Tuberculous infection of the elbow joint

Tuberculosis remains a major health problem worldwide with musculoskeletal involvement reported to be infrequent. A resurgence of pulmonary tuberculosis is being evidenced, especially along with the increasing incidence of immunocompromised states and with this a concomitant rise in musculoskeletal tuberculosis. Unusual presentations of tubercular arthritis and equivocal investigations along with clinician inexperience can result in delay in diagnosis. The morbidity of delayed or untreated tubercular arthritis can be devastating, ending in painful ankylosis or a requirement for salvage procedures like excisional arthroplasty or arthrodesis. The early diagnosis of osteoarticular tuberculosis can be difficult. Presentation of the disease can mimic other conditions like neoplasia, non-tubercular infections and inflammatory arthropathy. Reports of tuberculous infection of the elbow are few. We report a case of a primary tuberculous infection of the elbow joint that presented as an isolated abscess in the cubital fossa, without pulmonary or systemic involvement. To prevent considerable morbidity, a diagnosis of tuberculosis should be included in the repertoire of diagnostic possibilities when confronted with unusual musculoskeletal manifestations.     

Tuberculous tenosynovitis of the wrist. Two case reports

Tuberculosis was first described in 1756 by Acrel in a case report. Subsequent reports of musculoskeletal tuberculosis documented the uncommon occurrence of hand and wrist involvement. The two cases presented here demonstrate the difficulty in eradicating the organism even with modern regimens of chemotherapy. Intraoperative Gram's stain and frozen sections were useful to rule out other etiologies. Firm diagnosis must be established by tissue culture. The first case appeared cured after thorough initial debridement and had no recurrence for 36 years. While recurrences are common in patients treated with debridement alone, most appear within one year after the index procedure. The amount of time that elapsed in this case is unusual and serves as a sobering reminder that tuberculosis may recur at a time distant from the initial procedure. The second patient had tuberculosis diagnosed elsewhere and was treated twice with antituberculous chemotherapy. Although the first course of therapy for six months may have been inadequate, the second course with multiple drugs for 18 months would certainly be considered adequate; yet he had a recurrence in his wrist eight months after completing treatment. These two cases illustrate the fastidious nature of the Mycobacterium tuberculosis organism and the need for a combined treatment protocol of meticulous surgical debridement and combined chemotherapy.     

Persistent posttraumatic wrist pain: complex regional pain syndrome? Mycobacterium tuberculosis infection should be in the differential diagnosis

It is a common algorithm for hand surgeons to diagnose and treat persistent post-traumatic wrist pain as complex regional pain syndrome (CRPS). Although it works for many patients, some conditions that affect the wrist don’t fall in this category and worsen with this treatment practice. We present a single-handed patient who had had a non-displaced distal radius fracture and was treated as CRPS for the next three months. He was eventually diagnosed with late tuberculous tenosynovitis of the wrist and a total wrist arthrodesis was performed. We believe that Mycobacterium tuberculosis infection should be in the differential diagnosis of persistent post-traumatic joint pain. This is especially important as Mycobacterium infections are becoming more common due to an increase in patients with chronic immunosuppression and definitive diagnosis and treatment of tuberculous tenosynovitis needs a high index of clinical suspicion.     

Mycobacterium kansasii osteomyelitis of the scaphoid

A 31-year-old man was found to have a diffuse infection of the wrist and osteomyelitis of the scaphoid caused by Mycobacterium kansasii. The 3-year delay in establishing the diagnosis is characteristic of hand infections caused by atypical mycobacteria. We treated the patient surgically and with antituberculous chemotherapy. This is the only case of M. kansasii osteomyelitis of the scaphoid recorded in the medical literature.     

Mycobacterium tuberculosis in the acquired immunodeficiency syndrome

Patients with human immunodeficiency virus (HIV) infection, with or without the diagnosis of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC), have an increased incidence of tuberculosis, especially of an extrapulmonary nature. The condition is associated with significant morbidity and mortality. The reported incidence of the combination of tuberculosis and AIDS varies between 4% and 10% of AIDS patients, with a higher incidence noted in the male, inner-city, intravenous-drug-abuser population. Clinical findings may reflect the site of infection, but are often nondiagnostic. Diagnosis often requires biopsy for histopathologic evaluation and tissue culture to document the presence of granulomas and mycobacterial organisms. Universal body fluid precautions among these patients are mandatory, and respiratory isolation should be maintained during diagnostic evaluation and early treatment. These patients usually respond to standard antituberculosis therapy. Physicians should maintain a high index of suspicion of tuberculosis in patients with HIV infection. Conversely, the diagnosis of HIV infection should be considered in patients with unusual manifestations of tuberculosis. Because tuberculosis is one of the few potentially curable infections in the AIDS patient, recognition of its presence is crucial.     

Tuberculous extensor tenosynovitis of the hand

Tuberculous tenosynovitis is a rare manifestation of extrapulmonary tuberculosis (Tb), especially if solely the dorsal hand compartment is affected. In this report, we present the medical history of an immuno-competent 32-year-old man presented with a painful swelling of the right dorsal wrist. Initial inflammation onset had occurred 6?months before he consulted our service, resulting in consultation of several physicians and extensive diagnostic procedures without gaining a specific diagnosis. Finally, after extensive diagnostic tests, a tenosynovectomy was performed and tuberculosis-induced extensor tenosynovitis was detected. The diagnosis was established by positive histology, repeated specific PCR and T-SPOT.TB. Tuberculous tenosynovitis can easily be overlooked as a cause of chronic tenosynovitis particularly in immunocompetent young people lacking any risk factors.     

Total hip replacement infected with Mycobacterium tuberculosis. A case report with review of literature

Mycobacterium Tuberculosis infection of a total joint prosthesis in patients with previous pulmonary or osteoarticular tuberculosis is well recorded in literature. We describe the case of a 59-year-old woman with tuberculous infection complicating a total hip arthroplasty 15 months after surgery for osteoarthritis. The patient had no prior history of exposure to tuberculosis and no evidence of pulmonary or osteoarticular tuberculosis. She was treated with four-drug antituberculous chemotherapy for 12 months with retention of the prosthesis. The purpose of this case report and literature review is to highlight to the Western Orthopaedic surgeon the importance of keeping in mind a differential diagnosis of tuberculosis while dealing with prosthetic joint infections. The infection of a joint with Mycobacterium Tuberculosis in patients without previous tuberculosis is very uncommon. We have reviewed the surgical and medical management of the cases reported in literature.     

Skeletal tuberculosis of the wrist and hand: A study of 27 cases

The 27 cases of skeletal tuberculosis in the hand and wrist reported represented 6.9% of the skeletal tuberculosis seen at our hospital and 32% of the skeletal tuberculosis found in the upper extremity. In a majority of these patients a single bone or joint was involved and 18.5% of the patients had bone and/or joint involvement outside the hand. Pulmonary tuberculosis was present in 10.7% of these cases. The clinical picture of tuberculosis is similar to that of other infections and tumorous conditions, but a history of absent bacille Calmette Guerin protection and positive tine test should arouse one's suspicion to the condition. Eight-six percent of our patients had x-ray findings that included bone atrophy, bone or joint destruction with discrete periostitis, or the presence of the typical spina ventosa. We found no case of resistance to various combinations of the usual drugs in any patients. Supportive orthopaedic splints were used over short periods (3 months) and surgery was used for diagnostic purposes (biopsies) and in treatment by fusion of two wrists in this patient series. Finger joint involvement responded satisfactorily to drug and conservative orthopaedic treatment and in no case were these joints fused or replaced by a prosthesis.     

Tuberculosis of the greater trochanter: a report of three cases

Trochanteric tuberculosis represents less than 2% of all musculo-skeletal tuberculosis. The diagnosis is difficult especially if abscess and fistula are missing. The authors report 3 cases of trochanteric tuberculosis. The diagnosis was established, respectively, 4, 9 months and 1 year after the beginning of the symptoms. The tuberculosis was plurifocal in all cases. Diagnosis was based on the presence of caseum granuloma in the first case, positive Lowenstein culture in the second case and on clinical and paraclinical arguments in the third one. Healing was obtained after medical treatment alone. The authors discuss the potential role of the newer imaging modalities in diagnosis of trochanteric tuberculosis and the indications of medical and surgical treatment.     

结核致阴茎毁损1例误诊分析（附文献复习）

报告1例结核致阴茎毁损，分析了长达15个月的误诊原因并结合文献对其感染途径、分型及诊断进行了讨论，提出对久治不愈的阴茎溃疡病变应想到结核杆菌感染的可能，及时诊治。     

Salmonella osteomyelitis. An important differential diagnosis of granulomatous osteomyelitis

A case of septicemia owing to Salmonella choleraesuis with localization in the lumbar spine and left knee is described. The spinal lesion is dominated by tuberculoid granulomas with or without central necrosis. The necrotic foci within some granulomas show heavy polymorph infiltration, whereas in others they simulate caseous necrosis and are indistinguishable histologically from tuberculosis, brucellosis, and fungal infections. As Salmonella osteomyelitis has a strong tendency to chronicity if antimicrobial treatment is delayed, inappropriate, or inadequate, this diagnosis should be considered in all cases of granulomatous osteomyelitis, especially when the patient is immunosuppressed or has hemoglobinopathy.     

沿海地区手部慢性特殊感染病因学及诊治研究

目的 探讨沿海地区手部慢性特殊感染的致病因素,以及与结核杆菌的关系,为临床早期正确诊治提供依据。方法对2002年6月至2004年4月收治的29例手部慢性特殊感染病例做组织病理学检查,直接抗酸染色,普通细菌培养,真菌培养,分枝杆菌培养,并对分离菌株进行生化分型。结果29例患者中细菌培养阳性12例。其中普通细菌培养阳性2例,其中1例为星形诺卡氏菌,另1例为表皮葡萄球菌;分枝杆菌培养阳性10例。直接抗酸染色检查2例阳性。结论手部慢性特殊感染患者应同时做常规细菌培养,真菌及分枝杆菌培养。非结核分枝杆菌感染尤其是海分枝杆菌远比结核菌常见,是沿海地区手部特殊感染的主要致病因素。     

Polymerase chain reaction for the detection of Mycobacterium tuberculosis in synovial fluid, tissue samples, bone marrow aspirate and peripheral blood

Extrapulmonary tuberculosis accounts for approximately 10% of tuberculous infections; the musculoskeletal system is involved in a small number of these (10%). Skeletal tuberculosis is an indolent disease, and diagnosis may be delayed. Conventional methods are time consuming and have a low sensitivity rate. In recent years PCR-based protocols raised hopes as a reliable and fast diagnostic tool for extrapulmonary tuberculosis. The authors report the detection of Mycobacterium tuberculosis complex DNA in specimens from six patients using a nested PCR protocol specific for IS6110 insertion element of Mycobacterium tuberculosis complex. Three men and three women are reported with ages ranging from 42 to 68 years. The sites of infection were the knee and shoulder in one case each, the hip in two cases, and the thoracic spine in two cases. Diagnosis was established within three days, and treatment was initiated promptly. PCR is a technically easy approach that can be used as a first step diagnostic tool for early recognition and treatment of bone and joint tuberculosis.     

A Rare Manifestation of Tuberculosis in a Renal Transplant Patient: A Case Report

Cutaneous lesions in the presence of fever in patients undergoing immunosuppressive therapy are a diagnostic challenge and may represent manifestations of multiple diseases, such as fungal infections, nocardiosis, lymphoproliferative diseases, zoonosis, and tuberculosis. The authors report a case of a 66-year-old white man with chronic kidney disease since 2014 (chronic pyelonephritis) who had a renal transplant in the previous 6 months. Induction therapy was performed with thymoglobulin, and his current immunosuppression scheme included tacrolimus, mycophenolate mofetil, and prednisolone. The patient had no history of pulmonary tuberculosis. The patient presented with 2 cutaneous lesions, localized on the back and abdomen, that appeared to be firm, painful, subcutaneous, erythematous nodules with an approximately 5 cm diameter overlying an infected focus and purulent material inside. The patient also had a fever and fatigue. Blood analysis showed pancytopenia with an elevation of inflammatory markers and graft dysfunction. Tissue cultures and skin biopsy with histological analysis were performed. Histopathology of the lesion showed a nonspecific inflammatory infiltrate without granulomas, and acid-fast bacillus staining was negative. Nevertheless, serum QuantiFERON testing was positive. But polymerase chain reaction finally confirmed the presence of Mycobacterium tuberculosis, which confirmed the diagnosis of cutaneous tuberculosis. A chest computed tomography scan showed a lung pattern of miliary tuberculosis. The patient was treated with multidrug tuberculosis therapy, resulting in lesion clearance after 3 weeks. Tuberculosis is a serious infection, especially in high-risk patients, such as those in an immunocompromised state. The incidence of cutaneous tuberculosis is rare, but it should be considered in patients presenting with atypical skin lesions suggestive of an underlying infectious etiology.     

Lunotriquetral instability in a climber - case report and review

Wrist injuries and carpal instability may result from various sport-related acitivites. Lunotriquetral instability (LTI) is an infrequently recognized cause of wrist pain in athletes. The diagnosis of LTI through history and physical examination can be confirmed by Magnetic Resonance Arthrogram (MRA). This case report describes a case of clinically suspected LTI confirmed by MRA. Relevant literature on lunotriquetral injuries is discussed. Lunotriquetral joint injury can present itself and should be considered within a differential diagnosis of a wrist injury. The diagnosis of LTI through clinical history and physical examination can be confirmed by MRA. This case report demonstrates the importance of MRA in the accurate diagnosis and management of a patient with wrist pain.     

Unusual presentation of tuberculosis reactivation in childhood: an anterior neck mass

Although extrapulmonary tuberculosis has a broad spectrum of clinical manifestations, involvement of the thyroid gland in children has been reported very rarely. The authors report a case of an 11-year-old girl with a nontender nodular swelling of the thyroid, whose symptoms, tomographic and scintigraphic features, mimicked a nodule with a cystic component. Although seldom observed, tuberculosis should be considered in the differential diagnosis of nodular lesions of the thyroid in children, especially in the patient with known history of exposure to tuberculosis.     

Renal allograft tuberculosis: report of three cases and review of literature

Renal transplant recipients are prone to a variety of infections due a persistent immunodepleted state. Incidence of tuberculosis in this population is much higher compared with the general population. While pulmonary tuberculosis still remains the commonest form in this population, renal allograft tuberculosis is very rare. We report two cases of isolated allograft tuberculosis and one case of allograft tuberculosis with coexistent pleuro-pulmonary and bone marrow involvement. All three cases had presented with pyrexia of unknown origin, wherein despite extensive investigations the cause was not found. In two cases the diagnosis was confirmed on histology. Two cases responded to non-rifampicin-based modified antitubercular treatment and one to conventional four-drug Rifampicin-based regimen. Graft function improved in two cases while in one case the graft was lost. Tuberculosis involving the renal allograft is a potential cause for graft dysfunction/loss and requires a high index of suspicion for diagnosis. Timely detection and early institution of therapy can help save the renal allograft.     

Tuberculosis of the clavicle presenting as an expansile lytic lesion: a case report

An unusual case of skeletal tuberculosis, presenting as an expansile osteolytic lesion in the lateral end of the clavicle is presented. Diagnostic confusion delayed appropriate medical therapy, leading to development of a discharging sinus with secondary infection, which further confused the picture. With re-emergence of tuberculosis as an important infection worldwide, and the ability of this disease to mimic many skeletal pathologies, this has to be included in the differential diagnosis, especially at unusual sites.     

Intra-articular Myxoma Arising from the Scapholunate Ligament: A Rare Cause of Dorsal Wrist Swelling

The differential diagnosis of a dorsal wrist swelling includes ganglion, lipoma, cutaneous tumors, and benign peripheral nerve sheath tumors, with ganglions being the most common. We present the case of a myxoma arising from the dorsal scapholunate ligament mimicking a dorsal wrist ganglion. Volar wrist joint myxomas have been previously reported, but this is the first report of a myxoma arising from the dorsal side of the wrist joint.     

Left colon stenosis caused by tuberculosis

The authors present a case of intestinal tuberculosis affecting exclusively the left colon causing severe undernourishment, abdominal pain, and bowel obstruction with a sealed colonic fistula in a 10-year-old child. These clinical characteristics and difficulties led to a diagnosis of intestinal tuberculosis in childhood. Intestinal tuberculosis affecting exclusively the colon is very rare, and differential diagnosis with Crohn’s disease is difficult. Surgical complications are frequent, especially intestinal obstruction, and can be treated in most cases by resection of the affected segment and primary anastomosis.