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Nouran Abaza - One of the best experts on this subject based on the ideXlab platform.
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THU0587 TB OR NOT TB? THIS IS THE QUESTION. CASE REPORT OF AN EXTRAPULMONARY Tuberculous Arthritis.
Annals of the Rheumatic Diseases, 2020Co-Authors: Nouran AbazaAbstract:Background: Tuberculous (TB) Arthritis consists of 1-3% of all TB cases, whereas TB tenosynovitis & bursitis account for 1%. Primarily it involves large joints but occasionally smaller non-weight-bearing joints. Diagnosis is usually delayed due to lack of awareness, radiographic findings & constitutional or pulmonary involvement. Objectives: We aim to increase rheumatologists awareness to detect possible TB etiology for Arthritis & tenosynovitis. Methods: Our case is a 32 years old male complaining of polyArthritis of wrists, MCPs, ankle joints 4 months prior to presentation. Patient was referred as diagnosed rheumatoid patient resistant to treatment based on clinical presentation & laboratory investigation. His lab. was as follows; ESR 76 mm/hr, CRP 56.6 mg/L, RF 181.8 IU/ml, Serum creat 0.8 mg/dL, SGOT 20 SGPT 22, FBS 94, Uric acid 5.4, Hepatitis & HIV negative. CBC showing Hb 14.1 g/dL, TLC 7030/ml & platelets 289000/ml. There was no history of genitourinary, gastrointestinal manifestations, oral/genital ulcers, ophthalmological, mucocutaneous, cardiac, pulmonary, hepatic nor renal manifestations. The treatment at time of presentation was Methotrexare 25mg/week IM injection, Leflunamide 20mg/d & low dose steroids, prednisolone 5mg/d. Patient was referred to our department to assess activity, perform musculoskeletal ultrasound to the various involved joints. Hence, expected by referring physician to shift from DMARDs to biologic treatment. Results: MSUS study following eular guidlines showed active synovitis in both radiocarpal & midcarpal joints bilaterally grade II by doppler signal (figure 1). Other active synovitis in multiple MCPs as well as tenosynovitis of Peroneus longus and brevis bilaterally was detected (figure 1). The swelling aound the ankle was alarming though the other swollen joints seemed to be consistent with a case of RA in activity. This swelling revealed a well-defined hypoechoic heterogeneous cystic fluid collection with posterior through-transmission (figure 2) & hyperechoic hyperemic wall on PD imaging opposite medial malleolous of right fibula. The laboratory investigations prior to shifting patient had to included TB tests, tuberculin test and PCR following the positive result that we found in the skin test. Aspiration was performed from the cystic swelling and sent for clinical pathology analysis. Thick yellowish fluid aspirate on cytology revealed moderately cellular mainly of PMN cells, neutrophils, nuclear debris in proteinaceous background no atypical or malignant cells were found. As regards bacteriology no pus with no growth (both aerobic & anerobic). These results warranted us to perform a culture for atypical bacteria and revealed growth of mycobacterium tuberculosis. AntiTB therapy was started for 9 months in the form of 2 months of isoniazid (INH) and rifampicin (RIF), pyrazinamide (PZA) and ethambutol (EMB) followed by 7 months of INH and RIF. Excision of the synovial cyst was done on the spot. Conclusion: Extrapulmonary TB is usually diagnosed late due to a reduced diagnostic suspicion. A variant of 8 - 60% of TB cases are +ve for RF & 7–39% +ve for ACPA. Musculoskeletal manifestations occur in approximately 1-3% of TB cases. Of these, spondylitis and Arthritis are the most frequent, whereas bursitis and tenosynovitis are exceptional. Extraarticular cystic masses occur in Tuberculous Arthritis. Mixture of septic Tuberculous Arthritis and Poncet’s disease is rare but documented. References: [1]Varshney et al. Isolated tuberculosis of Achilles tendon. Joint Bone Spine, 74 (2007): 103-106. [2]Lee et al. Tuberculous Tenosynovitis and Ulnar Bursitis of the Wrist. Ann Rehabil Med. 2013 Aug; 37(4): 572–576. [3]Rekha et al. Tuberculous Olecranon Bursitis. Case Reports in Clinical Medicine, 2014, 3, 281-285. [4]Kim et al. Tuberculosis of the trochanteric bursa: a case report. Journal of Orthopaedic Surgery 2014;22(1):126-9. Disclosure of Interests: None declared
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thu0587 tb or not tb this is the question case report of an extrapulmonary Tuberculous Arthritis
Annals of the Rheumatic Diseases, 2020Co-Authors: Nouran AbazaAbstract:Background: Tuberculous (TB) Arthritis consists of 1-3% of all TB cases, whereas TB tenosynovitis & bursitis account for 1%. Primarily it involves large joints but occasionally smaller non-weight-bearing joints. Diagnosis is usually delayed due to lack of awareness, radiographic findings & constitutional or pulmonary involvement. Objectives: We aim to increase rheumatologists awareness to detect possible TB etiology for Arthritis & tenosynovitis. Methods: Our case is a 32 years old male complaining of polyArthritis of wrists, MCPs, ankle joints 4 months prior to presentation. Patient was referred as diagnosed rheumatoid patient resistant to treatment based on clinical presentation & laboratory investigation. His lab. was as follows; ESR 76 mm/hr, CRP 56.6 mg/L, RF 181.8 IU/ml, Serum creat 0.8 mg/dL, SGOT 20 SGPT 22, FBS 94, Uric acid 5.4, Hepatitis & HIV negative. CBC showing Hb 14.1 g/dL, TLC 7030/ml & platelets 289000/ml. There was no history of genitourinary, gastrointestinal manifestations, oral/genital ulcers, ophthalmological, mucocutaneous, cardiac, pulmonary, hepatic nor renal manifestations. The treatment at time of presentation was Methotrexare 25mg/week IM injection, Leflunamide 20mg/d & low dose steroids, prednisolone 5mg/d. Patient was referred to our department to assess activity, perform musculoskeletal ultrasound to the various involved joints. Hence, expected by referring physician to shift from DMARDs to biologic treatment. Results: MSUS study following eular guidlines showed active synovitis in both radiocarpal & midcarpal joints bilaterally grade II by doppler signal (figure 1). Other active synovitis in multiple MCPs as well as tenosynovitis of Peroneus longus and brevis bilaterally was detected (figure 1). The swelling aound the ankle was alarming though the other swollen joints seemed to be consistent with a case of RA in activity. This swelling revealed a well-defined hypoechoic heterogeneous cystic fluid collection with posterior through-transmission (figure 2) & hyperechoic hyperemic wall on PD imaging opposite medial malleolous of right fibula. The laboratory investigations prior to shifting patient had to included TB tests, tuberculin test and PCR following the positive result that we found in the skin test. Aspiration was performed from the cystic swelling and sent for clinical pathology analysis. Thick yellowish fluid aspirate on cytology revealed moderately cellular mainly of PMN cells, neutrophils, nuclear debris in proteinaceous background no atypical or malignant cells were found. As regards bacteriology no pus with no growth (both aerobic & anerobic). These results warranted us to perform a culture for atypical bacteria and revealed growth of mycobacterium tuberculosis. AntiTB therapy was started for 9 months in the form of 2 months of isoniazid (INH) and rifampicin (RIF), pyrazinamide (PZA) and ethambutol (EMB) followed by 7 months of INH and RIF. Excision of the synovial cyst was done on the spot. Conclusion: Extrapulmonary TB is usually diagnosed late due to a reduced diagnostic suspicion. A variant of 8 - 60% of TB cases are +ve for RF & 7–39% +ve for ACPA. Musculoskeletal manifestations occur in approximately 1-3% of TB cases. Of these, spondylitis and Arthritis are the most frequent, whereas bursitis and tenosynovitis are exceptional. Extraarticular cystic masses occur in Tuberculous Arthritis. Mixture of septic Tuberculous Arthritis and Poncet’s disease is rare but documented. References: [1]Varshney et al. Isolated tuberculosis of Achilles tendon. Joint Bone Spine, 74 (2007): 103-106. [2]Lee et al. Tuberculous Tenosynovitis and Ulnar Bursitis of the Wrist. Ann Rehabil Med. 2013 Aug; 37(4): 572–576. [3]Rekha et al. Tuberculous Olecranon Bursitis. Case Reports in Clinical Medicine, 2014, 3, 281-285. [4]Kim et al. Tuberculosis of the trochanteric bursa: a case report. Journal of Orthopaedic Surgery 2014;22(1):126-9. Disclosure of Interests: None declared
Mustafa Caniklioglu - One of the best experts on this subject based on the ideXlab platform.
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total knee arthroplasty for the management of joint destruction in Tuberculous Arthritis
Knee Surgery Sports Traumatology Arthroscopy, 2014Co-Authors: Yusuf Ozturkmen, Onat Uzumcugil, Mahmut Karamehmetoglu, Cem Leblebici, Mustafa CanikliogluAbstract:The purpose of this study was to evaluate our experience to clarify the suggestion that there should be a significant disease-free interval before total knee arthroplasty (TKA) and to determine the correct timing of surgery for reconstruction of the joint destruction in patients suffering from Tuberculous Arthritis. Twelve patients with advanced joint destruction and Tuberculous Arthritis of the knee with recent onset were reviewed in this study. The time interval from our diagnosis of active infection to arthroplasty averaged 4 ± 1.5 months. Histopathology of the biopsy specimens revealing granulomatous lesions, including epithelioid histiocytes surrounded by lymphocytes, confirmed the diagnosis of each patient. A primary knee prosthesis was performed in seven knees. In five knees, there was severe bone loss after the extensive debridement of the entire joint, and thereafter, revision prosthesis was preferred to preserve the joint line. Patients were given post-operative antiTuberculous treatment for a total of 1 year, whereas for three patients, whose erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values remained above normal by the sixth month, the chemotherapy was continued for up to 18 months. The Knee Society TKA roentgenographic evaluation and scoring system was used for radiological evaluation of the knees. Clinical evaluation of the knees was done preoperatively and at the time of the most recent follow-up using the American Knee Society Scoring System. Within the average follow-up period of 6.1 ± 1.8 years, no reactivation of Tuberculous infection was found in any of the patients. ESR was normal, less than 20 mm/h, after a mean time of 5.5 ± 2.0 months. The CRP was normal, less than 0.8 mg/dl, after a mean time of 4.6 ± 1.3 months. At the most recent follow-up, the average knee score improved from 32.4 ± 19.4 to 83.4 ± 14.0 points (p < 0.05), and the average function score improved from 33.3 ± 11.9 to 86.6 ± 7.7 points (p < 0.05). Ten knees showed good integrity, and no radiolucent lines were found in the bone–prosthesis interface in relation to any component. Radiolucent lines were apparent on the tibial side in two knees. They were less than 1 mm thick and non-progressive, and clinically, there was no evidence of loosening of the component. Culture specimens were positive for five patients. TKA is a safe procedure for Tuberculous Arthritis with recent onset providing symptomatic relief, functional improvement and early return to activity when performed in correct time. A long disease-free interval should not be a prerequisite for arthroplasty. Wide surgical debridement is the mainstay to eradicate the disease, and post-operative antiTuberculous chemotherapy controls the residual foci. IV.
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Total knee arthroplasty for the management of joint destruction in Tuberculous Arthritis
Knee Surgery Sports Traumatology Arthroscopy, 2014Co-Authors: Yusuf Ozturkmen, Onat Uzumcugil, Mahmut Karamehmetoglu, Cem Leblebici, Mustafa CanikliogluAbstract:Purpose The purpose of this study was to evaluate our experience to clarify the suggestion that there should be a significant disease-free interval before total knee arthroplasty (TKA) and to determine the correct timing of surgery for reconstruction of the joint destruction in patients suffering from Tuberculous Arthritis. Methods Twelve patients with advanced joint destruction and Tuberculous Arthritis of the knee with recent onset were reviewed in this study. The time interval from our diagnosis of active infection to arthroplasty averaged 4 ± 1.5 months. Histopathology of the biopsy specimens revealing granulomatous lesions, including epithelioid histiocytes surrounded by lymphocytes, confirmed the diagnosis of each patient. A primary knee prosthesis was performed in seven knees. In five knees, there was severe bone loss after the extensive debridement of the entire joint, and thereafter, revision prosthesis was preferred to preserve the joint line. Patients were given post-operative antiTuberculous treatment for a total of 1 year, whereas for three patients, whose erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values remained above normal by the sixth month, the chemotherapy was continued for up to 18 months. The Knee Society TKA roentgenographic evaluation and scoring system was used for radiological evaluation of the knees. Clinical evaluation of the knees was done preoperatively and at the time of the most recent follow-up using the American Knee Society Scoring System. Results Within the average follow-up period of 6.1 ± 1.8 years, no reactivation of Tuberculous infection was found in any of the patients. ESR was normal, less than 20 mm/h, after a mean time of 5.5 ± 2.0 months. The CRP was normal, less than 0.8 mg/dl, after a mean time of 4.6 ± 1.3 months. At the most recent follow-up, the average knee score improved from 32.4 ± 19.4 to 83.4 ± 14.0 points ( p
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Total knee arthroplasty for the management of joint destruction in Tuberculous Arthritis
Knee surgery sports traumatology arthroscopy : official journal of the ESSKA, 2013Co-Authors: Yusuf Ozturkmen, Onat Uzumcugil, Mahmut Karamehmetoglu, Cem Leblebici, Mustafa CanikliogluAbstract:The purpose of this study was to evaluate our experience to clarify the suggestion that there should be a significant disease-free interval before total knee arthroplasty (TKA) and to determine the correct timing of surgery for reconstruction of the joint destruction in patients suffering from Tuberculous Arthritis. Twelve patients with advanced joint destruction and Tuberculous Arthritis of the knee with recent onset were reviewed in this study. The time interval from our diagnosis of active infection to arthroplasty averaged 4 ± 1.5 months. Histopathology of the biopsy specimens revealing granulomatous lesions, including epithelioid histiocytes surrounded by lymphocytes, confirmed the diagnosis of each patient. A primary knee prosthesis was performed in seven knees. In five knees, there was severe bone loss after the extensive debridement of the entire joint, and thereafter, revision prosthesis was preferred to preserve the joint line. Patients were given post-operative antiTuberculous treatment for a total of 1 year, whereas for three patients, whose erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values remained above normal by the sixth month, the chemotherapy was continued for up to 18 months. The Knee Society TKA roentgenographic evaluation and scoring system was used for radiological evaluation of the knees. Clinical evaluation of the knees was done preoperatively and at the time of the most recent follow-up using the American Knee Society Scoring System. Within the average follow-up period of 6.1 ± 1.8 years, no reactivation of Tuberculous infection was found in any of the patients. ESR was normal, less than 20 mm/h, after a mean time of 5.5 ± 2.0 months. The CRP was normal, less than 0.8 mg/dl, after a mean time of 4.6 ± 1.3 months. At the most recent follow-up, the average knee score improved from 32.4 ± 19.4 to 83.4 ± 14.0 points (p
Heung Sik Kang - One of the best experts on this subject based on the ideXlab platform.
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Rheumatoid Arthritis and Tuberculous Arthritis: Differentiating MRI Features
AJR. American journal of roentgenology, 2009Co-Authors: Jung-ah Choi, Sung Hye Koh, Sung-hwan Hong, Yong Hwan Koh, Ja Young Choi, Heung Sik KangAbstract:OBJECTIVE. The purpose of our study was to determine the MRI findings of rheumatoid Arthritis (RA) and Tuberculous Arthritis, with emphasis on differential diagnostic features.MATERIALS AND METHODS. MR images of 63 joints in 62 patients with clinically or pathologically proven RA (36 joints in 35 patients) or Tuberculous Arthritis (27 joints in 27 patients) were evaluated retrospectively with regard to pattern and degree of synovial thickening, size of bone erosions, rim enhancement at bone erosions, degree of bone marrow and periarticular soft-tissue edema, and presence and number of extraarticular cystic masses. MRI findings were compared between RA and Tuberculous Arthritis by statistical analysis using kappa statistics, the Mann-Whitney U test, linear-by-linear association, and the chi-square test.RESULTS. Nonuniform and greater degree of synovial thickening was more frequent in RA (p < 0.01); the thicker the synovial membrane, the greater the likelihood of RA (p < 0.01). Bone erosions of Tuberculous ...
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Tuberculous versus pyogenic Arthritis: MR imaging evaluation.
Radiology, 2001Co-Authors: Sung-hwan Hong, Sung Moon Kim, Joong Mo Ahn, Hyewon Chung, Myung Jin Shin, Heung Sik KangAbstract:PURPOSE: To assess magnetic resonance (MR) imaging features in differentiating Tuberculous Arthritis from pyogenic Arthritis. MATERIALS AND METHODS: Findings in 29 patients with Tuberculous Arthritis were compared with those of 13 patients with pyogenic Arthritis. Bone erosion, marrow signal intensity, synovial lesion signal intensity, boundaries (smooth or irregular) for extraarticular extension of infection, and abscess rim enhancement (thin and smooth or thick and irregular) were analyzed. RESULTS: Bone erosion was more common in patients with Tuberculous Arthritis (24 [83%] of 29) than in those with pyogenic Arthritis (six [46%] of 13) (P = .026), while subchondral marrow signal intensity abnormality was seen more frequently in patients with pyogenic Arthritis (12 [92%] of 13) than in those with Tuberculous Arthritis (17 [59%] of 29) (P = .036). On T2-weighted images, there was no significant difference between the synovial lesion signal intensities of Tuberculous Arthritis and pyogenic Arthritis. Les...
Jonghoon Park - One of the best experts on this subject based on the ideXlab platform.
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Tuberculous Arthritis of the knee joint mimicking pigmented villonodular synovitis
Knee Surgery Sports Traumatology Arthroscopy, 2012Co-Authors: Jonghoon ParkAbstract: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.
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Tuberculous Arthritis of the knee joint mimicking pigmented villonodular synovitis
Knee surgery sports traumatology arthroscopy : official journal of the ESSKA, 2011Co-Authors: Dae Hee Lee, Dong Ki Lee, Soon-hyuck Lee, Jonghoon Park, Chul Hwan Kim, Seung Beom HanAbstract: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.
Dean T. Tsukayama - One of the best experts on this subject based on the ideXlab platform.
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Tuberculous Arthritis of the knee treated with two-stage total knee arthroplasty. A case report.
The Journal of bone and joint surgery. American volume, 2009Co-Authors: Lance E. Leclere, V. Franklin Sechriest, Keith G. Holley, Dean T. TsukayamaAbstract:It has been estimated that 2 billion people worldwide currently have tuberculosis in its latent form and that the active form of the disease will develop in 8 million people annually1. Tuberculous Arthritis of the knee is one of the most common musculoskeletal manifestations2-6. While chemotherapy remains the cornerstone of treatment7, surgery of the knee may also be indicated and has been reported to include debridement and synovectomy8-10, arthrodesis11-14, amputation15-18, resection arthroplasty19-23, and prosthetic joint replacement24. Recently, there have been several reports of successful management of Tuberculous Arthritis of the knee with primary total knee arthroplasty25-31. Most of the world's experience in managing musculoskeletal tuberculosis is reported from outside of the United States. Yet, the prevalence of this disease in the United States is substantial and, according to recent data, may be on the rise32. To raise awareness and improve management of this disease, we report the case of a patient with advanced, active, and refractory Tuberculous Arthritis of the knee with extensive joint destruction. Our patient was managed with medical therapy and a two-stage surgical approach that was designed to sterilize the joint and permit successful total knee arthroplasty. The patient was informed that data concerning the case would be submitted for publication, and he consented. A sixty-two-year-old native-born Filipino man, 167 cm tall and weighing 77 kg, presented in January 2004, with symptoms of fever and a productive cough of several weeks' duration. The patient had immigrated to the United States in 1955 and had become a U.S. citizen, but he still frequently visited the Philippines. After a positive Mantoux skin test, further workup included chest …
