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.

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.

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.

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.

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.

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.

Delays in the diagnosis and treatment of bone and joint tuberculosis in the United Kingdom.

AIMS: Tuberculosis (TB) infection of bones and joints accounts for 6.7% of TB cases in England, and is associated with significant morbidity and disability. Public Health England reports that patients with TB experience delays in diagnosis and treatment. Our aims were to determine the demographics, presentation and investigation of patients with a TB infection of bones and joints, to help doctors assessing potential cases and to identify avoidable delays. PATIENTS AND METHODS: This was a retrospective observational study of all adults with positive TB cultures on specimens taken at a tertiary orthopaedic centre between June 2012 and May 2014. A laboratory information system search identified the patients. The demographics, clinical presentation, radiology, histopathology and key clinical dates were obtained from medical records. RESULTS: A total of 31 adult patients were identified. Their median age was 37 years (interquartile range (IQR): 29 to 53); 21 (68%) were male; 89% were migrants. The main sites affected were joints (10, 32%), the spine (8, 26%) and long bones (6, 19%); 8 (26%) had multifocal disease. The most common presenting symptoms were pain (29/31, 94%) and swelling (26/28, 93%). 'Typical' symptoms of TB, such as fever, sweats and weight loss, were uncommon. Patients waited a median of seven months (IQR 3 to 13.5) between the onset of symptoms and referral to the tertiary centre and 2.3 months (IQR 1.6 to 3.4.)) between referral and starting treatment. Radiology suggested TB in 26 (84%), but in seven patients (23%) the initial biopsy specimens were not sent for mycobacterial culture, necessitating a second biopsy. Rapid Polymerase Chain Reaction-based testing for TB using Xpert MTB/RIF was performed in five patients; 4 (80%) tested positive for TB. These patients had a reduced time between the diagnostic biopsy and starting treatment than those whose samples were not tested (median eight days versus 36 days, p = 0.016). CONCLUSION: Patients with bone and joint TB experience delays in diagnosis and treatment, some of which are avoidable. Maintaining a high index of clinical suspicion and sending specimens for mycobacterial culture are crucial to avoid missing cases. Rapid diagnostic tests reduce delays and should be performed on patients with radiological features of TB. Cite this article: Bone Joint J 2018;100-B:119-24.

A Rare, Unusual Presentation of Primary Tuberculosis in the Temporomandibular Joint.

Tuberculosis (TB) is a very common health problem in developing nations such as India. It can present as its primary form or as secondary forms (extrapulmonary TB). Maxillofacial manifestations of TB compose nearly 10% of all extrapulmonary manifestations of the disease. Extrapulmonary TB involving the maxillofacial region is very rare and can present in any tissues in this region. These infections generally involve the head and neck through hematogenous or lymphatic routes. Very few cases of primary TB of the temporomandibular joint (TMJ) have been reported in the literature. The presentation of TB infection of the TMJ can resemble arthritis, osteomyelitis, or any other kind of chronic joint disease. It is very important to diagnose this disease at an early stage. If left untreated, it can prove fatal within 5 years in more than half the cases. Therefore, early diagnosis and management of these cases is critical. This article describes a case of primary TB of the TMJ that presented as a preauricular swelling.

The clinical-morphological profile of bone and joints tuberculosis - our experience in relation to literature data.

AIM: The authors made a morphological assessment of musculoskeletal tissue samples from patients admitted in Surgical Departments of the Emergency County Hospital of Craiova, Romania, between 1990 and 2015, proved as presenting tuberculous lesions in the Department of Pathology of the same Hospital. MATERIALS AND METHODS: The studied material consisted of bone, joint and sometimes muscle tissue fragments resulted from biopsies or surgical excisions from 54 cases coming out of 841 patients investigated in the above-mentioned period of time, where the established histological diagnosis was tuberculosis (TB). For diagnostic confirmation, Ziehl-Neelsen staining has been used as a rule but, in some cases, immunohistochemistry was also used. RESULTS: TB lesions have prevailed in men and around the age of 50 despite the tissue involved (either bones or joints or both structures). Bone tissue, lower limb and right side of the body have been more frequently touched by the TB lesions. Axial bones (spine, ribs and hip bone) and knee joint have been the favorite sites. From morphological point of view, the inflammatory cellular population has been dominated by the epithelioid and giant Langhans cells that surrounded areas less or more extended of classical acidophilic fine granular necrosis. The fibrosis was observed more frequently around bone lesions, usually in an incipient phase. Overall, the granulomatous reaction was of reactive type but one should notice hyporeactive or areactive, disorganized reaction encountered quite often in bone or associated bone and joints lesions. CONCLUSIONS: Osteoarticular tuberculosis (OATB) has a complex and dynamic clinical morphological picture, which is still partly known, described and understood especially in the field of morphological changes. Further detailed and integrative analysis of both clinical and morphological aspects is required so the suspicion of diagnosis at the admission becomes as soon as possible certitude.

The epidemiology of tuberculous dactylitis: A case report and review of literature.

The literature on tuberculous dactylitis is poor, and most literature consists of isolated case reports. The aim of this case series is to study the particularities and the epidemiological aspects of tuberculous dactylitis in Tunisian patients. Google and Medline search was done using key words "tuberculous dactylitis" and "spina ventosa." Only Tunisian reports in adult patients were included. Eleven cases including this mentioned case were included in this review. There was a female predominance, high frequency of trauma before disease installation, rarity of predisposing factors, and less inflammation in blood tests when comparing with other cases in literature.

Sternoclavicular joint tuberculosis: A series of 9 cases.

Tuberculosis (TB) is a chronic disease that may affect any part of the human body. Though the osteoarticular TB is not uncommonly seen, TB of the sternoclavicular joint (SC joint) is an infrequently reported condition. The very fact that many physicians have never seen a single case of SC joint TB in their entire career makes them never think of this condition in cases of chronic swellings of the medial end of clavicle. We are reporting here our experience with nine cases of SC joint TB that were treated by us. Delay in diagnosis in each of the case was a common feature, and they had been treated in line of inflammation elsewhere. Diagnosis was arrived at by clinical, radiological, and microscopic examinations. Six of the reported cases responded well to antitubercular chemotherapy, and in one of the cases, chemotherapy was combined with debridement, which was actually done during biopsy and primarily for tissue diagnosis; in another two cases, immunomodulation therapy for HIV was given along with antitubercular therapy. Tuberculous etiology should be considered for patients presenting with atypical sites of skeletal inflammation, and a high index of suspicion by the treating physician is necessary to make early diagnosis and appropriate treatment.

Clinical and diagnostic features of trochanteric tuberculosis.

Trochanteric tuberculosis is a very rare localization of musculo-skeletal tuberculosis. The diagnosis is difficult and is often made in a late stage. The authors describe five cases of trochanteric tuberculosis. The mean age of patients was 46.6 years. Time to diagnosis was long (7.6 months on average). The tuberculosis was plurifocal in all cases. Diagnosis was based on positive Lowenstein culture in one case, on the presence of caseum granuloma in one case and through a pathognommonic manifestation in one case. For the remaining two cases, diagnosis was established on clinical and paraclinical arguments. The patients recovered after medical treatment alone.

Isolated tuberculosis of metacarpal bone in a 3 year-old child.

Primary tuberculosis osteomyelitis of metacarpal bone is rare. The majority of cases occur in children and young adults and there is difficulty in diagnosis mainly in young children. We report a new case in children aged of 3 years, presenting a swelling on the dorsal side of her right hand since 8 months. X-ray showed an expansile, cystic and lytic lesion involving the little finger metacarpal. Tuberculosis was confirmed on histological examination. No lesions in lung parenchyma or lymphadenopathy were associated. Patient was successfully managed by anti-tubercular drugs.

A 6500-year-old Middle Neolithic child from Pollera Cave (Liguria, Italy) with probable multifocal osteoarticular tuberculosis.

Clear skeletal evidence of prehistoric tuberculosis (TB) is rare, especially in children. We describe and differentially diagnose the pathological changes displayed by a five-year-old child, Pollera 21 (PO21) dated to the Middle Neolithic of Liguria (Italy), or 5740±30 BP (Beta-409341; 6635-6453cal BP, 2σ, OxCal 4.2). PO21 shows a number of osteoarticular lesions, mainly of a lytic nature with very little bone proliferation: the vertebral column, the shoulder and pelvic girdles, and the ribcage are involved. Given the nature and pattern of the lesions, we propose a diagnosis of multifocal (or multiple) bone TB. Attempts to detect TB aDNA through molecular analysis gave negative results, but this alone is not sufficient to prove that PO21 was not infected with TB. The lesions observed in PO21 share similarities with other published evidence, such as spinal and joint involvement, and disseminated cyst-like lesions. Conversely, PO21 does not show diffuse bone deposition, such as hypertrophic osteoarthropathy (HOA) or endocranial modifications such as serpens endocrania symmetrica (SES). PO21 adds to our knowledge of patterns of TB manifestation in archaeological skeletal remains, which is especially important considering the variability in types and patterns of osteoarticular lesions seen today in people with TB.