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TUBERCULOSIS OF THE BONE

Tuberculosis is a disease caused by the bacteria Mycobacterium tuberculosis. Although this


disease most commonly infects the pulmonary system (the lungs), about 10 to 20 percent of all
diagnosed cases of tuberculosis infect the bones. Tuberculosis of bones and joints often presents as
gradually worsening arthritis. Tuberculous infections of the joints are usually more flagrant  and clinically
obvious in adults than in children. As a consequence,  the diagnosis of osteoarticular tuberculosis in
children is often more difficult and a delay in treatment is not uncommon.
Bone tuberculosis can occur at any age and can infect any bone within the body. Symptoms of
bone tuberculosis are often vague, making diagnosis difficult. Tuberculosis is a disease that has been
around since early Egyptian times. This disease is a bacterial infection that can be spread through the air
when an infected person coughs or sneezes. In some countries tuberculosis is endemic, meaning it is an
always present danger. In the United States, however, the disease is not as common but is still a threat,
especially in larger cities.

Symptoms
The most common symptom is localized pain, often in the back because the spine is the bone
often affected. Other symptoms may include fever and loss of weight. A cold abscess, which is swelling
without inflammation, is often suggestive of bone tuberculosis. Because some of these symptoms are
not specific to only bone tuberculosis, diagnosis is often difficult.
Systemic and pulmonary symptoms are frequently  absent, and the differential diagnosis must
include other possible causes of septic osteoarticular disease, inflammatory arthritis,  and possibly
internal derangement of the joint.
Osteoarticular tuberculos is rarely involves more than one joint, and this may  help to
differentiate tuberculous septic arthritis from other types of polyinflammatory disease.
Generally, the radiographic changes of tuberculosis that affect large weight-bearing joints  are slow to
develop compared with those of pyogenic infections, and a reduction in the joint space is often a late
occurrence. Any synovial space, bursa, or tendon sheath may be infected.
Diagnosis
Radiographs such as X-rays and bone scans do not show any specific features that conclusively
differentiate the disease as bone tuberculosis. Some common radiographic findings that suggest bone
tuberculosis are soft tissue swelling, narrowing of joint space, cysts in the bone, and loss of disc height in
the spine. Once bone tuberculosis is suspected based on the symptoms and scan findings, a biopsy of
the bone in question can provide a differential diagnosis.

Plain Radiographs
There are no specific radiographic features that are pathognomonic  of tuberculosis of bones or
joints. Common findings that shouldarouse suspicion of joint involvement include osteopenia, soft-
tissue swelling with minimum periosteal reaction, narrowing of the joint space, cysts in bone adjacent to
a joint, enlargement of the epiphysis in children, and subchondral erosions involving  both sides of the
joint. (These erosions cross the epiphysis in more than one-third of affected children.)

Culture
The ultimate diagnosis of tuberculosis depends
on the recognition of Mycobacterium tuberculosis on either histological study or culture, or, ideally,
both. Because of the frequency of associated tuberculosis in the lungs and kidneys,
culture of specimens of sputum and urine can be helpful, but these tests are often not performed on
orthopaedic patients.

Biopsy
If a biopsy specimen is taken from a joint, tissues from  adjacent cystic lesions and synovial tissue
should also be obtained and sent for both histological study and culture. Simple aspiration  of the joint is
much less likely to lead to a definitive diagnosis
This often involves a cold abscess, with  or without drainage. Magnetic resonance imaging generally
shows large intra-articular effusions, periarticular osteoporosis, and gross thickening  of thesynovial
membrane4. A differential diagnosis between  tuberculosis and pyogenic arthritis is difficult, and an
accurate diagnosis usually requires biopsy of synovial tissue and demonstration of the appropriate
organisms on either histological study or culture. Aspiration ofsynovial fluid is often insufficient to make
a diagnosis, and culture specimens from draining sinuses  are usually contaminated with other organisms.
Treatment
All types of tuberculosis are treated with antituberculous drugs. Three medications are given in
combination to fight this disease, including isoniazid, rifampin and ethambutol. Because the tuberculosis
bacteria can become drug-resistant, The Centers for Disease Control provide recommendations for the
United States on the exact combination, dosages and duration of treatment based on the current
trends.
Pathological fractures are rare but can develop in or adjacent  to a tuberculous joint. They can be treated
with standard techniques of fracture management, including internal fixation.  Appropriate and
prolonged chemotherapy at the time of treatment of the fracture, combined with radical
débridement and drainage of abscesses.

Operative Treatment
Knee
In the early stages of disease of the knee, before there is substantial loss of bone or cartilage,
operative intervention is necessary only to drain large abscesses and to obtain synovial  tissue for biopsy.
Synovectomy is rarely indicated in the early stages, and a prolonged course of adequate
chemotherapy generally sterilizes the joint. We use external immobilization  only to correct fixed
deformities, as we believe that early motion is necessary after adequate débridement. The long-
term prognosis depends on the extent of the disease at the time of the initial presentation
and the adequacy and duration of chemotherapy.
Arthrodesis and joint replacement have been advocated in  the later stages, when there is
loss of the joint space and osseous architecture. Because tuberculosis rarely involves multiple
joints, the patient is usually able to compensate with  motion of other joints.
Total knee arthroplasty after chemotherapeutic sterilization  of a tuberculous knee joint is
gaining in popularity. At a minimum, three months of adequate chemotherapy is required to sterilize a
joint, and only then if all clinical and laboratory  criteria suggest that the joint is adequately sterile,
should an arthroplasty be considered. The arthroplasty must be followed  by a prolonged
period of antituberculous chemotherapy.
CASE ANALYSIS

TUBERCULOSIS OF THE BONE


(Osteoarticular TB)

MCMC
OPD WARD
April 25-29 2011

Submitted by:
Jennifer Sumadsad
Faida Riza Soon

Submitted to:
Mr. Cura

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