A 20-year retrospective study of osteoarticular tuberculosis in a pediatric third level referral center.

PURPOSE: The objective of the present study is to describe the clinical, diagnostic, radiological and therapeutic aspects of osteoarticular tuberculosis (OATB) in patients in a tertiary pediatric hospital, to know if the diagnosis of OATB in pediatrics is a challenge due to its insidious clinical presentation. METHODS: A retrospective, descriptive study of the cases of Tuberculosis (TB) in children was carried out. A total of 159 cases met the condition for the analysis. RESULTS: The most frequent TB modality was extrapulmonary in 85%. Out of this, only 29% was OATB. The mean age was 4.9 years (range 8 months-16 years). Eighty-six per cent of cases received Bacille Calmette-Guérin (BCG) vaccination at birth. Median time of symptoms prior to diagnosis was 8 months. Microbiological confirmation was achieved only in five cases, with a high sensitivity to the antimicrobial treatment. Mycobacterium bovis BCG strain Tokio 172 was confirmed in three cases. Mortality rate was 0% during the time of study CONCLUSION: Our study describes the epidemiological characteristics of OATB cases in Mexican children. This data revealed a high prevalence of bone and joint TB infection. Pediatric OATB should be considered in cases with lytic bone lesions, fever and local pain. In countries with BCG immunization program, M. bovis should not be forgotten as an etiological agent. The low detection rate with one technique approach highlights the urgent need for more sensitive test to diagnose OATB in children.

Retrospective Study of Bone-TB in Oman: 2002-2019.

OBJECTIVE: Little information is available about the etiology, pathophysiology, risk factors, and epidemiologic features of Bone Tuberculosis (Bone-TB). In this work, we present the epidemiological data about the Bone-TB in the Sultanate of Oman. METHODS: Retrospectively, we identified and assessed those patients who were diagnosed with Bone-TB between January 2002 and December 2019 at Khoula Hospital. The following data were collected: demographics, clinical presentation, anatomical location, diagnosis, and treatment of the Bone-TB. RESULTS: During the study period, 115 cases of Bone-TB were diagnosed. Males were affected more than females (57.4% and 42.6%, respectively). About 30% of Bone-TB cases were primary diagnosed in other organs particularly the lungs and then after disseminated to the bone. However, the Bone-TB was detected in hip, leg, hand, shoulder, and skull bones, the most detected Bone-TB was in spine (66% of cases). After vaccination the Bacillus Calmette-Guérin (BCG) strains were identified in the bones of eight babies. Tubercle bacilli were detected by Acid-Fast Stain (AFS) in 59% of cases, and the rest of cases were confirmed using polymerase chain reaction (PCR) tests. There are two used treatment regimens, with 12.4% relapse. The gastrointestinal tract (GIT) disturbances were the most related side effects. The resistance has been detected to pyrazinamide in six cases, rifampicin in three cases, and isoniazid, streptomycin and kanamycin were detected in one case. CONCLUSION: The most predominant Bone-TB cases were spine-TB that were mainly disseminated from the lungs. AFS failed to detect tubercle bacilli in 40% of cases. There is no statistical significance in relapse between the used two regimens. The death was predominant among skull-TB cases.

Elbow arthroplasty complicated by Mycobacterium tuberculosis infection: A case report.

INTRODUCTION: Total elbow arthroplasty (TEA) is an orthopedic procedure that is relatively infrequently performed, but its use has been increasing over time. Infection remains one of the most concerning complications after TEA, although Mycobacterium tuberculosis (TB) as a microbial etiology, is extremely rare. Here, we present a case of M. tuberculosis infection after TEA. PATIENT CONCERNS: A 45-year-old woman underwent TEA for severe traumatic arthritis of the elbow following failure of conservative treatment. Four months after TEA, the patient experienced progressive elbow pain and swelling, without other external signs of infection such as a sensation of local heating and erythematous alterations. DIAGNOSIS: Pulmonary computed tomography showed stable pulmonary TB in the right upper lobe. The T-SPOT, TB, and purified protein derivative test results were positive, and M. tuberculosis exhibited growth on cultures. The final diagnosis was periprosthetic infection of M. tuberculosis. INTERVENTIONS: The patient was treated with debridement with submission of deep tissue cultures. According to these cultures and suggestions of a bacteriologist, anti-TB treatment was administered for 12 months. OUTCOMES: The symptoms of the infection were controlled, and the prosthesis was retained. At the time of writing this case report, the elbow prosthesis had survived for more than 2 years, and no recurrent infection had been observed. CONCLUSION: The diagnosis of TB infection after TEA is difficult to confirm due to its nonspecific signs and symptoms. Despite the extremely low incidence, failure to consider this possibility for diagnosis can lead to delayed treatment. Proper diagnosis allows for antitubercular therapy with retention of a prosthesis.

Total Knee Arthroplasty in Patients with Unsuspected Tuberculosis of the Joint: A Report of Four Cases and a Systematic Review of the Literature.

OBJECTIVES: To provide a case series and systematic review that explores the clinical manifestations, treatments, and methods for defining tuberculosis diagnoses in patients who have undergone total knee arthroplasty (TKA). METHODS: Four patients (three women, one man; average age, 59.5 ± 8.89 years; range, 48-69 years) underwent TKA and were subsequently treated for previously unsuspected knee tuberculosis between January 2013 and December 2019. We also reviewed published cases of tuberculous periprosthetic joint infections (TBPJIs) following TKA through databases of MEDLINE/PubMed, the Cochrane Library, and EMBASE. We reviewed studies that were published between January 1980 and December 2019. RESULTS: In our four cases, the preoperative diagnoses were osteoarthritis (n = 2), rheumatoid arthritis (one case), and Charcot's arthropathy (one case). The main clinical manifestations were knee swelling and pain, without fever, weakness, or weight loss. Comorbidities included multiple joints with rheumatoid arthritis or Charcot's arthropathy, diabetes mellitus, and uremia. One patient had a history of lumbar tuberculosis treated with debridement and intervertebral fusion. Preoperative elevated erythrocyte sedimentation rates (ESRs) were detected in all cases, and elevated C-reactive protein (CRP) levels were observed in three cases. The tuberculosis diagnoses were confirmed via histopathologic analysis (three cases) and second-generation sequencing (one case). Three patients received antituberculosis therapy for 1 year, without surgical intervention. Two-stage exchange arthroplasty was performed in one patient because of prosthesis loosening. Within an average follow-up period of 24.75 months, tuberculosis reactivation was not observed and overall functional improvement was demonstrated. Forty-four TBPJI cases were reported in the literature between January 1980 and December 2019. Most (59.09%) occurred within the first year after the index arthroplasty, and the diagnoses were confirmed by culturing Mycobacterium tuberculosis in 88.64% of cases. Favorable outcomes were achieved in 90.91% of the patients who did not undergo surgery, 71.43% of those treated with debridement, 93.33% undergoing revision arthroplasty, and in 90.91% of those undergoing resection and arthrodesis. CONCLUSIONS: Clinical manifestations of knee tuberculosis and TBPJI are atypical. Thus, attention should be paid to finding the causes of increased ESRs and CRP levels, particularly in patients with weakened immune functioning, before performing TKA. Pathological examination is an effective method for diagnosing tuberculosis, although sending multiple specimens for pathological examination is necessary.

Tuberculosis of the Ankle in a Non-immunocompromised Male: A Case Report and Review of the Literature.

The prevalence and incidence of tuberculosis has declined rapidly in Western Europe during the last century, although a slight increase is being seen due to immigration from countries where tuberculosis is still a common disease. We present a very rare case of primary ankle tuberculosis in a 51-year-old native German male without any risk factors or prior lung manifestation. A delay in diagnosis and treatment when a patient presents with ankle arthritis caused by Mycobacterium tuberculosis should make one aware of the possibility of primary joint tuberculosis, which is extremely unusual and it can mimic various other joint diseases. If the diagnosis is in doubt, early biopsy should be mandatory.

Tuberculous cold abscess of sternoclavicular joint: a case report.

Bone and joint tuberculosis is a serious medical problem; tuberculosis of sternoclavicular joint is rare. We present a case of a healthy 37-year old man with sternoclavicular joint tuberculosis. The subject presented with a three weeks history of left sternoclavicular joint painless swelling without fever or weight loss. He had no previous history of pulmonary tuberculosis. Laboratory testing revealed erythrocyte sedimentation rate of 70 mm/hour, C-reactive protein of 30 mg/liter and a normal leucocyte count. Biopsy of the lesion showed caseous necrosis and pus culture revealed Mycobacterium tuberculosis. He was treated with joint debridement and anti-tuberculous medications. Tuberculosis resolved completely but post-infection patients had residual joint arthritis. Tuberculosis may infect unusual joints such as the sternoclavicular joint.

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.

Primary Epiphyseal Osteomyelitis (PEO) in 18 Children: A Rare Entity With Atypical Features.

OBJECTIVES: The purpose of this study is to discuss the natural history and management of primary epiphyseal osteomyelitis (PEO), to differentiate clinico-radiologic features of PEO caused by Mycobacterium and other organisms, and to discuss their intermediate-term outcomes. METHODS: Between 2006 and 2017, 18 patients of PEO were managed at our center. Blood investigations, x-rays, and magnetic resonance imaging of affected part were carried out. Surgical drainage of lesions was done to retrieve infective fluid and tissue for examination. Antibiotics were administered for 1 year in Mycobacterial PEO and for 6 weeks in bacterial PEO. Average follow-up of patients was 5.5 years (range, 2 to 11 y). RESULTS: Boys were more commonly affected (11/18). Distal femur was the most common site involved (12/18). Eleven patients had Mycobacterium tuberculosis as the causative organism, 6 were positive for Staphylococcus aureus, and 1 for Brucella. Swelling and limp were predominant in patients with Tubercular PEO, whereas pain was more common in bacterial PEO. Nine of 11 patients with Tubercular PEO had penetration into the joint, whereas none in bacterial PEO. All patients recovered completely without residual movement restriction or growth alteration. On follow-up magnetic resonance imaging, 4 patients with Tubercular PEO had thinning of articular cartilage. CONCLUSION: High index of suspicion is required for early diagnosis of PEO. It is important to differentiate Tubercular from other bacterial PEO as it has more subtle symptoms and poor prognosis if left untreated. Aggressive surgical treatment followed by antibiotic therapy of appropriate duration is required to avoid complications related to joint destruction. To our knowledge, this is the largest reported series with longest follow-up.

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.

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.

Comparing tuberculosis in children aged under 5 versus 5 to 14 years old in a rural hospital in southern Ethiopia: an 18-year retrospective cross-sectional study.

BACKGROUND: There are few data available about childhood tuberculosis (TB) in rural hospitals in low-income countries. We assessed differences in epidemiological characteristics and treatment outcomes in children with TB aged 0-4 versus 5-14 years in rural Ethiopia. METHODS: For this retrospective cross-sectional study, we analyzed childhood TB registers from a rural Ethiopian hospital. We collected data on the number of cases, type of TB, and treatment outcomes using standard definitions. By means of binary and logistic regression analyses, data were compared from 1998 to 2015 in children aged under 5 versus those aged 5-14 years. RESULTS: We included 1282 TB patients: 583 (45.5%) were under 5 years old, and 699 (54.5%) were aged 5-14 years. More than half (67.2%, n = 862) had pulmonary TB (PTB), which was more common in younger children (82.5%, 481/583) than in older ones (54.5%, 381/699; p < 0.001). Most cases of PTB (87.5%, 754/862) were smear negative, including virtually all (99.6%, 479/481) younger children and most older ones (72.2%, n = 275/381; p < 0.001). The most common types of extrapulmonary TB (EPTB) were TB adenitis (54.5%, 229/420) and bone TB (20%, 84/420). Children under five showed a lower prevalence of adenitis TB (9.9% [58/583] versus 24.5% [171/699], p < 0.001), bone TB (2.9% [17/583] versus 9.6% [69/699], p < 0.001), and abdominal TB (0.9% [5/583] versus 6.3% [44/699], p < 0.001). Most diagnoses were new cases of TB (98.2%, 1259/1282). Overall, 63.5% (n = 814) of the children successfully completed treatment (< 5 years: 56.6%, 330/583; 5-14 years: 69.2%, 489/699; p < 0.001). In total, 16.3% (n = 209) transferred to another center (< 5 years: 19.4%, 113/583; 5-14 years: 13.7%, 96/699; p = 0.006). Thirteen percent of patients (n = 167) were lost to follow-up (< 5 years: 16.0%, 93/583; 5-14 years: 10.4%, 74/699; p = 0.004). Fifty-two (4.1%) children died (no age differences). Being aged 5-14 years was independently associated with successful treatment outcomes (adjusted odds ratio 1.59; 95% confidence interval: 1.16, 1.94, p = 0.002). CONCLUSIONS: We observed a very low diagnostic yield for spontaneous sputum smear in children with TB. In this rural setting in Ethiopia, very young children tend to present with new cases of smear-negative PTB. They have less EPTB than older children but more TB meningitis and show lower rates of treatment success.

Inflammatory arthritis and Mycobacterium Tuberculosis infection: a diagnostic and management challenge for Knee arthroplasty in endemic areas.

Tuberculosis continues to be one of the most challenging health problems more prevalent in developing countries. Pakistan ranks 5th in tuberculosis prevalence among the high-burden countries. Prosthetic joint infection of the knee by acid fast bacilli is a rare and distressing complication, occurring in nearly 1% of primary joint arthroplasties requiring prolonged medical treatment and multiple surgeries. A recent publication extensively reviewed English literature from 1952 to 2016, and repor ted only 64 prosthetic joint infec tion with tuberculosis, of which 27 cases involved the knee. Tuberculosis is a global health problem adding to the challenges that arthroplasty surgeons face in our resource-constrained setting. Furthermore, it presents as other inflammatory arthritis with almost same laboratory and radiological findings. The current paper was planned to highlight the preoperative and postoperative challenges that the arthroplasty surgeon may have in diagnosis and management of this rare infection. We included studies from 1996 to date which reported knee tuberculosis prosthetic joint infection that were managed by medication alone or with surgical intervention in patients who had undergone arthroplasty.

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.

Prosthetic joint infections due to Mycobacterium tuberculosis: A retrospective study.

OBJECTIVE: Tuberculous prosthetic joint infection (PJI) is uncommon and often diagnosed late. The objective here is to describe the management of tuberculous PJI at an osteoarticular infection referral center. METHODS: A single-center retrospective study of patients managed between 1987 and 2016 was performed. RESULTS: We identified 9 patients with a median age of 80 years. The hip was involved in all 9 patients. A known history of tuberculosis was noted in 2 patients and tuberculosis was present at other sites in 4 patients (lung, n = 3; urinary tract and scrotum, n = 1; and spine, n = 1). The diagnosis was established by routine intra-operative microbiological sampling, during (n = 4) or at a distance from (n = 5) hip arthroplasty. In the 8 patients with available follow-up data, mean antibiotic therapy duration was 16 months (range, 12-18 months). None of the 4 patients in whom the infection was diagnosed during arthroplasty required surgical revision because of the infection. Of the other 5 patients, 3 were managed by exchange arthroplasty and 1 by excision of the hip without subsequent prosthesis implantation; the remaining patient did not undergo revision surgery. The infection was eradicated in all 9 patients, after 15 months to 10 years. CONCLUSION: Tuberculous PJI is uncommon. The prognosis is good with prolonged antibiotic therapy, although the optimal duration remains unclear. The surgical strategy should be discussed on a case-by-case basis. The prosthesis can be retained if the tuberculous infection is an unexpected finding during arthroplasty.

Characteristics and management of bone and joint tuberculosis in native and migrant population in Shanghai during 2011 to 2015.

BACKGROUND: China had the third highest burden of tuberculosis population in the world. Bone and joint tuberculosis was a major part and its characteristics were rarely discussed before. This study was designed to review the characteristics and management of bone and joint tuberculosis among native and migrant population in Shanghai, China during 2011-2015. METHODS: A retrospective analysis of the patient clinical records on their demographic information, clinical features and treatment was conducted from three tertiary referral hospitals. Analysis of continuous variables included calculation of the median value with interquartile range. Categorical variables were displayed as percentages and compared using the Fisher's exact test and chi-square test. All continuous variables were compared using Student's unpaired t-test and Mann Whitney U test. RESULTS: One hundred fifteen patients with bone and joint tuberculosis were involved in this study. Native people were generally older (p = 0.003) and had more comorbidities like hypertension (40.74% vs. 16.39%, p = 0.004), diabetes mellitus (38.89% vs. 13.11%, p = 0.001), and cancer (31.48% vs. 14.75%, p = 0.032) than migrants. Migrant patients generally experienced a longer period of uncomfortable feelings before going to doctor than native people (p = 0.007). Spine was a major infection site in comparison with other peripheral joints. Radiological evaluation displayed increased osteolytic reaction in migrant patients compared with native people (p = 0.031). The mean time for anti-tuberculosis treatment was significantly longer in native Shanghai patients (8.96 months vs. 7.94 months, p = 0.003). The curative ratio displayed a significant difference between native and migrant patients (88.24%vs.75.93%, p = 0.009). CONCLUSION: Bone and joint tuberculosis exhibited a poorer outcome in migrant people, who also had longer period of manifestation, more severe osteolytic reaction from CT scan and higher recurrent rate than native people. The surgical treatment in addition to anti-tuberculosis drug therapy had great implications for bone and joint tuberculosis recovery.

Diagnosis and treatment of tuberculosis of the foot and ankle-A literature review.

Foot osteoarticular tuberculosis is uncommon. Late diagnosis and sub-optimal management can lead to significant morbidity, deformity and even death. Preservation of life, limb and function can be achieved with prompt diagnosis and treatment. In 1882, Robert Koch published his discovery of mycobacterium tuberculosis as the causative agent of tuberculosis (TB), and showed the disease was infectious rather than inherited. Over two centuries later, TB remains one of the top 10 causes of death worldwide. Whilst in 90% of cases TB infects the respiratory system, in 10% it is extrapulmonary and can infect the skeletal, nervous, lymphatic and genitourinary systems. The spine is the most frequently affected site in the musculoskeletal system and this is known as Pott's disease. The foot and ankle is affected in only 0.13% cases of extrapulmonary TB. A high index of suspicion is thus required. This infrequency in incidence, heterogeneity of its presentation along with the difficulty in early diagnosis often causes significant delays in its treatment and hence results in a considerable disability. The medical treatment is well established but the role of surgery, its usefulness and its correct timing remain controversial. The main diagnostic issues include imaging being non-specific. Plain radiographs remain the first line imaging modality. MRI and CT scans provide greater detail and capture the disease at an earlier stage. Microbiological testing has low sensitivity and specificity becasue TB lesions are paucibacillary. Bone biopsy is of significant diagnostic value as it not only allows histological examination to detect granulomas but enables sensitivity and resistance testing of anti-tuberculous therapy (ATT). Issues relating to treatment include timing, duration, combination of chemotherapy and the challenge of multi drug resistant tuberculosis MDR-TB. The selection and timing of appropriate surgical techniques and optimal duration of follow-up are further points to consider. In this article we aim to review the literature on diagnosis and treatment of foot and ankle TB.

Two-stage revision arthroplasty for Mycobacterium Tuberculosis periprosthetic joint infection: An outcome analysis.

BACKGROUND: Mycobacterium tuberculosis periprosthetic joint infection (TBPJI) is a rare complication of hip/knee joint arthroplasty. The outcomes of hip/knee TBPJI treatment are still unreported. The objective of this study was to investigate the outcomes of hip/knee TBPJI following treatment with two-stage exchange arthroplasty. MATERIALS AND METHODS: From 2003 to 2013, 11 patients with TBPJI (six hips and five knees) were treated with two-stage exchange arthroplasty at our institution. We collected and analyzed variables including demographic data, comorbidities, microbiological data, duration of symptoms, and types of antibiotic used in bone cement. RESULTS: At the most recent follow-up, the success rate of two-stage exchange arthroplasty was 63.3% (7 of 11). All five knee treatments resulted in infection eradication and successful prosthesis reimplantation. However, only two hip TBPJI treatments resulted in successful outcomes; two patients died and two experienced chronic infection. Overall, secondary bacterial infections were common in patients with TBPJI (5 of 11 cases, 45.5%). Streptomycin in bone cement increased the success rate (83.33% vs. 40%). CONCLUSION: More than one third of the patients treated with two-stage exchange arthroplasty for TBPJI showed infection relapse or uncontrolled infection. Streptomycin-loaded interim cement spacers appeared to help ensure successful treatment. Routine M. tuberculosis culture is recommended when treating TBPJI in areas of high tuberculosis prevalence.

Tuberculous sacroiliitis with secondary psoas abscess in an older patient: a case report.

BACKGROUND: Tuberculosis is the leading infectious cause of death worldwide. Among native Swiss people, tuberculosis is more common in older people than in younger people. Approximately 25-30% of reported cases of tuberculosis are purely extrapulmonary; skeletal tuberculosis is reported in 3-5% of cases. The purpose of this case report is to draw attention to the diagnostic challenge of tuberculous sacroiliitis with secondary psoas abscess, as this clinical picture is very rare. CASE PRESENTATION: A magnetic resonance imaging scan of an 85-year-old (Swiss-German) Caucasian woman with chronic left-sided hip pain and limitation of hip joint movement showed a progressive destruction of her sacroiliac joint and a large collection in her left iliopsoas muscle. Drainage of the abscess revealed pus; a polymerase chain reaction assay was positive for Mycobacterium tuberculosis complex. Tuberculous sacroiliitis with secondary iliopsoas abscess was diagnosed 9 months after the start of the symptoms. Combination treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol was started. CONCLUSIONS: Sacroiliitis with secondary psoas abscess is an unusual cause of hip pain and is likely to be overlooked since joint pain of the lower extremity and lumbar pain are some of the most common complaints in older individuals. A high level of suspicion and invasive diagnostic procedures are needed for timely diagnosis of tuberculous sacroiliitis not only in immunocompromised patients living in or originating from endemic areas.

Delayed diagnosis of chronic postoperative sternal infection: a rare case of sternal tuberculosis.

Sternal osteomyelitis secondary to mycobacterium tuberculosis (TB) is rare, with <1% of musculoskeletal TB cases reported. The recurrent scenario is unresolving infection and delayed diagnosis. A 75-year-old woman presented with a persistently discharging sternal wound 10 months after coronary artery bypass grafting. Multiple antibiotics, wound debridement and removal of sternal wires was attempted; however, progression to local osteomyelitis and sternoclavicular joint destruction occurred. Tissue biopsies were finally sent for mycobacterial culture testing positive for Mycobacterium tuberculosis High index of suspicion is necessary for diagnosis of sternal tuberculosis, confirmed through timely microbiological investigations. MRI may identify soft-tissue and bone oedema characteristic of TB osteomyelitis. This patient had no TB risk factors. The source of infection is unclear and warrants further investigation. Sternal TB osteomyelitis is uncommon and largely reported through case reports, thus management and indications for surgery remain undefined. If sensitive, standard TB four-drug regimen may be trialled.

Successfully treating hand primary tuberculous synovitis by synovectomy combined antituberculous therapy: A case report.

RATIONALE: Primary tuberculous infection in hand and wrist is a rare disease. Few articles reported on hand primary tuberculous synovitis. PATIENT CONCERNS: A 68-year-old Chinese male, without history of tuberculosis (TB), had complained of pain and swelling in right palm and little finger for 3 months. Patient came to our hospital on 9th Oct 2016. X-ray just showed soft tissue swelling in little finger. Magnetic resonance imaging (MRI) showed synovitis around flexor tendon of little finger, volar palm, and carpal tunnel. Notably, it also implied nodular images in little finger sizing 5 mm × 11 mm. Laboratory tests revealed C-reactive protein (CRP): 22 mg/L, erythrocyte sedimentation rate (ESR): 49 mm/h, and white blood cells (WBC): 11.8 × 10/L. DIAGNOSES: He was diagnosed with primary hand tuberculous synovitis. INTERVENTIONS: The patient received aspiration biopsy in right palm guided by ultrasound on 13rd Oct and pathological examination indicated Mycobacterium tuberculosis (MTB) infection. We performed radical synovetomy and collected abnormal tissue for pathological examination on 18th Oct. Finally, result showed MTB infection, which was the same with the result of first pathological examination. Then, this patient received antituberculous treatment. OUTCOMES: One year after operation, pain and swelling relieve and no recurrence of the clinical symptoms happened. LESSONS: Primary tuberculous synovitis of hand and wrist is rare, MTB infection should be considered as an infectious agent, especially in developing countries. Radical synovectomy and antituberculous treatment regain a satisfactory outcome.