Diagnosing osteoarticular tuberculosis and detecting rifampicin resistance: A comparative analysis of Truenat MTB Plus vs GeneXpert Ultra.

SETTING: Diagnosing osteoarticular tuberculosis (OATB) and detecting drug resistance is a challenge in an endemic country like India. OBJECTIVE: Truenat MTB Plus assay (TruPlus), a chip-based portable machine, was compared with GeneXpert Ultra (GxUltra) for diagnosing drug-resistant OATB. DESIGN: 115 synovial fluid and pus specimens [22 culture-positive confirmed, 58 culture-negative clinically-suspected, 35 non-TB controls] processed between 2017 and 2023 were subjected to TruPlus, GxUltra and multiplex-PCR for diagnosing OATB. They were further screened for rifampicin resistance using TruRif chip. The performance was evaluated against composite reference standard, phenotypic drug susceptibility testing and rpoB gene sequencing. RESULTS: TruPlus, GxUltra and MPCR detected 77.5 %, 71.25 %, and 83.75 %, cases of OATB, respectively. TruPlus detected five additional cases missed by GxUltra. The performance of TruPlus was comparable to GxUltra (p = 0.074) and to MPCR (p = 0.074), while performance of GxUltra was significantly inferior to MPCR (p = 0.004). The overall agreement with reference standard was substantial for TruPlus and MPCR and moderate for GxUltra. Both TruRif and GxUltra reported 4 cases as rifampicin resistant. CONCLUSION: TruPlus along with TruRif offers better sensitivity than GxUltra. Its compact and portable platform allows wider application in peripheral settings, thus making it a pragmatic solution for diagnosing OATB and its drug resistance.

Indolent ulcer and discharging sinus on the eyelid of healthy Indian children and an adult: Orbital tuberculosis, a spot-diagnosis.

Five cases of tuberculous osteomyelitis of the fronto-zygomatic (F-Z) region presented with a non-healing ulcer or discharging sinus in the eyelid skin in healthy children and an adult. Lack of awareness about peri-ocular manifestations of extra-pulmonary tuberculosis and delayed referral to specialists, along with poor compliance to long-term ATT, could be the reason for its underreporting in India.

Extraspinal osteoarticular tuberculosis: A diagnostic and therapeutic challenge.

Tuberculosis (TB) is a major cause of morbidity and mortality, representing a challenge for health-care providers worldwide. Extraspinal osteoarticular tuberculosis (ESOTB) represents a rare location of TB. We aim to describe ESOTB focusing on clinical, diagnostic, and therapeutic characteristics of this entity. We report a retrospective case series of patients diagnosed with ESOTB, treated, and followed up between 2015 and 2022. The diagnosis was based either on bacteriological results (culture and polymerase chain reaction [PCR]) or histological analysis. Five patients with confirmed ESOTB, three women and two men, with a mean age of 46.4 (16-72), were enrolled in study. The affected sites were the elbow (one case), the shoulder (one case), the greater trochanter (one case), the second metatarsal (one case), and the distal interphalangeal joint (one case). The mean delay to diagnosis was 5.8 months (3-10)]. The most common symptoms on presentation were pain (all cases), swelling (all cases), and limited joint range of motion (all cases). One case presented with a draining sinus (20%). Radiological findings were soft tissue swelling (two cases) and periarticular bone destruction (all cases). Four patients presented with pathognomonic histology. PCR was performed in two patients and was positive in both of them. All cases were cured after 9-12 months of oral TB treatment without relapse for the 12-18 months of follow-up. Only one patient underwent surgery for abscess drainage to gain local infection control. ESOTB is a mysterious condition that must not be overlooked and should be suspected in cases of long-standing bone and joint pain and swelling.

Tubercular osteomyelitis of calcaneum in an immunocompetent adult.

Tuberculosis (TB) affecting calcaneum is relatively rare in immunocompetent adults. Due to its nonspecific presentation and the absence of constitutional symptoms of TB, diagnosis is often delayed. The authors present a case of TB of calcaneum in a young male. A 20-year-old male presented with persistent pain and mild swelling of the right heel for 6 months. Upon evaluation with radiographs, a lytic lesion was noted in the posteromedial aspect of the right calcaneum. Magnetic resonance imaging was done and was reported as subacute osteomyelitis with Brodie's abscess. An open biopsy was performed and the obtained tissue was sent for histopathological examination. Histopathology showed features suggestive of Koch's etiology. All the microbiological investigations, including polymerase chain reaction for TB were negative. The patient was started on antitubercular therapy (ATT) based on weight. After 4 months of ATT, the patient developed multiple discharging sinuses over a previous open biopsy scar for which repeat debridement was done. After 12 months of ATT, the patient was asymptomatic, and radiologically, the lesion was healed. Early diagnosis and treatment with ATT will prevent massive destruction and collapse of the calcaneal body and further spread into the subtalar joint. Repeated debridements may be needed in case of nonhealing discharging sinuses to decrease the local infection load.

Mycobacterium tuberculosis infectious monoarthritis in a paediatric patient.

Mycobacterium tuberculosis is uncommon in the USA, and when it is diagnosed, it is usually in adult patients with identifiable risk factors presenting with pulmonary manifestations of the disease. Paediatric tuberculosis is rare, and a minority of those cases can present with isolated extrapulmonary infection. When the musculoskeletal system is involved, there are often no constitutional symptoms, and it can resemble other infectious and inflammatory processes. Diagnosis is challenging, and delay leads to irreversible destructive osteoarticular changes. A prompt diagnosis requires a high index of suspicion. This report presents a case of successfully diagnosed paediatric M. tuberculosis monoarthritis of the knee to highlight these challenges.

An extensor tenosynovitis complicated with extensor tendon rupture revealing a hand tuberculosis.

Tuberculous hand tenosynovitis is a rare localization of tuberculosis. It is dominated by flexor tendon involvement; tenosynovitis of the extensor tendons is exceptional. The diagnosis is usually delayed and sometimes overlooked because of the paucity and the chronicity of the symptoms and signs with the patients often seen at the stage of tendon rupture. We, hereby, report the case of a tuberculous tenosynovitis of the extensors of the left hand having evolved into a ruptured extensor tendons to the 4th and 5th digits. The surgical treatment in conjunction with the antituberculous drugs resulted in the healing of this condition.

Several potential serum proteomic biomarkers for diagnosis of osteoarticular tuberculosis based on mass spectrometry.

BACKGROUND: Osteoarticular tuberculosis is one of the extrapulmonary tuberculosis (EPTB) diseases, which is mainly caused by infection of Mycobacterium tuberculosis (MTB) in bone and joints. The limitation of current clinical test methods is leading to a high misdiagnosis rate and affecting the treatment and prognosis. This study aims to search serum biomarkers that can assist in the diagnosis of osteoarticular tuberculosis. METHODS: Proteomics can serve as an important method in the discovery of disease biomarkers. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to analyze proteins in 90 serum samples, which were collected from June 2020 to December 2021, then evaluated by statistical analysis to screen potential biomarkers. After that, potential biomarkers were validated by enzyme-linked immunosorbent assay (ELISA) and diagnostic models were also established for observation of multi-index diagnostic efficacy. RESULTS: 118 differential expressed proteins (DEPs) were obtained in serum after statistical analysis. After the diagnostic efficacy evaluation and clinical verification, inter-alpha-trypsin inhibitor heavy chain H2 (ITIH2), complement factor H-related protein 2 (CFHR2), complement factor H-related protein 3 (CFHR3), and complement factor H-related protein 5 (CFHR5) were found as potential biomarkers, with 0.7167 (95 %CI: 0.5846-0.8487), 0.8600 (95 %CI: 0.7701-0.9499), 0.8150 (95 %CI: 0.6998-0.9302), and 0.9978 (95 %CI: 0.9918-1.0040) AUC value, respectively. The remaining DEPs except CFHR5 were constructed as diagnostic models, the diagnostic model contained CFHR2 and CFHR3 had good diagnostic efficacy with 0.942 (95 %CI: 0.872-0.980) AUC value compared to other models. CONCLUSION: This study provides a reference for the discovery of serum protein markers for osteoarticular tuberculosis diagnosis, and the screened DEPs can also provide directions for subsequent pathogenesis research.

Tuberculous Osteomyelitis of The Pubic Symphysis - a Case Report of a Rare Entity Mimicking Spondyloarthritis.

Tuberculosis (TB) osteomyelitis of the pubic symphysis is an extremely rare diagnosis. Axial spondyloarthritis (SpA) is characterized by inflammatory back pain and enthesitis, and involvement of pubic symphysis is very unusual at presentation. A 36-year-old female patient with a history of inflammatory back and pubic pain was referred to Rheumatology. She had a pelvic magnetic resonance imaging (MRI) suggestive of osteitis pubis. She was started on etoricoxib 90mg/day as axial spondyloarthritis was suspected, with no improvement. Pelvic MRI was repeated and showed osteomyelitis of the iliopubic branches. An ultrasound-guided biopsy was performed, and culture was positive for Mycobacterium tuberculosis. Further imaging studies revealed small cavitations and several centrilobular micronodules with a tree-in-bud pattern in the upper lung lobes and in the upper segment of the lower left lobe. She was started on anti-tuberculous treatment for 1 year and had a good clinical and radiological response. TB osteomyelitis of the pubic symphysis is a rare entity and has seldom been reported. However, this is the first case, to our knowledge, where the clinical picture mimicked an itself unusual presentation of SpA.

Clinical utility of tuberculosis RNA in the rapid diagnosis of bone and joint tuberculosis.

OBJECTIVES: To evaluate the diagnostic accuracy of tuberculosis RNA (TB-RNA) for the rapid diagnosis of bone and joint tuberculosis (BJTB). METHODS: We conducted a retrospective study to evaluate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) of TB-RNA and acid-fast bacillus (AFB) smear against the final clinical diagnosis. RESULTS: A total of 268 patients were included. The overall sensitivity, specificity, PPV, NPV, and AUC of AFB smear for BJTB were 0.7%, 100.0%, 100.0%, 49.3%, and 0.50, respectively, whereas those of TB-RNA were 59.6%, 100.0%, 100.0%, 70.6%, and 0.80, respectively; for cases of confirmed (culture-positive) BJTB, these values were 82.8%, 99.4%, 99.7%, 89.2%, and 0.91, respectively. CONCLUSIONS: The diagnostic accuracy of TB-RNA in the rapid diagnosis of BJTB was relatively good, especially in culture-positive BJTB. The use of TB-RNA could be an effective technique for the rapid diagnosis of BJTB.

Osteoarticular tuberculosis in Central India: Changing epidemiological profile and emerging challenges.

Background: Osteoarticular tuberculosis (OATB) is a form of extrapulmonary tuberculosis (TB) affecting bones and joints. There is a paucity of data on skeletal TB epidemiology in the annual TB reports and current literature. Many atypical presentations of the disease have also emerged. This necessitates periodic observation of the epidemiological profile of OATB. The aim of this study is to analyze the prevailing epidemiological trends of OATB in Central India. Methods: The 5-year ambispective observational study was conducted at the department of orthopedics of a tertiary care center in Central India. Records of patients diagnosed with OATB from January 2017 to December 2021 were analyzed for demographic factors, site of lesion, comorbidities (pulmonary TB, human immunodeficiency virus, and diabetes), etc., Chi-square test for linear trend was used to determine whether a linear trend exists in the number of diagnosed cases. Results: Two hundred and ten skeletal TB lesions were found in 208 patients included in the study. OATB was highly reported in young adults and females. Spinal lesions were three times more common than extraspinal OATB lesions. The lumbar spine was the most affected region. Hip was the most common extraspinal site. Unusual sites such as sternoclavicular joint and ischial tuberosity were also involved. Conclusion: The burden of OATB is increasing, especially spinal TB. The involvement of atypical sites insists on strong clinical suspicion for early diagnosis. The practice of empirical antitubercular chemotherapy needs to be reviewed considering the risk of drug resistance.

Tuberculosis of hand and wrist: Varied clinical presentation and functional outcome by surgical intervention in 13 cases.

A prospective study of 13 cases with tuberculosis of hand and wrist was presented with mean age of patients being 42.7 years (range 18 months to 84 years). Pain, swelling and difficulty in movement of adjacent joints were the most common presenting complaints. The discharging sinus, abscess & nerve compression were also observed in some cases. Out of 13 cases, bone involvement was seen in one case, joint involvement in five cases, soft tissue involvement in five cases and two cases had both soft tissue and joint involvement. All patients had undergone operative intervention for confirmation of diagnosis and improvement in function. Surgeries like open biopsy, debridement and tenosynovectomy were performed. Depending upon drug sensitivity on culture and histopathology report, standard anti-tuberculous treatment (ATT) was commenced under supervision of Infection Disease expert. Hand function was evaluated by modified Green and O'Brian score. The mean score was 58.84 (35-70) before any intervention and it improved to 89.23 (60-100) at 6 months follow up after surgical intervention and ATT. In conclusion, surgery may help for early functional recovery and for encouraging patient to use their hand for activities of daily living.

Disseminated tuberculosis after anti-TNF alpha treatment: Do not blindly trust the IGRA test / Tuberculosis diseminada tras tratamiento anti-TNF alfa: no confíe ciegamente en la prueba IGRA

Introduction: Interferon gamma release assay (IGRA) is used to detect latent tuberculosis prior to biological treatments in the context of suspected inflammatory rheumatism. Methods: We report the case of a 50-year-old woman with negative IGRA test before adalimumab introduction for presumed axial spondyloarthritis. Results: The worsening of symptoms under treatment led to further investigations and the diagnostic of disseminated tuberculosis (TB) was later established with miliary and multiple bone locations such as spondylitis and sacroilitis. The patient's history revealed past exposure to tuberculosis. This observation illustrates the limitations of IGRA in such situation due to its variable performance for active TB diagnosis. Conclusion: Misdiagnosis is frequent in bone tuberculosis due to non-specific signs. We draw the attention to the importance of a global risk assessment prior to the introduction of biological treatment for suspected chronic inflammatory rheumatism and recall the risk factors for false-negative IGRA. An extended treatment course may be necessary after exposure to anti-TNF-alpha.(AU)

Introducción: El ensayo de liberación de interferón gamma (IGRA) se utiliza para detectar tuberculosis latente antes de los tratamientos biológicos en el contexto de sospecha de reumatismo inflamatorio. Métodos: Presentamos el caso de una mujer de 50 años con IGRA negativo antes de la introducción de adalimumab por presunta espondiloartritis axial. Resultados: El empeoramiento de los síntomas bajo tratamiento llevó a nuevas investigaciones y posteriormente se estableció el diagnóstico de tuberculosis (TB) diseminada con localizaciones pulmonar y óseas múltiples como espondilitis y sacroilitis. La historia de la paciente reveló una exposición pasada a la TB. Esta observación ilustra las limitaciones del IGRA en tal situación debido a su rendimiento variable para el diagnóstico de la TB activa. Conclusiones: El diagnóstico erróneo es frecuente en la TB ósea debido a signos inespecíficos. Llamamos la atención sobre la importancia de una evaluación de riesgo global antes de la introducción de un tratamiento biológico para la sospecha de reumatismo inflamatorio crónico, y recordamos los factores de riesgo para falsos negativos del IGRA. Puede ser necesario un curso de tratamiento prolongado después de la exposición al tratamiento anti-TNF-alfa.(AU)

Decrease in osteoarticular tuberculosis in Spain between 1997 and 2018.

BACKGROUND AND OBJECTIVE: osteoarticular tuberculosis represents 2%-5% of the manifestations of tuberculosis. The objective was to calculate the incidence and describe the epidemiological characteristics of patients with osteoarticular tuberculosis who received hospital care in Spain between 1997-2018. METHODS: A retrospective study was conducted of patients treated with osteoarticular tuberculosis in Spanish hospitals between 1997 and 2018, using the data from the Minimum Basic Data Set at hospital discharge, using the ICD-9-CM and ICD-10 codes. RESULTS: 5710 patients with osteoarticular tuberculosis were detected over the 22 years in Spain. The mean annual incidence for the period was 6 cases per million inhabitants (95% CI 5.58-6.30). There was a significant difference between the mean annual incidence per million inhabitants of the first period (1997-2007) of 6.95 and that of the second (2008-2018) of 5.35 (p<.001). CONCLUSIONS: The incidence of osteoarticular tuberculosis in Spain is low, has reduced over 22 years and predominates in men.

Musculoskeletal tuberculosis revisited: bone and joint tuberculosis in Austria.

BACKGROUND: To prevent further spread of the disease and secondary deformity, musculoskeletal tuberculosis (TB) remains a challenge in terms of early diagnosis and treatment. This study gives an overview on TB trends in Austria (pulmonary and extrapulmonary TB) (A) and analyses a retrospective series of musculoskeletal TB cases diagnosed and treated at an Austrian tertiary centre (B). METHODS: (A) We analysed data obtained from the Austrian national TB registry to provide information on TB patients´ demographics and manifestation sites between 1995 and 2019. (B) Furthermore, we performed an observational study of all patients with a confirmed diagnosis of musculoskeletal TB who were admitted to the Department of Orthopaedics and Trauma, Medical University of Graz (2005-2019). Demographic, diagnostic, clinical and follow-up data were retrieved from the medical records. RESULTS: (A) From 1995 to 2019, a significant linear reduction in overall Austrian tuberculosis incidence rates occurred (p < 0.001). In the period investigated, Austria recorded a total of 307 patients with musculoskeletal TB. (B) Our retrospective case-series included 17 individuals (9 males, 8 females; average follow-up 48.4 months; range 0-116). There was a biphasic age distribution with a peak in elderly native Austrians (median 69, range 63-92), and a second peak in younger patients with a migration background (median 29, range 18-39). Sites of manifestation were the spine (n = 10), peripheral joints (n = 5), and the soft tissues (n = 2). Diagnosis was based on histology (n = 13), PCR (n = 14), and culture (n = 12). Eleven patients underwent surgery (64.7%). Secondary deformities were frequent (n = 9), and more often observed in patients with spinal TB (n = 6). CONCLUSION: Musculoskeletal TB should be considered if untypical joint infections or nonspecific bone lesions occur in younger patients with a migration background or in patients with specific risk factors.

Bone tuberculosis, in patients with no prior history of tuberculosis.

There are different types of infection caused by Mycobacterium tuberculosis, the pulmonary variety is the most common of them; infection of the bone secondary to joint replacement, is usually caused by a previous lung infection that has been disseminated. However primary bone infection is very rare and little reported, which makes information on the matter very scarce. A female patient is presented with a history of congenital hip dysplasia, who underwent multiple surgical interventions, including total hip arthroplasty (THA), afterwards she presented a fistula and persistent serous exudate; a biopsy was performed where acid-fast bacilli were detected. The delay in the diagnosis of osteoarticular tuberculosis (OATB) can lead to negative consequences, affecting the quality of life of the patient. Conventional diagnostic methods may be insufficient for the diagnosis of OATB.

Existen diferentes tipos de infección causadas por Mycobacterium tuberculosis, siendo la variedad pulmonar la más común de ellas; la infección del hueso secundaria a la artroplastia suele estar causada por una infección pulmonar previa que se ha diseminado. Sin embargo, la infección ósea primaria es muy rara y poco reportada, lo que hace que la información al respecto sea muy escasa. Se presenta un paciente femenino con antecedentes de displasia del desarrollo de la cadera, que se sometió a múltiples intervenciones quirúrgicas, incluida artroplastia total de cadera (ATC), posteriormente presentó una fístula y exudado seroso persistente; se realizó una biopsia donde se detectaron bacilos ácido-alcohol resistentes. El retraso en el diagnóstico de la tuberculosis osteoarticular (TBOA) puede tener consecuencias negativas, afectando la calidad de vida del paciente. Los métodos diagnósticos convencionales pueden ser insuficientes para el diagnóstico de TBOA.

Gluteus maximus abscess revealing a tuberculous arthritis: A case report and review of the literature.

Although tuberculosis is a widespread disease in Morocco, musculoskeletal form is relatively rare and even rarer when affects the sacroiliac joint. Tuberculous sacroiliitis remains a challenge for orthopedists owing to its insidious onset and non-specific clinical presentation. Herein, we report the case of a 23-year-old male with a growing mass in his left gluteal area, diagnosed with tuberculous sacroiliitis, based on bacteriological and histological findings. The aim of our work is to draw attention to the importance of continued awareness for early detection and adequate treatment of this very rare entity.