Extrapulmonary, Chronic Septic Arthritis From Mycobacterium tuberculosis in the Ankle and Subtalar Joints.

In the United States, rates of Mycobacterium tuberculosis infection have been declining for decades. Osteoarticular tuberculosis of the ankle is rarely observed. We present the case of a 65-year-old man who immigrated to the United States from India 24 years before the onset of symptoms. The patient initially reported atraumatic swelling and pain of the left ankle and foot and was treated for venous insufficiency. Later, the patient was referred to a nonsurgical orthopaedic clinic for additional workup and was found to have elevated inflammatory markers. MRI showed septic arthritis and osteomyelitis of the talus, distal tibia, and calcaneus. Joint aspiration revealed elevated white blood cell counts with predominately PMNs. The patient was then referred to an orthopaedic foot and ankle surgeon and underwent extensive irrigation and débridement. The patient was discharged on empiric antibiotics. Culture results from the original joint aspirate returned 14 days after surgery as positive for acid-fast bacillus, later identified as M tuberculosis by sequencing. Empiric antibiotics were discontinued, and the patient was started on appropriate antituberculotic therapy. This case report illustrates the challenge in the diagnosis of skeletal tuberculosis and the importance of including this condition on the differential for patients with atypical foot and ankle presentations.

Pediatric Multidrug-Resistant Disseminated Tuberculosis Presenting as Small Finger Tuberculous Osteomyelitis: A Case Report.

CASE: We report a case in the United States of a 12-year-old girl with multidrug-resistant tuberculous (MDR-TB) osteomyelitis of the hand managed with surgical debridement and second-line anti-TB therapy. The disease course was complicated by dissemination and multifocal progression. CONCLUSION: Despite early intervention, multidrug resistance makes TB treatment challenging and facilitated progression to disseminated disease in this case. We review the difficulties in diagnosis and treatment of pediatric MDR-TB.

Unveiling foot tuberculosis as an under-recognized source of foot pain.

PURPOSE: Foot tuberculosis is a rare form of osteoarticular tuberculosis, accounting for less than 1% of cases. It presents unique diagnostic challenges due to its nonspecific clinical features and overlapping symptoms with other conditions. This study aimed to investigate the clinical presentation, radiographic findings, and prognosis of foot tuberculosis, with the goal of improving early recognition and appropriate intervention. METHODS: A prospective study was conducted between November 2016 and July 2021, involving 39 patients diagnosed with foot tuberculosis. Clinical examinations, laboratory tests, X-rays, and MRI evaluations were performed to aid in the diagnosis. Biopsy was conducted on patients with radiological lesions. Patients were treated with an 18-month course of antitubercular therapy (ATT). Foot Function Index (FFI) scores were recorded before and after treatment. Statistical analysis was conducted to assess factors impacting prognosis. RESULTS: Unilateral foot involvement was observed in all patients, with a male predominance (61.5%) and a mean age of 31.3 years. The most common symptoms were pain and edema, with sinus tracts present in 17.9% of patients. Radiographic findings showed cystic and sclerotic lesions, with the "spina ventosa" appearance primarily affecting the metatarsal bones. MRI played a valuable role in early detection. Histopathological examination confirmed tuberculosis in all cases, and acid-fast bacilli were found in 23% of patients. Most patients (79.4%) responded well to ATT without requiring surgery. Factors such as high initial ESR, delayed ATT initiation, multiple lesions, and tarsal involvement were associated with unfavourable outcomes. CONCLUSION: Foot tuberculosis presents with nonspecific symptoms, leading to misdiagnosis and delays in appropriate treatment. Clinical examination, radiographic evaluation, and biopsy are essential for accurate diagnosis. Early initiation of ATT is crucial for favourable outcomes. Factors such as high initial ESR, delayed treatment initiation, multiple lesions, and tarsal involvement negatively impact prognosis. This study highlights the importance of recognizing foot tuberculosis and provides insights into its clinical presentation, radiographic features, and treatment outcomes, facilitating timely intervention and improved patient management.

"Tuberculosis on the spot" - Discussion of a probable sternal tuberculosis from a late medieval cemetery from Hungary.

Investigations of non-adult remains are particularly suitable for finding epidemic periods in past populations. This study presents a probable unique example of osseous manifestation of tuberculosis on a child's skeletal remains from medieval Hungary. Between 2009 and 2011 the Field Service for Cultural Heritage excavated the exceptional cemetery of Perkáta - Nyúli-dulo in Hungary, with around 5000+ graves. The analysed skeleton (SNR 948) was located in the medieval (10-16th century) part of the cemetery. Besides the standard macroscopic pathological observation, we also performed radiographic analysis. The remains of the child (13-14 year-old) showed numerous skeletal lesions: the ribs have proliferative lesions (dense nodules) on the visceral surface of the shaft, lytic lesions with rounded edges occurred on the thoracic and lumbar vertebral bodies, and on the facies auricularis of the left ilium we can see pitting and new bone formation. What makes this pathological case exceptional is the significant change in the manubrium. It shows extensive osteolytic lesions, probably due to tuberculous osteomyelitis, which is a unique phenomenon in an archaeological context. This rare type of extra-spinal tuberculous osteomyelitis appears in less than 1% of cases with skeletal TB, and even less in case of children, according to modern medical literature. Although some cases of slight lesions on the manubrium have been described from an archaeological context, no such cases showing advanced lesions have been published so far. In the future, biomolecular analyses should be conducted as well, in order to confirm the presence of TB in this individual.

Clinical characteristics and treatment outcomes of tuberculous tenosynovitis of the hand and wrist.

Objective: Vietnam is endemic with tuberculosis (TB), which is highly prevalent in the community. TB tenosynovitis of the wrist and hand is uncommon. Because of its insidious progression and atypical presentations, it is often difficult to diagnose, leading to treatment delays. This study investigates the characteristics of clinical and subclinical signs and treatment outcomes of patients with TB tenosynovitis in Vietnam. Patients and Methods: This prospective longitudinal cross-sectional study included 25 TB tenosynovitis patients in the Rheumatology Clinic at University Medical Center Ho Chi Minh City. The diagnosis was made based on a tuberculous cyst in histopathological specimens. The data were collected through medical history, physical examination, and medical records, including demographics, signs, symptoms, condition duration, and related laboratory tests and imaging. The outcomes of all participants were assessed after 12 months of treatment. Results: The most common symptom of TB tenosynovitis was swelling of the hand and wrist, which was present in all patients. Its other symptoms included mild pain and numbness of the hand in 72% and 24% of patients, respectively. It can affect any site on the hand. Hand ultrasound findings included thickening of the synovial membrane (80%), peritendinous effusion (64%), and soft tissue swelling (88%). Most patients (18/22) had a good outcome after the treatment with anti-tubercular drugs. Conclusions: TB tenosynovitis progression is often insidious. Its most common symptoms are swelling of the hand and mild pain. Ultrasound is a useful tool to support the diagnosis. A histological examination confirms the diagnosis. Most cases respond and have a good outcome after 9-12 months of anti-tuberculosis treatment.

Efficacy analysis of anterior debridement and bone graft fusion in the treatment of sacroiliac joint tuberculous arthritis: a retrospective analysis of 17 patients.

BACKGROUND: Sacroiliac joint tuberculous arthritis is a relatively rare site of tuberculosis infection, but it can lead to severe sacroiliac joint destruction and dysfunction. Since there are few studies on the surgical methods of sacroiliac joint tuberculosis (SJT), we adopted three different surgical methods based on different degrees of destruction of sacroiliac joint tuberculous arthritis. While revealing its clinical symptoms to improve the diagnostic accuracy, and to determine the safety and feasibility of this surgical approach in the treatment of sacroiliac joint tuberculous arthritis. METHODS: We retrospectively analyzed 17 patients with tuberculous arthritis of the sacroiliac joint treated by anterior debridement. All these patients underwent anterior debridement of tuberculosis with or without bone graft fusion. Mean postoperative follow-up was 17.2 months (12-25 months). The erythrocyte sedimentation rate (ESR) was used to judge the general situation after surgery, and the fusion of sacroiliac joints was observed by X-ray films and CT scans. And VAS and ODI were used to score to observe postoperative functional recovery. RESULTS: Anterior approach debridement is an effective surgical approach for sacroiliac joint tuberculous arthritis. All patients achieved effective relief of lower back and hip pain. The pain was significantly relieved 3 months after the operation, and the pain basically disappeared 6 months after the operation. The erythrocyte sedimentation rate was also significantly reduced after the operation, and it can basically return to the normal level 3 months after the operation. The VAS score and ODI index of the other 16 patients after surgery were significantly lower than those before surgery, except for 1 patient who died of severe type I respiratory failure and septic shock 3 months after surgery, The surviving patients were basically able to achieve stable fusion of the sacroiliac joint at 12 months postoperatively. None of the patients reported significant pain until the last follow-up visit. CONCLUSIONS: The anterior approach is a very effective surgical method for the treatment of sacroiliac joint tuberculous arthritis, and it is safe and feasible. A clear operative field of view facilitates complete debridement and reduces recurrence, and its function recovers well with stable arthrodesis.

[Tuberculous osteomyelitis in the lateral cuneiform bone causing prolonged pain].

Tuberculous osteomyelitis is an uncommon infection. In this case report, a 29-year-old Greenlandic male with increasing pain, swelling and discolouring of his left foot for four months was admitted to the hospital. He had no systemic symptoms. A CT scan of the foot showed a pathological fracture of the lateral cuneiform bone, and a chest X-ray revealed apical infiltrates indicating tuberculosis. Cultivation of bronchoalveolar lavage fluid was positive for Mycobacterium tuberculosis which confirmed the diagnosis of tuberculosis in the lungs and bone. The patient was treated with immobilization of the foot and antitubercular drugs for 12 months.

Costal tubercular osteomyelitis presenting as an orbital abscess.

Orbital abscesses are most commonly associated with co-existing active paranasal sinus infection. Herein, the authors present the case of an orbital abscess in the setting of costal tubercular osteomyelitis and an anterior chest wall abscess in the absence of any paranasal sinus pathology in an immunocompetent patient. Costal tuberculosis is a very rare form of extrapulmonary skeletal tuberculosis and is challenging to diagnose. Initial presentation as an orbital abscess remote from the site of the primary pathology is of extremely rare occurrence. In this instance, the diagnosis of tuberculous osteomyelitis was suspected primarily on the basis of clinicoradiological features. The patient was treated with, and responded well to, standard first-line anti-tubercular therapy (ATT) for extrapulmonary tuberculosis.

Tuberculosis of the Cuboid in a 16-Month-Old Child: A Case Report.

CASE: A 16-month-old male child presented with swelling over the dorsolateral aspect of the right foot associated with limp and no other constitutional symptoms. Tenderness and swelling were noted over the dorsolateral aspect, and radiographs revealed an eccentric lytic expansile lesion in the right cuboid. Biopsy of the lesion revealed necrotizing granulomas, and molecular testing later documented tuberculosis. The child received antitubercular medications and was relieved of symptoms in 6 weeks. Complete healing was observed after 12 months. CONCLUSION: In developing countries, a high index of suspicion helps in the early diagnosis and appropriate management of tubercular osteomyelitis in children.

Calvarial tuberculosis in a paediatric patient: a diagnosis not to forget.

We report the case of a 10-year-old boy that presented with a palpable, painless, frontal lesion. Laboratory assessments were unremarkable and the patient was asymptomatic. Initial investigation, with a skull radiograph and unenhanced CT scan, showed a lytic midline frontal lesion involving the inner and outer tables of the skull and a large subgaleal hypodense component. MRI further depicted communication with the epidural space and contact with the superior sagittal sinus (SSS). Subsequent evaluation by Doppler ultrasound and MR angiography excluded a sinus pericranii and showed normal patency of the SSS. Surgical biopsy revealed chronic granulomatous inflammation; PCR was positive for Mycobacterium sp. One year after surgical resection and antitubercular therapy, there are no signs of recurrence. Primary calvarial involvement by tuberculosis is rare, even in developing countries. Familiarity with the expected clinical and imaging features is required to avoid diagnostic delay.

MRI findings on extrapulmonary tuberculosis in a pediatric patient / [Hallazgos de tuberculosis extrapulmonar en imágenes de resonancia magnética en una paciente pediátrica].

Pulmonary tuberculosis is the most common in children and its extrapulmonary manifestations are present in 30% to 40% of cases. We present the case of an indigenous girl with disseminated tuberculosis: pulmonary, brain, medullary, and musculoskeletal with substantial neurodevelopmental sequelae. This case exemplifies the spectrum of pediatric extrapulmonary tuberculosis in endemic developing countries. Furthermore, it shows the severity of highly disabling neurological complications and stresses the importance of radiological imaging in guiding diagnostic suspicion of extrapulmonary involvement.

La tuberculosis pulmonar es la más común en niños y su forma extrapulmonar corresponde aproximadamente a 30 a 40 % de los casos. Se presenta el caso de una niña indígena con tuberculosis diseminada: pulmonar, cerebral, medular y musculoesquelética, con importantes secuelas en el neurodesarrollo. Este caso ilustra el espectro de la tuberculosis extrapulmonar pediátrica en países endémicos en desarrollo. Además, evidencia la gravedad de las complicaciones neurológicas causantes de grave discapacidad y resalta el valor de las imágenes radiológicas para orientar la sospecha diagnóstica de compromiso extrapulmonar.

The development of musculoskeletal radiology for 100 years as presented in the pages of Acta Radiologica.

During the last 100 years, musculoskeletal radiology has developed from bone-only radiography performed by everyone to a dedicated subspecialty, still secure in its origins in radiography but having expanded into all modalities of imaging. Like other subspecialties in radiology, it has become heavily dependent on cross-sectional and functional imaging, and musculoskeletal interventions play an important role in tumor diagnosis and treatment and in joint diseases. All these developments are reflected in the pages in Acta Radiologica, as shown in this review.

Diagnostic values of peripheral blood T-cell spot of tuberculosis assay (T-SPOT.TB) and magnetic resonance imaging for osteoarticular tuberculosis: a case-control study.

OBJECTIVE: Early diagnosis of osteoarticular tuberculosis helps improve patients' outcomes, but little is known about the accuracy of noninvasive diagnostic methods. This case-control study aimed to assess the diagnostic value of peripheral blood T-cell spot of tuberculosis assay (T-SPOT.TB) and magnetic resonance imaging (MRI). METHODS: Patients suspected with osteoarticular tuberculosis were retrospectively included and diagnosed according to the composite reference standard. T-SPOT.TB was used to detect the number of cells secreting Interferon gamma. Diagnostic performance of T-SPOT.TB and MRI alone and combined were evaluated. RESULTS: Among the suspected patients, 92 had osteoarticular tuberculosis and 137 non- osteoarticular tuberculosis. T-SPOT.TB assay alone had a higher sensitivity (0.73 vs. 0.60) but a lower specificity (0.69 vs. 0.91 P>0.05) in diagnosing osteoarticular tuberculosis. Combined serial test showed a sensitivity and specificity 0.47, 0.97, respectively, whereas combined parallel test showed a sensitivity and specificity of 0.86, 0.65, respectively. Specificity was higher in the combined serial test than in the T-SPOT.TB assay (P=0.007) or MRI alone (P < 0.001). Furthermore, sensitivity was higher in the combined parallel test than in the T-SPOT.TB assay (P < 0.001) or MRI alone (P < 0.001). CONCLUSIONS: Combined blood T-cell spot of tuberculosis assay and osteoarticular MRI have higher sensitivity and specificity for noninvasive osteoarticular tuberculosis diagnosis, compared with either method alone.

Role of 18F-FDG PET/CT in the Assessment of Response to Antitubercular Chemotherapy and Identification of Treatment Endpoint in Patients With Tuberculosis of the Joints: A Pilot Study.

AIMS: The aim of this study was to explore the utility of 18F-FDG PET/CT in the assessment of response to antitubercular treatment (ATT) and identification of treatment endpoint. PATIENTS AND METHODS: Forty patients (mean age, 35.3 years; 27 men) with clinically, radiologically, and histopathologically proven joint tuberculosis prospectively underwent clinical, biochemical, and PET/CT evaluation at baseline and after ~6, 12, and 18 months of ATT. Two patients were lost to follow-up, and 1 defaulted treatment. The remaining 37 were followed up until complete response (CR) was achieved. Images were visually and quantitatively (SUVmax ratio and metabolically active disease volume [MV]) evaluated by 2 experienced nuclear medicine physicians. RESULTS: Knee (n = 18) and ankle (n = 7) were the most frequently involved sites. The median MV and SUVmax ratio at baseline were 85.10 mL and 7.21, respectively. Five patients had noncontiguous vertebral involvement, 12 had pulmonary lesions, 2 had abscesses, 6 had mediastinal, and 30 had local lymph nodal involvement. Complete response was seen in 1/39, 11/37, and 30/37 patients after 6, 12, and 18 months of ATT. Significant reductions in visual analog scale score, tenderness, joint swelling, SUVmax ratios, and MVs (Friedman test, P < 0.001) were seen after each follow-up. The median time-to-CR in skeletal lesions was significantly longer than extraskeletal lesions (591 vs 409 days; Wilcoxon signed-rank test, P < 0.001). Time-to-CR in joint lesions positively correlated with MV at first follow-up (Pearson = 0.452, P = 0.005) and negatively correlated with percentage change in MV (first follow-up from baseline) (Pearson = -0.620, P < 0.001). ROC analysis yielded a cutoff of ≤71% reduction in MV at first follow-up (80.8% sensitivity, 81.8% specificity) to predict extension of ATT beyond 12 months. Using ROC analysis at second follow-up, a cutoff of ≤12.67 mL (for CR) was derived and was validated in patients at the third follow-up, with an accuracy of 84.4%. Patients with CR in PET/CT maintained disease-free state during a mean follow-up of 271 days. CONCLUSIONS: 18F-FDG PET/CT is an excellent tool in estimating total disease burden, assessing response to ATT and identification of treatment endpoint in joint tuberculosis.

A rare presentation of isolated carpal bone tuberculous osteomyelitis mimicking gouty arthritis.

Tuberculosis (TB) is the most prevalent infectious disease in Southeast Asia. It causes both pulmonary and extrapulmonary diseases. TB of the wrist is rare and presents as osteomyelitis or tenosynovitis. We report a middle-aged male with carpal bone tuberculous osteomyelitis. He presented with left wrist pain initially treated as gouty arthritis. Within 2 weeks, he developed seropurulent discharge with osteomyelitic changes on imaging. He underwent debridement, and intraoperatively, there was destruction of most carpal bones. Histopathological examination revealed chronic granulomatous inflammation with abscess formation. Anti-TB medication was initiated, and he made a complete recovery with almost full range of wrist movement after 9 months of treatment. This case serves as a reminder that TB is a great mimicker, and a high index of suspicion is required to make a diagnosis of TB of the wrist. Early initiation of anti-TB is pivotal to prevent complications and deterioration of joint functions.