[Diagnosis of tuberculous arthritis : a sometimes long and winding road]. / Arthrite tuberculeuse : un diagnostic parfois long et semé d'embûches.

Extraspinal tuberculous arthritis is a rare entity in developed countries, mostly found in populations of migrants. We describe a case of foot osteoarthritis in a young migrant, with an arduous diagnostic process. The sequence of the diagnostic studies (imaging, articular tap, bone biopsy together with cultures and molecular biology) must follow a logic based on clinical suspicion and on the knowledge of the diagnostic values of different tests. The diagnosis of tuberculous arthritis, a slowly progressing infection with a low bacteriologic burden, is difficult. The reported case emphases the need for perseverance. It shows the value of diagnostic procedures, their limits and the need for their integration to the clinical judgement.

L'arthrite tuberculeuse non rachidienne est rare dans les pays occidentaux où elle touche avant tout les populations de migrants. Nous décrivons un cas d'ostéoarthrite du pied, dont le processus diagnostique s'est révélé ardu. La succession des examens pratiqués (radiologie, ponction puis biopsie avec les cultures et la biologie moléculaire) doit s'inscrire dans une logique dictée par la suspicion clinique et la connaissance des performances diagnostiques des différents tests. Le diagnostic d'arthrite tuberculeuse, une infection d'évolution lente, pauvre en charge bactérienne, est difficile. Le cas présenté révèle le besoin de persévérer et permet de discuter la valeur des procédures diagnostiques, leurs limites et leur intégration dans le raisonnement clinique.

Diagnostic efficiency of Xpert MTB/RIF assay for osteoarticular tuberculosis in patients with inflammatory arthritis in China.

BACKGROUND: Both osteoarticular tuberculosis (OA-TB) and inflammatory arthritis can lead to osteoarticular structural damage. These conditions exhibit similar symptoms, physical signs, and imaging features. Rapidly and accurately diagnosing OA-TB in patients with inflammatory arthritis presents a challenge to clinicians. Xpert MTB/RIF (Xpert) has been endorsed by the World Health Organization (WHO) as a rapid diagnostic tool for diagnosis of pulmonary and extrapulmonary TB. This study was designed to investigate diagnostic efficiency of Xpert for OA-TB in patients with inflammatory arthritis in China. METHODS: A total of 83 consecutive patients with inflammatory arthritis and suspected OA-TB were enrolled prospectively from June 2014 to May 2018. Demographic, clinical, and biological data were recorded. Xpert assay, smear microscopy examination (smear), BACTEC MGIT 960 (MGIT 960), pathological examination, and T-SPOT.TB test were performed for each patient who received operations. Diagnostic efficiency of Xpert was evaluated based on a composite reference standard (CRS). RESULTS: A total of 49 out of 83 patients with inflammatory arthritis and suspected OA-TB received operations, and 49 specimens were obtained during operations. According to CRS, 36 out of 49 patients with inflammatory arthritis were diagnosed with OA-TB, and 13 were not affected by the condition. Sensitivity of Xpert assay, smear, MGIT 960, pathological examination, and T-SPOT.TB test reached 66.70% (24/36), 25.00% (9/36), 30.55% (11/36), 47.22% (17/36), and 80.55% (29/36), respectively. Specificity of Xpert assay, smear, MGIT 960, and pathological examination was all 100% (13/13). Specificity of T-SPOT.TB test was 53.84% (7/13). Sensitivity of Xpert was higher than that of smear, MGIT 960 and pathological examination, but the sensitivity of Xpert was lower than that of T-SPOT.TB. Sensitivity of Xpert was statistically different from that of smear and MGIT 960 (P<0.001, P = 0.002), but the sensitivity of Xpert was not significantly different from that of pathological examination and T-SPOT.TB (P = 0.096, P = 0.181). Specificity of T-SPOT.TB was less than that of Xpert, smear, MGIT 960, and pathological examination, and the difference between them was statistically significant (P = 0.015). Among the 27 OA-TB patients with smear negative results, Xpert had the highest sensitivity, but sensitivity of Xpert was not significantly different from that of pathological examination and T-SPOT.TB (P = 0.413, P = 0.783). 2 of 36 OA-TB patients exhibited RIF resistance. Xpert was concordant with MGIT 960-based drug susceptibility testing (DST) in detecting rifampin (RIF) resistance. CONCLUSIONS: Xpert is an efficient tool with high sensitivity and specificity for OA-TB diagnosis in patients with inflammatory arthritis in high-TB prevalence countries. Compared with conventional methods, Xpert has two advantages: one is fast, and the other is able to provide RIF resistance information simultaneously.

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.

Tuberculous Dactylitis: An Uncommon Presentation of Skeletal Tuberculosis.

BACKGROUND: Skeletal involvement accounts 1-5% of all cases of Tuberculosis. The vertebrae are more commonly affected. The bones of the hands are more affected than the bones of the feet. The term "spina ventosa" has been used to describe this disorder because of its radiographic features of cystic expansion of the involved short tubular bones. Tuberculous dactylitis mainly occurs through lympho-hematogenous spread. The lung is the primary focus in 75% of cases. CASE DETAILS: A 4 years old female child developed a painless swelling on her left index finger two months prior to her presentation. Following an unsuccessful treatment as a case of osteomyelitis with antibiotics, imaging showed an expansile lytic lesion with sclerosis, and fine needle aspiration confirmed tuberculous dactylitis. The child was initiated on anti-tubercular treatment with subsequent marked clinical and radiologic improvement. CONCLUSION: Presence of longstanding finger swelling and pain should alert a clinician to consider active disseminated tuberculosis. Furthermore, proper interpretation of imaging and use of fine needle aspiration has been highlighted.

AG 85, a major secretion protein of Mycobacterium tuberculosis, can be identified in ancient bone.

For the confirmation of Ag 85 in ancient and recent ECM of native macerated human bone, five cases were investigated. In three individuals, highly positive results for Ag 85 were identified in Western blot: 1) a male from Arzhan, South Siberia, dating from the 7th century BC, 2) a male from Kirchberg in Hesse, Germany, dating from the 10th - 12th century AD and 3) a recent female with a proven diagnosis of TB. As a negative control, a recent male is presented who did not suffer from TB. In another recent male, Ag 85 could be identified only very weakly. From cases in the literature it is well-known that highly positive results for Ag 85 indicate active TB, however, weakly positive results indicate a silent initial infection with Mtb. Thus, apparently, also in ancient individuals, it might well be possible to differentiate between diseased persons and disease carriers using paleoproteomic techniques.

Childhood bone tuberculosis from Roman Pécs, Hungary.

A child from a Roman necropolis in Pécs, Hungary (4th century CE) was initially diagnosed with severe spinal osteomyelitis. The post-cranial skeleton displayed bone alterations in the lower thoracic and upper lumbar segments, including vertebral body destruction, collapse and sharp kyphosis, and additional multiple rib lesions, suggesting a most likely diagnosis of pulmonary and spinal tuberculosis. This study discusses a number of selected diagnoses in the context of our pathological findings, complementing the macroscopic examination with radiological and biomolecular analyses.

Analysis of 30 patients with acupuncture-induced primary inoculation tuberculosis.

Primary inoculation tuberculosis is a skin condition that develops at the site of inoculation of Mycobacterium tuberculosis in tuberculosis-free individuals. This report describes the diagnosis, treatment and >1 year follow-up of 30 patients presenting with acupuncture-induced primary inoculation tuberculosis. Our data provide a deeper insight into this rare route of infection of tuberculosis. We also review effective treatment options.

Prosthetic knee infection in the young immigrant patient--do not forget tuberculosis!

Skeletal tuberculosis (TB) frequently masquerades as more common etiologies and can be difficult to diagnose. We describe a case of TB knee arthritis in a young Haitian-born woman in whom the diagnosis was not initially suspected, resulting in treatment with total knee arthroplasty that subsequently failed. A long course of medical and surgical therapies was then necessary to treat this patient. Issues in the diagnosis and management of TB in the native and prosthetic knee joint are presented.

Tuberculous arthritis of the knee joint mimicking pigmented villonodular synovitis.

UNLABELLED: Tuberculous arthritis is difficult to diagnose early because of its atypical insidious clinical manifestations and non-specific imaging findings. Specifically, monoarticular tuberculosis of the knee may mimic pigmented villonodular synovitis (PVNS). The present report describes a young patient with tuberculous arthritis of the knee. Proper diagnosis was delayed due to magnetic resonance imaging findings, such as hemosiderin deposits and a nodular mass around the knee joint, suggesting the diffuse type of PVNS. These findings suggest that the first step in the diagnosis of tuberculous knee arthritis is to have a high index of suspicion. LEVEL OF EVIDENCE: IV.

Tubercular osteomyelitis of the second metatarsal: a case report.

A number of studies have described the osteoarticular involvement of tuberculosis, but very few cases of tubercular osteomyelitis of the foot have been reported. We describe a case of spina ventosa affecting the second metatarsal, with a review of the literature and description of the clinical manifestations, diagnostic images, and treatment of skeletal tuberculosis.

Tuberculosis de la muñeca y de la mano / Tuberculosis of the hand and wrist

Introducción: La tuberculosis osteoarticular se observa en la columna, la rodilla y la cadera y, menos a menudo,en las vainas tenosinoviales, y en los huesos de la mano y la muñeca. El objetivo del presente trabajo es analizar esta patología y su tratamiento, y valorar la técnica de reconstrucción simultánea a largo plazo. Materiales y métodos: El estudio abarca a 19 pacientes tratados en 45 años, correspondientes a: 3 espinas ventosas, 10 tenosinovitis de flexores, 4 tenosinovitis de extensores y 2 artritis de muñeca. Empleamos una metodología diagnóstica moderna y el estudio retrospectivo de los pacientes, sus tratamientos y resultados. Resultados: El tratamiento farmacológico correcto es eficaz en 99 por ciento de los casos para la infección tuberculosa. El quirúrgico acelera la curación y consiste en la resección de los tejidos necróticos y la reconstrucción funcional, primaria o secundaria. La curación de la infección se logra siempre; la recuperación funcional estará en relación con el tipo, la. gravedad y la extensión de la lesión. Conclusiones: Se demuestra la frecuencia de estas patologías en los trabajadores de la carne o que están en contacto diario con hacienda. Se destacan los procedimientos modernos de diagnóstico. Se enfatiza en un tratamiento médico completo en calidad, duración y tipo de fármacos. Se destacan las bondades de los tratamientos quirúrgicos y de la reconstrucción funcional simultánea que propusimos en 1965.

Tuberculosis de la muñeca y de la mano / Tuberculosis of the hand and wrist

Introducción: La tuberculosis osteoarticular se observa en la columna, la rodilla y la cadera y, menos a menudo,en las vainas tenosinoviales, y en los huesos de la mano y la muñeca. El objetivo del presente trabajo es analizar esta patología y su tratamiento, y valorar la técnica de reconstrucción simultánea a largo plazo. Materiales y métodos: El estudio abarca a 19 pacientes tratados en 45 años, correspondientes a: 3 espinas ventosas, 10 tenosinovitis de flexores, 4 tenosinovitis de extensores y 2 artritis de muñeca. Empleamos una metodología diagnóstica moderna y el estudio retrospectivo de los pacientes, sus tratamientos y resultados. Resultados: El tratamiento farmacológico correcto es eficaz en 99 por ciento de los casos para la infección tuberculosa. El quirúrgico acelera la curación y consiste en la resección de los tejidos necróticos y la reconstrucción funcional, primaria o secundaria. La curación de la infección se logra siempre; la recuperación funcional estará en relación con el tipo, la. gravedad y la extensión de la lesión. Conclusiones: Se demuestra la frecuencia de estas patologías en los trabajadores de la carne o que están en contacto diario con hacienda. Se destacan los procedimientos modernos de diagnóstico. Se enfatiza en un tratamiento médico completo en calidad, duración y tipo de fármacos. Se destacan las bondades de los tratamientos quirúrgicos y de la reconstrucción funcional simultánea que propusimos en 1965.(AU)

Spina ventosa discharging tubercle bacilli--a case report.

Tubercular dactylitis is an unusual form of skeletal tuberculosis. Radiographic features of cystic expansion of the short tubular bones have led to the name of "Spina Ventosa" for tuberculosis dactylitis of the short bones. We report here a case of a Spina Ventosa in a 15 year-old female, who presented with complaint of draining sinus on the dorsum of the third digit of the left foot.

Recommendations for the diagnosis and treatment of latent and active tuberculosis in inflammatory joint diseases candidates for therapy with tumor necrosis factor alpha inhibitors: March 2008 update.

The Portuguese Society of Rheumatology and the Portuguese Society of Pulmonology have updated the guidelines for the diagnosis and treatment of latent tuberculosis infection (LTBI) and active tuberculosis (ATB) in patients with inflammatory joint diseases (IJD) that are candidates to therapy with tumour necrosis factor alpha (TNFalpha) antagonists. In order to reduce the risk of tuberculosis (TB) reactivation and the incidence of new infections, TB screening is recommended to be done as soon as possible, ideally at the moment of IJD diagnosis, and patient assessment repeated before starting anti-TNFalpha therapy. Treatment for ATB and LTBI must be done under the care of a TB specialist. When TB treatment is indicated, it should be completed prior to starting anti-TNFalpha therapy. If the IJD activity justifies the need for immediate treatment, anti-TNFalpha therapy can be started two months after antituberculous therapy has been initiated, in the case of ATB, and one month after in the case of LTBI. Chest X-ray is mandatory for all patients. If Gohn s complex is present, the patient should be treated for LTBI; healed lesions require the exclusion of ATB. In cases of suspected active lesions ATB should be excluded/confirmed and adequate therapy initiated. Tuberculin skin test, with two units of RT23, should be performed in all patients. If the induration is <5 mm, the test should be repeated within 1 to 2 weeks, on the opposite forearm, and will be considered negative only if the result is again <5 mm. Positive TST implicates LTBI treatment, unless previous proper treatment was provided. If TST is performed in immunossuppressed IJD patients, LTBI treatment should be offered to the patient before starting anti-TNFalpha therapy, even in the presence of a negative test, after risk/benefit assessment.

Tuberculosis of the metacarpals and phalanges of the hand.

Skeletal tuberculosis (TB) is less common than the pulmonary form. Involvements of the metacarpals and phalanges of the hand are infrequent. The authors report their experience with treatment and outcome of TB of the metacarpals and phalanges of the hand in 7 patients. There were 4 women and 3 men in the study who ranged in age from 3 to 60 years (average age, 22.7 years). The duration of complaints at presentation ranged from 4 to 17 months (average, 9 months). The most common presentation was pain and swelling. The presumptive preoperative diagnoses were bone tumor in 4 patients, spina ventosa in 2, and chronic pyogenic osteomyelitis in 1 patients. The results of the laboratory examination showed a mild increase in the erythrocyte sedimentation rate. No patient had an active tubercular lesion or history of pulmonary disease. The diagnosis was based on the clinical picture and radiographic features, and was confirmed by open biopsy. No patient had bony debridement or arthrodesis to control the infection. The treatment of all patients began with a 4-drug regimen for 2 months, followed by a 2-drug regimen for 10 months. The mean follow-up was 30.28 months (range, 16-52 months). At the time of the last follow-up, all lesions had healed with no recurrence. The functional results were satisfactory in all patients. One patient with thumb metacarpophalangeal TB had joint irregularity and thumb metacarpal shortening. Arthrodesis was not needed in any patient. TB of the metacarpals and phalanges of the hand can be difficult to diagnose during the early stages. TB should be suspected in cases of long-standing pain and swelling in the metacarpals and phalanges. It is necessary to keep TB in mind when making the differential diagnosis of several osseous pathologies.