively. Positive cultures were reported in only 16.0% of STB cases. When patients aged ≥ 60 years old were used as the control group, youths (< 18 years old) were less likely to have spinal TB (aOR, 0.29; 95% CI, 0.21-0.41). The prevalence of MDR-TB was 12.5% among the STB cases, and more female cases were afflicted with drug-resistant STB than with drug-susceptible STB (aOR, 0.50; 95% CI, 0.27-0.94). In addition, patients aged < 18 years had significantly higher odds of having drug-resistant STB compared with those aged ≥ 60 years (aOR, 20.778; 95% CI, 4.49-96.149). In conclusion, our data demonstrate that spinal TB is the most frequent form of STB in China. The youths are less likely to have spinal TB compared with elderly patients, while the patients aged < 18 years have significantly higher odds of having drug-resistant STB than elderly patients.

A Unique Spectrum of Tuberculosis Flare Up Related to Cardiothoracic Surgery.

Three cases of tuberculosis (TB) related to or complicating cardiothoracic surgery are presented in this paper. The aim of this article is to alert cardiothoracic surgeons about the presence or rebound of TB, which can complicate cardiothoracic surgeries even in the immediate postoperative course.

Posttraumatic tuberculous osteomyelitis of the foot--A rare case report.

Skeletal tuberculosis developing after trauma is a rare occurrence.We report a rare case of posttraumatic tubercular osteomyelitis of mid-tarsal bone of the right foot. Patient was treated with regular dressing and anti-tubercular drugs. Posttraumatic skeletal tuberculosis should be considered in patient with non-healing ulcer.

Late onset Mycobacterium tuberculosis infection after total knee arthroplasty: a systematic review and pooled analysis.

BACKGROUND: Mycobacterium tuberculosis (TB) is a rare cause of prosthetic joint infection. The purpose of this study was to provide an evidence-based summarization of the outcomes of TB infection after total knee arthroplasty (TKA) with a pooled analysis of the reported cases. METHODS: We conducted a systematic review of published studies that have evaluated the outcomes of prosthetic knee joint infections due to TB. A structured literature review of multiple databases referenced articles from January 1950 to July 2012. RESULTS: A total of 15 patients were identified from 13 published studies. Tuberculosis was confirmed in all cases by histological examination and positive culture or histochemical stain/polymerase chain reaction (PCR). Treatment consisted of anti-tuberculosis medication therapy (AMT) only in 2 patients, AMT plus debridement and retention of the arthroplasty in 5 patients, and AMT plus removal/exchange of the arthroplasty in 8 patients. The average follow-up after TB infection was 29 months (range 1-96 months) and there were 3 deaths, giving a crude death rate of 0.7 per 100 person-months. At the final follow-up, the outcomes of TB infection after TKA were good except in the 3 patients who died. CONCLUSIONS: TB infection after TKA is a rare disease, however good clinical outcomes can be achieved with proper management including AMT and surgical intervention.

Tubercular arthritis of the elbow joint following olecranon fracture fixation and the role of TGF-beta in its pathogenesis.

Tuberculosis (TB) occurring after a closed bone fracture in the patient with no history of TB and no evidence of TB infection at the time of initial fracture is a rare entity. We report one such case of a 48-year-old female, who presented in the emergency department with an olecranon fracture which was open reduced and internally fixed with tension band wiring. Patient presented in the outpatient department with serosanguineous discharge at 3 weeks after surgery. The discharge was sent for culture and sensitivity tests, and the patient was managed by antibiotics and daily dressings. There was wound dehiscence and the underlying implant was exposed, which was removed at 12 weeks after surgery. Repeat debridements and dressings continued for 6 months, but the discharge from the wound site continued. X-rays of the elbow performed at 6 months raised the suspicion of TB, which was confirmed by Ziel-Neelsen staining and histopathological examination of the debrided tissue. Following the confirmation, patient was put on antitubercular drugs. The patient responded to antitubercular drug therapy (ATT), the purulent discharge from the wound ceased, and eventually the wound healed after 2 months of starting ATT.

Bacille Calmette-Guérin Vaccine-Induced Tuberculous Elbow Osteomyelitis in an Infant: A Case Report.

CASE: We report a case of Bacillus Calmette-Guérin (BCG) vaccine-induced osteomyelitis of the distal end of the right humerus in a 1-year and 8-month-old girl. The patient was treated with debridement and a 12-month antituberculosis drug. After 3 years of follow-up, no growth disturbances or sequelae were observed. CONCLUSION: BCG osteomyelitis is difficult to diagnose because of its rarity. It is important to suspect BCG osteomyelitis based on symptoms and blood tests and to perform PCR testing. Long-term follow-up after treatment is necessary to monitor for recurrence and avoid growth disturbances until epiphyseal line closure occurs.

Pulmonary tuberculosis and tuberculous arthritis of knee joint associated with rheumatoid arthritis treated with anti-tumor necrosis factor (TNF)-alpha medication: a case report.

Tuberculosis infection (TB) is one of the most important problems for the rheumatoid arthritis (RA) patients treated with anti-TNF agents. Pulmonary tuberculosis is the most common clinic form of the TB in these patients. However, tuberculosis arthritis is very rare. We present here a 72-year-old Caucasian woman with seropositive RA, treated with etanercept/adalimumab for the last 2 years, who presented with resistant knee pain and joint effusion. We believe that this treatment caused the tuberculosis in this patient, which is the most worried complication. Interestingly, tuberculosis was in the knee joint at this time.

[A rare case of tubercular tenosynovitis in hospital surgeon as a result of an occupational accident caused by puncture with an infected needle. Prevention aspects and legal-medical evaluation]. / Un raro caso di tenosinovite tubercolare in operatore sanitario a seguito di incidente occupazionale per puntura da ago cavo infetto. Aspetti di prevenzione e valutazione medico legale.

BACKGROUND: The subject was a hospital surgeon who, in the course of routine outpatient surgery with aspiration to collect right lumbar material in a patient with suspected TB infection, accidentally punctured the fifth finger of the left hand with the needle used for this procedure. This led to involvement of the fifth finger of the left hand restricted to the soft tissue with preservation of joint and bone and tenosynovial involvement of the entire extremity. OBJECTIVES: To draw attention to the repercussions for insurance with resulting absence from work for 126 days and an assessment of biological impairment of 2% by the Insurance Institute (INAIL). METHODS: A case report is described of rare occupational tubercular synovitis. CONCLUSIONS: A rare event is reported that occurred in a senior staff member with particular insurance repercussions.

Multifocal osteoarticular tuberculosis in a systemic lupus erythematosus (SLE) patient: a rarity or an underdiagnosed condition?

Tuberculosis (TB) and its association with rheumatic diseases have been widely recognised. Occurrence of multifocal skeletal involvement constitutes <5% of all skeletal TB cases. We present a Malay patient with multifocal osteoarticular TB (OATB). A 35 year-old SLE woman with background usage of corticosteroid therapy and Azathioprine presented with lupus nephritis flare. Renal biopsy revealed diffuse proliferative lupus nephritis and intravenous (IV) Cyclophosphamide 0.5 g/m2 (850 mg) was initiated. One week later, patient complained dorsum of left hand and right knee swelling. On physical examination, patient was afebrile and the left hand swelling was cystic in consistency while right knee was warm and tender. Erythrocyte Sedimentation Rate (ESR) was 50 mm/hr and C-Reactive Protein (CRP) was 9.4 mg/L. Her Mantoux test was positive with 20 mm induration. Wrist radiograph and chest radiograph was normal. Musculoskeletal ultrasound showed 4th extensor compartment tenosynovitis with Doppler signal and right knee effusion with synovial proliferation. Extensor tenosynovectomy and right knee aspiration was performed. Left hand excised tissue and right knee synovial fluid for acid-fast bacilli (AFB) stain, TB PCR, bacterial and fungal cultures were negative. Urgent histopathological examination of the excised tissue showed necrotising granulomatous inflammation. Patient was empirically started on TB treatment and subsequent mycobacterial culture confirmed the diagnosis of TB. The joints swelling resolved after one month of TB treatment. Multifocal OATB is an infrequent form of extrapulmonary TB and diagnosing OATB requires high index of suspicion particularly in SLE patient on immunosuppression. Prompt investigations are essential to the diagnosis of this rare condition for early initiation of anti-tuberculous therapy.

BCGitis of the wrist after intravesical BCG therapy: A case report.

Septic arthritis of the wrist can result in joint destruction, making timely diagnosis crucial for initiating empiric antibiotics and surgical intervention. Mycobacterium is a rare cause of this disorder. A 47-year-old man with bladder cancer was treated surgically and received BCG intravesical therapy. Eleven months later, this patient developed severe carpal BCGitis requiring total carpal resection. The first step was addition of a cement spacer and radiometacarpal stabilisation (Masquelet technique). Secondary infections occurred aggravating the prognosis. This case emphasises the importance of taking into account the patient's medical history. Tuberculosis of the wrist is a rare etiology for septic arthritis; delayed treatment leads to severe complications and functional sequelae.

Tuberculosis osteomyelitis in an old fused hip; activated by prednisolone, salazosulfapyridine, and low-dose methotrexate therapy in a patient with rheumatoid arthritis.

Osteoarticular tuberculosis can occur in patients with rheumatoid arthritis (RA) receiving immunosuppressive therapy. Here, we describe a case of tubercular osteomyelitis in an old fused hip of a patient with RA who received prednisolone, salazosulfapyridine (SASP), and low-dose methotrexate (MTX). A 77-year-old man with a 4-year history of RA was admitted with a complaint of general fatigue. His symptoms of RA had been well controlled with a combination of prednisolone, SASP, and low-dose MTX. Because the laboratory data showed an increase in serum C-reactive protein levels, we suspected pneumonia. There was expansion of a pre-existing consolidation in the right lower lobe of his lung on chest computed tomography, and the sputum culture was positive for Klebsiella oxytoca. His family physician prescribed empiric antibiotics for pneumonia. Although the QuantiFERON® test result was positive, the acid-fast bacillus staining result was negative in the sputum. He started complaining of pain in his left hip, where arthrodesis was performed for an unknown reason at the age of 20 years. Sonographic examination of his left thigh revealed fluid collection. The aspiration culture of the fluid was positive for Mycobacterium tuberculosis. He was initiated on rifampicin, isoniazid, pyrazinamide, and ethambutol. Surgical debridement of the fused left hip was performed twice along with a removal of previously implanted materials. Although infrequent, osteoarticular tuberculosis can occur during immunosuppressive therapy, especially in elderly patients. Physicians should be aware of a history of possible tuberculosis infection, such as hip arthrodesis, when prescribing MTX along with SASP and corticosteroid in the elderly.

Tubercular infection after arthroscopic anterior cruciate ligament reconstruction.

PURPOSE: Tubercular infection has not been described, to our knowledge, in the literature after anterior cruciate ligament (ACL) reconstruction, and, hence, the purpose of our case series was to describe our experience, evaluate the clinical and laboratory findings, and assess the treatment outcome. METHODS: We performed a retrospective analysis of 1,152 cases of arthroscopic ACL reconstruction with autografts performed at our institution between January 1998 and May 2007. Tubercular infection was considered to be present in the setting of recurrent negative bacterial cultures but a positive result on microscopy, culture, histopathology, or polymerase chain reaction (PCR). All patients underwent arthroscopic lavage and synovectomy, followed by antitubercular therapy for 12 months. RESULTS: We identified 8 patients (0.69%) with infection. Bone-patellar tendon-bone graft was used in 1 and hamstring graft in 7. All patients were immunocompetent. The mean time from surgery to presentation was 64.4 days (range, 23 to 152 days). Aspirate fluid staining and culture for acid-fast bacilli was negative in all cases, synovial tissue culture was positive in 3, characteristic histopathology was positive in 7, and PCR was positive in 6. A mean of 1.25 surgeries (range, 1 to 2) were performed. The mean length of follow-up in our series was 43.6 months (range, 25 to 73 months), with no reinfections. The mean postoperative Lysholm knee score was 80. CONCLUSIONS: Tubercular infection as a complication after arthroscopic ACL reconstruction, though rare, should be kept in mind as a possible cause of infection in immunocompetent patients in zones endemic for tuberculosis. It should also be kept in mind in nonendemic areas, among immigrants from endemic areas, and in cases with persistent swelling and discharge, effusion with minimal inflammatory signs, and negative cultures. We recommend deoxyribonucleic acid-PCR testing for early diagnosis of tuberculosis. Arthroscopic debridement and antitubercular chemotherapy together are the mainstay of treatment.

Postoperative Mycobacterium tuberculosis infection after total knee arthroplasty.

The tuberculosis prosthetic joint infection is a rare complication. We reported a case of tuberculosis prosthetic joint infection following total knee arthroplasty, and the infection was controlled without the removal of implant with the anti-tuberculosis drugs for 12 months and there has been no evidence of recurrence. Although the tuberculosis prosthetic joint infection is few of all prosthetic joint infection, early appropriate treatment can make good result without the removal of implant. This case appeared to be an early postoperative tuberculosis infection in a patient with no prior history of tuberculosis and hence conclusion could be made that early postoperative tuberculosis infection after total knee arthroplasty may occur in a patient with no prior history of exposure to tuberculosis.

[Osteitis as a complication of BCG vaccination].

OBJECTIVES: To investigate the incidence and increasing tendency of osteitis after BCG vaccination and, in addition, its clinical features, diagnostic methods and results of treatment. SUBJECTS: 22 cases of Japanese children who received BCG vaccination between 1998 and 2007 and developed osteitis, and were reported in medical journals or meetings. RESULTS AND DISCUSSION: Incidence was very low, 0.2 per 100,000 vaccinations, and an increasing tendency was not seen after 2005, when the vaccination in Japan was limited to below 6 months after birth. However, it might be necessary to follow for much longer period. About 73% of cases of osteitis were seen from 9 to 18 months after receiving the vaccination. The bones of the extremities were commonly affected. Radiography usually showed the defect and cavity formation of the affected bone and often abscess around the lesion. Definitive diagnosis was made by the detection of BCG from the pus or biopsied materials. Recently, multiplex PCR method have been utilized and proved to be a rapid and reliable diagnostic method. Tuberculin reaction was positive, but QFT was negative in all tested cases; QFT will be available for the differential diagnosis of BCG and tuberculous infection. Only 2 patients had multiple lesions, and they had partial interferon-gamma receptor 1 deficiency. Immunodeficiency might have some relationship to the development of osteitis after BCG vaccination. The treatment using INH and RFP was very effective and the outcome was favorable; most of the patients were cured after 6 to 12 months chemotherapy without any complications. However, there is the possibility of defects occurring in the bone and restriction of the articular movement when the diagnosis and treatment are delayed. CONCLUSION: BCG osteitis, although rare, should be considered as a possible complication of the BCG vaccination, and early diagnosis and treatment of this complication is necessary.

[Clinical and epidemiological features of tuberculosis ostitis in BCG-vaccinated children].

There has been a drastic increase in the incidence of ostitis in children since 2001. Comparison of current tuberculous ostitis (n = 70) and primary pulmonary tuberculosis (n = 60) in infants revealed significant clinical and epidemiological differences. Molecular genetic methods identified BCG M. bovis strain DNA in 13 (46.4%) intraoperative samples and 4 samples of obtained cultures from bone destruction foci. Isolation of BCG cultures and/or verification of BCG M. ovis DNA from the bone lesion focus by polymerase chain reaction is a significant criterion for verification of the BCG etiology of ostitis having a morphological pattern of productive necrotic tuberculosis in children.

Central Nervous System Tuberculosis : Etiology, Clinical Manifestations and Neuroradiological Features.

PURPOSE: As a result of multilateral migration and globalization in times of humanitarian crises, western countries face a possible increase in the incidence of central nervous system tuberculosis (CNS TB). The diagnosis of CNS TB is challenging and often delayed due to the manifold and often non-specific presentation of the disease. The aim of this review is to analyze and summarize imaging features and correlated clinical findings of CNS TB. METHODS: The different manifestations of CNS TB are explained and illustrated by characteristic neuroradiological as well as neuropathological findings. An overview on diagnostic and therapeutic approaches is provided. For clarity, tables summarizing the lesion patterns, differential diagnoses and diagnostic hints are added. RESULTS: The CNS TB can be manifested (1) diffuse as tuberculous meningitis (TBM), (2) localized as tuberculoma or (3) tuberculous abscess or (4) in extradural and intradural spinal infections. Information on clinical presentation, underlying pathology and the distinguishing features is demonstrated. The TBM is further described, which may lead to cranial nerve palsy, hydrocephalus and infarction due to associated arteritis of the basal perforators. The differential diagnoses are vast and include other infections, such as bacterial, viral or fungal meningoencephalitis, malignant causes or systemic inflammation with CNS. Complicating factors of diagnosis and treatment are HIV coinfection, multi-drug resistance and TB-associated immune reconstitution inflammatory syndrome (IRIS). CONCLUSIONS: Neurologists and (neuro-)radiologists should be familiar with the neuroradiological presentation and the clinical course of CNS TB to ensure timely diagnosis and treatment.

Reactivation of ancient joint tuberculosis of the knee following total knee arthroplasty after 61 years: a case report.

The prevalence of pulmonary tuberculosis is increasing and is associated with a rise in skeletal tuberculosis. Even after appropriate anti-tuberculosis therapy, reactivation of the infection may occur, even after many years. In this case report we describe a patient who had a reactivation of tuberculosis in the knee after total knee arthroplasty. At the age of 14 years, the patient had isolated tuberculosis arthritis of the left knee. Reactivation occurred after total knee arthroplasty 61 years later, at the age of 75. The patient was treated with a combined therapy; first the joint was irrigated with povidine-iodine and saline solution, and gentamicin beads were left behind. When the cultures revealed Mycobacterium tuberculosis, drug therapy of isoniazid, rifampicin, ethambutol and pyrazinamide was started and was continued for 9 months postoperatively. At a recent follow-up, the patient is doing well, with good range of motion in the knee.

Bone marrow infection with bacillus Calmette-Guérin (BCG) after intravesical immunotherapy.

Instillation of bacillus Calmette-Guérin (BCG) into the urine bladder is an effective treatment of superficial bladder cancer. BCG-mediated anti-tumor activity appears to be a local phenomenon in which cell-mediated immunity, involving cytotoxic T cells, lymphokine-activated killer cells and natural killer cells, is important for the elimination of malignant cells. Serious side-effects of BCG therapy are rare; nevertheless, BCG is a live, attenuated strain of Mycobacterium (M.) bovis and may exhibit invasive properties. Both local and distant or generalized infections have been reported after treatment with BCG. We describe the case of a 68-year-old man who developed bone marrow infection with BCG two years after intravesical instillation of BCG for treatment of superficial bladder cancer. He presented with intermittent fever, weight loss and pronounced pancytopenia. A bone marrow biopsy specimen showed granulomatous inflammation and BCG was cultured from the urine. Anti-mycobacterial treatment with isoniazid, rifampicin and ethambutol (pyrazinamide is inactive against M. bovis) led to full clinical recovery of the patient.