Bone and Joint Tuberculosis

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Bone and joint tuberculosis

Author: Jason Stout, MD
Section Editor: John Bernardo, MD
Deputy Editor: Elinor L Baron, MD, DTMH
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2021. | This topic last updated: Nov 30, 2020.
INTRODUCTION
Skeletal tuberculosis (TB) refers to TB involvement of the bones and/or joints. It is an ancient
disease; features of spinal TB have been identified in Egyptian mummies dating back 9000
years [1,2], and analysis of 483 pre-Columbian skeletons in Chile showed lesions consistent
with bony TB in 2 percent of cases [3]. Subsequently, molecular studies have established the
presence of Mycobacterium tuberculosis complex DNA in ancient bony specimens [2,4].
Clinical issues related to skeletal TB will be reviewed here. Other aspects of TB are discussed
separately. (See related topics.)
EPIDEMIOLOGY
Worldwide, skeletal TB accounts for 10 to 35 percent of cases of extrapulmonary TB (9.6

percent of United States extrapulmonary cases [n=185] and 2.0 percent of all United States
TB cases reported in 2017) [5-10]. Reported rates of extrapulmonary TB are higher among
immigrants from highly endemic areas to developed countries; this may be due in part to
immigration screening procedures for pulmonary TB [11]. One retrospective review of
skeletal TB between 1980 and 1994 in France noted 103 cases of spinal TB; 68 percent of
patients were foreign born, the majority from Africa [12]. The proportion of skeletal TB
among HIV-infected individuals is comparable with the proportion of skeletal TB among HIV-
uninfected individuals [13,14].
The most common form of skeletal TB is Pott disease, a disease of the spine; this entity
comprises approximately half of musculoskeletal TB cases. The next most common form of
musculoskeletal TB is tuberculous arthritis, followed by extraspinal tuberculous
osteomyelitis [15].
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PATHOGENESIS
During primary M. tuberculosis infection, bacillemia may lead to seeding of organisms in

bone and/or synovial tissue. In most cases, small foci of infection are confined by local
adaptive immune processes, and infection is subclinical. Following primary infection,
reactivating foci are usually contained by the cellular immune response. CD4 and CD8
lymphocytes play important roles, as does interferon-gamma [16]. The likelihood of
reactivation of infection with progression to clinically apparent disease increases when local
immune defenses fail, as in the setting of malnutrition, advancing age, HIV infection, or
advanced kidney disease [17].
Active TB disease can develop immediately or after decades of latent infection. In highly
endemic regions, musculoskeletal TB usually manifests clinically in the year following
primary lung infection and therefore occurs more frequently in relatively young patients
[18]. Outside highly endemic areas, musculoskeletal TB is more commonly associated with
late reactivation of infection and occurs mainly in adults.
Two types of bone and joint involvement associated with TB infection have been described:
the caseous exudative type and the granular type [19]. The caseous exudative type is
characterized by bone destruction, local swelling, abscess formation, sinus formation, and
constitutional symptoms; it occurs most often in children. The granular type is more
insidious and less destructive than the caseous exudative type, and abscess formation is less
common; it occurs most often in adults. However, host-parasite interactions in TB are
dynamic, often with mixed patterns and transitions along a continuum [20].
Rarely, bones and joints are involved in contiguous spread of TB from another site.
Contiguous spread from an apical pulmonary focus of active TB, for example, can lead to
atlantoaxial TB, involving the joint between the first and second cervical vertebrae [21].
CLINICAL MANIFESTATIONS
Forms of skeletal TB include spondylitis (Pott disease), arthritis, and osteomyelitis. From
published series of spinal TB, there is wide variation in reported rates of active concomitant
pulmonary TB at the time of diagnosis of the spinal TB [12,22,23]. The largest report series
including nearly 700 cases had the lowest reported rate (2.7 percent) [23]. The proportion is
likely to be similarly variable for other TB bone and joint infections, but series are too small
to provide reliable data. Virtually any bone can be infected with M. tuberculosis. The diagnosis
may be delayed when unusual bones such as the hyoid or digits are infected or when
multifocal bony involvement is present.

Spondylitis (Pott disease) — Tuberculous spondylitis (Pott disease) most commonly affects

the lower thoracic and upper lumbar region; involvement of cervical and upper thoracic
region is less common [24,25]. Progression of infection generally begins with inflammation
of the anterior aspect of intervertebral joints; typically, it spreads behind the anterior
ligament to involve the adjacent vertebral body. Once two adjacent vertebrae are involved,
infection enters the adjoining intervertebral disc space. This tends to occur later in Pott
disease than in bacterial vertebral osteomyelitis and may have the radiographic appearance
of relative disc sparing. Eventually, the avascular disc tissue dies; there is vertebral
narrowing and subsequent vertebral collapse. Gibbus deformity, a form of structural
kyphosis, distorts spinal canal anatomy ( image 1). The spinal cord is then at risk of
compression resulting in paraplegia, especially with involvement of the mid-thoracic region
where the spinal canal is relatively "tight" around the cord [26]. Occasionally, late-onset
paraplegia occurs due to osteophytes and other chronic degenerative changes at a site of
prior infection. Formation of a "cold abscess" (soft tissue mass) at the site is common.
Noncontiguous spinal disease (eg, disease at more than one level) is uncommon, although in
one South African series it was described in 16 of 98 cases [27].
The most common symptom is local pain, which increases in severity over weeks to months,
sometimes in association with muscle spasm and rigidity. The muscle spasm can extend
beyond the diseased area. In some cases, a characteristic erect posture and "alderman's"
gait may be observed in which the patient walks with short, deliberate steps to avoid jarring
of the spine [28]. Constitutional symptoms such as fever and weight loss are present in less
than 40 percent of cases [13,22,29-31].
The diagnosis of Pott disease is frequently delayed as a result of its subacute course,
especially in regions where the incidence of TB is relatively low [13,22]. In endemic areas, the
clinical presentation also tends to be relatively late due to limited access to medical care; in
these settings, patients have symptoms and signs of cord compression at the time of
diagnosis in 40 to 70 percent of cases [22,32]. Thus, late diagnosis is a major factor in
determining the outcome of the disease [33].
Arthritis
Infectious — Tuberculous arthritis can occur in virtually any joint, but it tends to occur in
the hip or the knee; usually, it is monoarticular. However, multifocal lesions are reported in
10 to 15 percent of cases in developing countries [34]. Hip involvement is the most common
presentation, the most difficult to diagnose, and the most debilitating [6]. Clinical
manifestations include swelling, pain, and/or loss of joint function that progresses over
weeks to months. The joint is generally "cold" (eg, erythema, warmth, and other signs of
acute infection are usually absent). Constitutional symptoms, fever, and weight loss occur in
only about 30 percent of cases [29].

Patients who present late in the course of disease often have evidence of joint destruction
including local deformity and restricted range of motion. Some patients with advanced
disease have draining sinuses. Granulomatous changes typically accompany synovial
proliferation in tuberculous arthritis, with joint effusion and erosion of cartilage. The
consequences are slowly progressive destruction, disorganization of joint architecture, and
potential deformity.
Some data suggest that total hip replacement in the setting of active TB is acceptable if
undertaken in association with appropriate debridement and antituberculous therapy [35].
Inflammatory (Poncet disease) — Poncet disease is an acute symmetric polyarthritis

involving large and small joints associated with active extrapulmonary, pulmonary, or miliary
TB. In general, there is inflammation of the involved joints but no objective evidence of
active TB [36-39]. Poncet disease is relatively rare, and the pathogenesis is unclear; it is
probably immune mediated [38]. HIV coinfection is also a risk factor [40,41]. The arthritis
generally resolves within a few weeks of initiation of anti-TB therapy, with no residual joint
destruction [37,42].
Prosthetic joint infection — Rarely, M. tuberculosis can cause infection at the site of a

prosthetic joint. Diagnosis has been described at the time of initial arthroplasty as well as
subsequent to hardware placement [43].
For cases in which TB is identified at the time of initial arthroplasty, the diagnosis is typically
a surprise to the surgeon who sends abnormal-appearing bone for histopathologic
examination or culture at the time of joint replacement. These patients generally have a
favorable outcome after standard antituberculous chemotherapy, even if the joint prosthesis
is not removed [43].
For cases in which infection is identified following hardware placement, a dormant nidus of
infection reactivates, and patients subsequently present with clinical findings of an infected
prosthesis. These patients often have painful, malfunctioning prostheses, and hardware
removal is required for cure. Some patients with late-onset tuberculous prosthetic joint
infections have coexisting bacterial infection that may mask or obscure the underlying
coinfection with M. tuberculosis.
Osteomyelitis — In addition to tuberculous vertebral osteomyelitis (Pott disease),

tuberculous osteomyelitis can occur in virtually any bone, including the ribs, skull, tubular
bones of the hands and feet (dactylitis), wrist, phalanx, pelvis, and long bones. The onset is
often insidious but, in rare cases, the onset may be acute or subacute [44]. Typically,
osteomyelitis occurs at a single site. However, rarely bony involvement can be multifocal.
The location and presentation can be variable as illustrated by the following case reports:

● Sternal osteomyelitis due to M. tuberculosis may follow coronary artery bypass surgery
[45] as a presentation of underlying mediastinal TB [46] or as primary sternal
osteomyelitis [47].
● Bony TB of the rib may present as a breast mass or chest wall mass [48,49].
● TB of the small bones of the hand can occur spontaneously in patients with no clinical
signs of pulmonary TB [50].
● Tuberculous mastoiditis can extend into the skull and produce facial nerve palsy [51].
● Lytic bony tubercular lesions in areas as unusual as the symphysis pubis, sacroiliac
joint, and elbow can be misdiagnosed as metastatic malignancy [52].
In some cases, bony infection may spread to contiguous soft tissues or even adjacent joints.
Rarely, involvement of multiple bones may be associated with erroneous diagnosis of
metastatic malignancy [53-55].
An antecedent history of trauma may lead to diagnostic confusion; TB can develop in a bone
or joint injured by previous trauma or surgery. Tuberculous osteomyelitis frequently
presents as a "cold abscess" with swelling, modest erythema or pain, and little or no local
warmth [15]. Spontaneous drainage may occur.
Other clinical manifestations — Musculoskeletal TB can occur as an abscess in the

epidural space (creating pressure on the spinal cord), as an extraspinal soft tissue mass
(eroding ribs and adjacent structures), or as a psoas abscess (which can track down to the
groin). (See "Psoas abscess".)
Radiography — Radiographic imaging can be useful to identify and establish the anatomy

of musculoskeletal TB, although there are no pathognomonic radiographic findings [56].
In the setting of tuberculous spondylitis (Pott disease), radiographic abnormalities are

usually first observed in the anterior aspect of a vertebral body, with demineralization of the
end plate and loss of definition of the bony margin [57]. Subsequently, the opposing
vertebra becomes involved and, in some cases, a paravertebral abscess may be seen.
Involvement of contiguous vertebrae is common, although it is not uncommon to see
noncontiguous spinal TB at multiple levels. As infection progresses, the disc space becomes
obliterated with anterior wedging and angulation. Reactive sclerotic changes remain
localized and the remainder of the vertebral structures is often spared ( image 2).
In some patients, spinal TB presents with osteolytic lesions in the absence of disc space
involvement; these lesions may occur at multiple sites. In one study of 103 French patients
with spinal TB, no disc involvement was observed in about half of cases; plain radiographs
demonstrated osteolytic lesions and multiple involved sites [12].

In the setting of tuberculous arthritis, local soft tissue swelling, osteopenia, and bone
destruction (with relative preservation of cartilage space) are observed. Subsequent findings
include structural collapse, sclerotic changes, and soft tissue calcification ( image 3). In
some cases, Phemister triad may be observed: juxta-articular osteopenia, peripherally
located osseous erosions, and gradual narrowing of the joint space ( image 4) [58,59].
In the setting of tuberculous osteomyelitis in children, cystic changes may be seen in the
metaphyses of long bones and in flat bones, such as the skull. In tuberculous osteomyelitis
involving a hand or foot, phalangeal bone(s) may have a ballooned appearance.
Computerized tomography, myelography, and magnetic resonance imaging (MRI) are all
useful tools in the diagnosis of musculoskeletal TB [24,60-64]. MRI is particularly valuable in
demonstrating soft tissue extension and encroachment on nearby vital structures, such as
the spinal cord ( image 5 and image 6 and image 7 and image 8) [65,66].
Chest radiography is not a sensitive test for the diagnosis of skeletal TB since there is no
evidence of active chest disease in the majority of cases [5,15,22,67]. However, chest
radiography should be obtained since it may inform decisions regarding isolation, and
collection of sputum specimens for mycobacterial culture should be attempted as the
organism can sometimes be isolated from sputum despite a normal chest radiograph. The
diagnosis of skeletal TB should be considered in patients with focal bony or joint
abnormalities and a chest radiograph compatible with old or active TB. (See "Diagnosis of
pulmonary tuberculosis in adults".)
DIAGNOSIS
General principles — The greatest challenge in diagnosis of skeletal TB is to consider the

diagnosis, especially since there is no evidence of active chest disease in the majority cases.
In addition, delays in diagnosis are common given the indolent nature of tuberculous bone
and joint disease [68]. Clinical clues usually come from the history, which should include
questions about the country of origin and history of prior known or possible TB infection or
contact. In addition, the diagnosis of skeletal TB may be overlooked in patients with HIV
infection and relatively high CD4 counts and no other signs or symptoms of TB.
The diagnosis of musculoskeletal TB is established by microscopy and culture of infected

material. Tissue may be obtained by needle aspiration and/or biopsy; computed tomography
(CT) guidance is useful in regions where available.
Biopsy and culture — The diagnosis of musculoskeletal TB is established by microscopy and

culture of infected material [69-71]. Drug susceptibility testing of isolates is essential. Tissue

may be obtained by needle aspiration and/or biopsy. CT guidance is useful in regions where
available [72,73].
The diagnosis of tuberculous arthritis can be established by synovial biopsy. Synovial fluid
may be examined [74], but findings are usually nonspecific; the white cell count can be high
or low, with preponderance of either neutrophils or lymphocytes [75].
In the setting of one or more draining sinuses, culture of this material may be useful,
although, in some cases, cultures may demonstrate colonizing bacteria or fungi that are
erroneously assumed to be the causative pathogen.
The high cost and technical demands of rapid automated growth systems and nucleic acid
detection methods often limits their use in the poorest countries with the highest incidence
of TB [76]. The Xpert MTB/RIF assay is an automated nucleic acid amplification test that can
simultaneously identify M. tuberculosis and rifampin resistance; data on use of this assay in
skeletal TB are limited and the test platform is not approved by the Food and Drug
Administration in the United States for use with specimens other than sputum. However, the
available data suggest that Xpert and the more sensitive Xpert Ultra may be useful adjuncts
to diagnosis of skeletal TB, with sensitivity of 79 and 91 percent, respectively [77]. The Xpert
MTB/RIF assay is discussed further separately. (See "Diagnosis of pulmonary tuberculosis in
adults".)
Additional issues related to diagnostic microbiology are discussed further separately. (See
"Diagnosis of pulmonary tuberculosis in adults".)
Differential diagnosis — The differential diagnosis of skeletal TB includes subacute or

chronic infections due to pathogens or diseases such as Staphylococcus aureus osteomyelitis,
brucellosis, melioidosis, actinomycosis, candidiasis, and histoplasmosis, depending upon
epidemiologic factors. Multifocal bone involvement may be confused for metastatic
malignancy.
The differential diagnosis of Pott disease includes degenerative disc and facet joint disease,
spondyloarthropathy, vertebral body collapse due to osteopenia (with a variety of causes
such as osteoporosis and chronic corticosteroid therapy), pyogenic spinal infection, and
malignancy. Each of these can present with similar clinical features; the main challenge for
diagnosis of TB is consideration of the diagnosis. Most of these conditions can be
distinguished with imaging studies where available.
TREATMENT
General approach — Treatment of musculoskeletal TB consists of antimicrobial therapy. In

some cases, surgical intervention is also warranted.
Antimicrobial therapy — The approach to selection of antituberculous therapy for

treatment of musculoskeletal TB is generally the same as that for pulmonary TB. The drug
regimen may require modification based on concurrent medications (eg, HIV coinfection) or
drug resistance. These issues are discussed in detail separately. (See "Treatment of drug-
susceptible pulmonary tuberculosis in HIV-uninfected adults" and "Treatment of pulmonary
tuberculosis in adults with HIV infection: Initiation of therapy" and "Treatment of drug-
resistant pulmonary tuberculosis in adults".)
The optimal duration of therapy for treatment of musculoskeletal TB is uncertain. For most
patients receiving first-line agents, six to nine months of therapy is sufficient [78]. A longer
duration of therapy (9 to 12 months) is warranted for patients on regimens that do not
include rifampin and/or for patients with extensive or advanced disease, particularly if it is
difficult to assess the response to therapy [78,79].
Data are limited on the optimal drug regimen and duration for treatment of musculoskeletal
infections due to drug-resistant M. tuberculosis. In one small series, 14 of 15 patients were
cured with combined medical/surgical therapy (eight patients) or medical therapy alone
(seven patients). Treatment was continued for 18 to 24 months; follow-up ranged from 5
months to 4.5 years [80].
Previously, longer therapeutic courses (12 to 18 months) have been favored for
musculoskeletal TB because of concerns about poor drug penetration into osseous and
fibrous tissues. However, several studies have shown that six- to nine-month regimens
containing rifampin are at least as effective as longer courses without rifampin [81-86]. The
efficacy of shorter-course therapy is illustrated by the following:
● A large prospective cohort study in Hong Kong demonstrated that 6 months of

antituberculous therapy combined with surgery (radical resection of the lesion and
insertion of autologous bone grafts) was comparable in efficacy with 9 to 18 months of
antituberculous therapy alone [81].
● In three randomized trials of short-course chemotherapy for spinal TB in Hong Kong,

India, and Korea reported after five years of follow-up, six- and nine-month regimens
with isoniazid and rifampin produced comparable results with 18 months of isoniazid
with either ethambutol or para-aminosalicylic acid [84].
● In a randomized trial of 203 Korean patients comparing four different treatment

regimens [(1) isoniazid plus rifampin for six months, (2) isoniazid plus rifampin for nine
months, (3) isoniazid plus ethambutol or para-aminosalicylic acid for nine months, or
(4) isoniazid plus ethambutol or para-aminosalicylic acid for 18 months], a favorable
outcome was achieved in 77 percent of cases after three years from the start of

therapy; those who received the nine-month regimen with isoniazid plus ethambutol or
para-aminosalicylic acid required additional treatment [85].
One small retrospective study from the United Kingdom did report a high rate of relapse
with a six-month course of therapy (62 percent); no relapse was observed among patients
who received nine months of treatment [86]. In contrast, a Chinese study reported that, in
selected patients and combined with appropriate surgical intervention, ultra-short-course
therapy of 4.5 months was as successful as a 9-month course and associated with fewer side
effects [87].
Surgery — Surgical intervention is warranted for patients in the following circumstances

[26,49,88,89]:
● Patients with spinal disease and advanced neurological deficits

● Patients with spinal disease and worsening neurological deficits progressing while on
appropriate therapy
● Patients with spinal disease and kyphosis >40 degrees at the time of presentation
● Patients with chest wall cold abscess
Forms of surgical intervention may include decompression, use of hardware for stabilization
of spine, abscess drainage, and/or debridement of infected material [25,89]. For the most
part, surgical intervention is safe and sometimes effective in improving neurological deficits;
various approaches have been described, depending on site of infection and related abscess
formation [90-92]. In some circumstances, reconstructive surgery may be important once
antimicrobial therapy has been completed [5]. Hardware is rarely needed for stabilization of
debrided bony lesions [93]. Minimally invasive surgical approaches such as video-assisted
thoracoscopic anterior surgery have been used successfully to manage patients with
neurological symptoms and/or extensive bony destruction involving the thoracic or lumbar
spine [94].
The role of surgery in treatment of other presentations of musculoskeletal TB is not always

clear [95]. In one retrospective review of 70 adults with thoracic spinal TB in India, medical
therapy alone was successful in 69 of 70 patients (mean follow-up of 40 months) [88].
Criteria for exclusion included advanced neurologic deficits, worsening neurologic deficits
while on antituberculous therapy, and kyphosis greater than 40 degrees on presentation.
Abscess was observed on presentation in 44 patients (21 of which were epidural), and 7
patients had signs of cord compression at the time of presentation. Routine surgical
intervention is not warranted [93,96].
Similar results were noted in a retrospective analysis of 52 children with TB of the knee [97].
The outcome of medical therapy without synovectomy was excellent in children who
presented with signs and symptoms of synovitis as long as the joint space was normal.

Monitoring clinical response — The response to therapy may be monitored by clinical

indicators such as pain, constitutional symptoms, mobility, and neurologic findings. Typically,
responses to therapy are relatively slow (several months). The role of inflammatory markers
in monitoring the response to TB therapy is limited. It is not useful to perform serial
radiographs since radiographic findings may appear to progress during appropriate
treatment [98].
In one study of 43 patients with Pott paraplegia, the most important prognostic factor that
predicted six-month outcome included muscle power, paraplegia score, sensory-evoked
potentials, and motor-evoked potentials [99]. Patients with mild weakness and lower
paraplegia scores were more likely to recover completely by six months than patients with
more severe prognostic indicators.
For patients on antituberculous therapy for skeletal TB in the setting of antiretroviral

treatment (ART) for HIV infection, it is important to monitor for immune reconstruction
inflammatory syndrome (IRIS). IRIS typically presents with paradoxical progression of TB
clinical manifestations and constitutional symptoms in the first few weeks following initiation
of ART. In the setting of skeletal TB, new clinical manifestations may appear and/or resolved
manifestations may reappear. IRIS is discussed further separately. (See "Immune
reconstitution inflammatory syndrome".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Diagnosis and
treatment of tuberculosis".)
SUMMARY AND RECOMMENDATIONS
● Skeletal tuberculosis (TB) refers to TB involvement of the bones and/or joints.

Musculoskeletal TB accounts for 10 to 35 percent of cases of extrapulmonary TB and
for almost 2 percent of TB cases overall. The proportion of skeletal TB among HIV-
infected individuals is comparable with the proportion of skeletal TB among HIV-
uninfected individuals. (See 'Epidemiology' above.)
● Tuberculous spondylitis (Pott disease) is the most common form of skeletal TB; it
usually affects the lower thoracic and upper lumbar region. Infection begins with
inflammation of the intervertebral joints and can spread to involve the adjacent
vertebral body. Once two adjacent vertebrae are involved, infection can involve the
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adjoining intervertebral disc space, leading to vertebral collapse. Subsequent kyphosis

can lead to cord compression and paraplegia. (See 'Spondylitis (Pott disease)' above.)
● The most common symptom of tuberculous spondylitis (Pott disease) is local pain,
which increases in severity over weeks to months, sometimes in association with
muscle spasm and rigidity. A characteristic erect posture and "alderman's" gait may be
observed in which the patient walks with short, deliberate steps to avoid jarring of the
spine. Constitutional symptoms such as fever and weight loss are relatively uncommon.
(See 'Spondylitis (Pott disease)' above.)
● Tuberculous arthritis tends to occur in the hip or the knee and is usually monoarticular.
Clinical manifestations include swelling, pain, and/or loss of joint function that
progresses over weeks to months. The joint is generally "cold" (eg, erythema, warmth,
and other signs of acute infection are usually absent). (See 'Arthritis' above.)
● Tuberculous osteomyelitis can occur in virtually any bone, including the ribs, skull,
phalanx, pelvis, and long bones. Typically, osteomyelitis occurs at a single site. The
onset is often insidious but, in rare cases, the onset may be acute or subacute.
Tuberculous osteomyelitis frequently presents as a "cold abscess" with swelling,
modest erythema or pain, and little or no local warmth. (See 'Osteomyelitis' above.)
● The diagnosis of musculoskeletal TB is established by microscopy and culture of

infected material. Tissue may be obtained by needle aspiration and/or biopsy; guidance
with computed tomography or ultrasound to obtain tissue is useful in regions where
available. Radiographic imaging can be useful to identify and establish the anatomy of
musculoskeletal TB, although there are no pathognomonic radiographic findings. (See
'Diagnosis' above.)
● Treatment of musculoskeletal TB consists of antituberculous therapy. The approach to

selection of therapy for treatment of musculoskeletal TB is generally the same as that
for pulmonary TB and is discussed in detail separately. (See "Treatment of drug-
susceptible pulmonary tuberculosis in HIV-uninfected adults" and "Treatment of
pulmonary tuberculosis in adults with HIV infection: Initiation of therapy" and
"Treatment of drug-resistant pulmonary tuberculosis in adults".)
● The optimal duration of therapy for treatment of musculoskeletal TB is uncertain. For

patients receiving treatment with first-line agents in the absence of extensive or
advanced disease, we suggest six months of therapy (rather than 9 or 12 months)
(Grade 2B). A longer duration of therapy (9 to 12 months) is warranted for patients on
regimens that do not include rifampin and/or for patients with extensive or advanced
disease. (See 'Antimicrobial therapy' above.)

● Surgical intervention is warranted for patients with spinal disease and advanced
neurological deficits or worsening neurological deficits progressing while on
appropriate therapy, as well as for patients with spinal disease and kyphosis >40
degrees at the time of presentation. (See 'Surgery' above.)
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REFERENCES
1. Daniel TM, Bates JH, Downes KA. History of tuberculosis. In: Tuberculosis: Pathogenesis,
Protection, and Control, Bloom BR (Ed), American Society for Microbiology, Washington
1994. p.13.
2. Hershkovitz I, Donoghue HD, Minnikin DE, et al. Detection and molecular
characterization of 9,000-year-old Mycobacterium tuberculosis from a Neolithic
settlement in the Eastern Mediterranean. PLoS One 2008; 3:e3426.
3. Arriaza BT, Salo W, Aufderheide AC, Holcomb TA. Pre-Columbian tuberculosis in

northern Chile: molecular and skeletal evidence. Am J Phys Anthropol 1995; 98:37.
4. Donoghue HD, Lee OY, Minnikin DE, et al. Tuberculosis in Dr Granville's mummy: a
molecular re-examination of the earliest known Egyptian mummy to be scientifically
examined and given a medical diagnosis. Proc Biol Sci 2010; 277:51.
5. Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am 1996;
78:288.
6. Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res 2004; 120:316.
7. Teo HE, Peh WC. Skeletal tuberculosis in children. Pediatr Radiol 2004; 34:853.
8. Fanning A. Tuberculosis: 6. Extrapulmonary disease. CMAJ 1999; 160:1597.
9. Peto HM, Pratt RH, Harrington TA, et al. Epidemiology of extrapulmonary tuberculosis in
the United States, 1993-2006. Clin Infect Dis 2009; 49:1350.
10. United States Centers for Disease Control and Prevention. Reported Tuberculosis in the
United States, 2018. https://www.cdc.gov/tb/statistics/reports/2018/table15.htm (Access
ed on October 16, 2020).
11. Johansen IS, Nielsen SL, Hove M, et al. Characteristics and Clinical Outcome of Bone and
Joint Tuberculosis From 1994 to 2011: A Retrospective Register-based Study in Denmark.
Clin Infect Dis 2015; 61:554.
12. Pertuiset E, Beaudreuil J, Lioté F, et al. Spinal tuberculosis in adults. A study of 103 cases
in a developed country, 1980-1994. Medicine (Baltimore) 1999; 78:309.
13. Fuentes Ferrer M, Gutiérrez Torres L, Ayala Ramírez O, et al. Tuberculosis of the spine. A
systematic review of case series. Int Orthop 2012; 36:221.

14. Trecarichi EM, Di Meco E, Mazzotta V, Fantoni M. Tuberculous spondylodiscitis:

epidemiology, clinical features, treatment, and outcome. Eur Rev Med Pharmacol Sci
2012; 16 Suppl 2:58.
15. Vohra R, Kang HS, Dogra S, et al. Tuberculous osteomyelitis. J Bone Joint Surg Br 1997;
79:562.
16. Kaufmann SH, Cole ST, Mizrahi V, et al. Mycobacterium tuberculosis and the host
response. J Exp Med 2005; 201:1693.
17. Ellner JJ. Review: the immune response in human tuberculosis--implications for
tuberculosis control. J Infect Dis 1997; 176:1351.
18. Held MFG, Hoppe S, Laubscher M, et al. Epidemiology of Musculoskeletal Tuberculosis in

an Area with High Disease Prevalence. Asian Spine J 2017; 11:405.
19. Tuli SM. Tuberculosis of the Skeletal System, Jaypee Brothers Medical Publishers, New D
elhi 2016.
20. Lenaerts A, Barry CE 3rd, Dartois V. Heterogeneity in tuberculosis pathology,

microenvironments and therapeutic responses. Immunol Rev 2015; 264:288.
21. Lifeso R. Atlanto-axial tuberculosis in adults. J Bone Joint Surg Br 1987; 69:183.
22. Nussbaum ES, Rockswold GL, Bergman TA, et al. Spinal tuberculosis: a diagnostic and
management challenge. J Neurosurg 1995; 83:243.
23. Turgut M. Spinal tuberculosis (Pott's disease): its clinical presentation, surgical
management, and outcome. A survey study on 694 patients. Neurosurg Rev 2001; 24:8.
24. Weaver P, Lifeso RM. The radiological diagnosis of tuberculosis of the adult spine.
Skeletal Radiol 1984; 12:178.
25. Lifeso RM, Weaver P, Harder EH. Tuberculous spondylitis in adults. J Bone Joint Surg Am
1985; 67:1405.
26. Khoo LT, Mikawa K, Fessler RG. A surgical revisitation of Pott distemper of the spine.
Spine J 2003; 3:130.
27. Polley P, Dunn R. Noncontiguous spinal tuberculosis: incidence and management. Eur
Spine J 2009; 18:1096.
28. Girdlestone GR, Somerville EW. Tuberculosis of Bone and Joint, 2nd ed, Oxford Universit
y Press, London 1952.
29. Hodgson SP, Ormerod LP. Ten-year experience of bone and joint tuberculosis in
Blackburn 1978-1987. J R Coll Surg Edinb 1990; 35:259.
30. Hopewell PC. Overview of clinical tuberculosis. In: Tuberculosis: Pathogenesis, Protectio
n and Control, Bloom BR (Ed), American Society for Microbiology Press, Washington, DC
1994. p.25.

31. Pigrau-Serrallach C, Rodríguez-Pardo D. Bone and joint tuberculosis. Eur Spine J 2013; 22
Suppl 4:556.
32. Hsu LC, Leong JC. Tuberculosis of the lower cervical spine (C2 to C7). A report on 40
cases. J Bone Joint Surg Br 1984; 66:1.
33. Kamara E, Mehta S, Brust JC, Jain AK. Effect of delayed diagnosis on severity of Pott's
disease. Int Orthop 2012; 36:245.
34. Kumar K, Saxena MB. Multifocal osteoarticular tuberculosis. Int Orthop 1988; 12:135.
35. Kim SJ, Postigo R, Koo S, Kim JH. Total hip replacement for patients with active
tuberculosis of the hip: a systematic review and pooled analysis. Bone Joint J 2013; 95-
B:578.
36. Isaacs AJ, Sturrock RD. Poncet's disease--fact or fiction? A re-appraisal of tuberculous
rheumatism. Tubercle 1974; 55:135.
37. Sood R, Wali JP, Handa R. Poncet's disease in a north Indian hospital. Trop Doct 1999;
29:33.
38. Dall L, Long L, Stanford J. Poncet's disease: tuberculous rheumatism. Rev Infect Dis
1989; 11:105.
39. Arora S, Prakash TV, Carey RA, Hansdak SG. Poncet's disease: unusual presentation of a
common disease. Lancet 2016; 387:617.
40. Kawsar M, D'Cruz D, Nathan M, Murphy M. Poncet's disease in a patient with AIDS.
Rheumatology (Oxford) 2001; 40:346.
41. Cuende E, Almeida V, Portu J, et al. Poncet's disease and papulonecrotic tuberculid in a
patient infected with the human immunodeficiency virus. Arthritis Rheum 1998;
41:1884.
42. Kroot EJ, Hazes JM, Colin EM, Dolhain RJ. Poncet's disease: reactive arthritis
accompanying tuberculosis. Two case reports and a review of the literature.
Rheumatology (Oxford) 2007; 46:484.
43. Spinner RJ, Sexton DJ, Goldner RD, Levin LS. Periprosthetic infections due to
Mycobacterium tuberculosis in patients with no prior history of tuberculosis. J
Arthroplasty 1996; 11:217.
44. Zahraa J, Johnson D, Lim-Dunham JE, Herold BC. Unusual features of osteoarticular
tuberculosis in children. J Pediatr 1996; 129:597.
45. Rubinstien EM, Lehmann T. Sternal osteomyelitis due to Mycobacterium tuberculosis

following coronary artery bypass surgery. Clin Infect Dis 1996; 23:202.
46. Gondal GM, Mushtaq S, Masood R, et al. Mediastinal tuberculosis presenting with
sternal osteomyelitis and discharging sinus. J Postgrad Med Inst 2011; 25:379.

47. Platt MA, Ziegler K. Primary sternal osteomyelitis with bacteremia and distal seeding. J
Emerg Med 2012; 43:e93.
48. Frouge C, Miquel A, Cochan-Priollet B, et al. Breast mass due to rib tuberculosis. Eur J
Radiol 1995; 19:118.
49. Kim YT, Han KN, Kang CH, et al. Complete resection is mandatory for tubercular cold
abscess of the chest wall. Ann Thorac Surg 2008; 85:273.
50. Karanas YL, Yim KK. Mycobacterium tuberculosis infection of the hand: a case report
and review of the literature. Ann Plast Surg 1998; 40:65.
51. Hadfield PJ, Shah BK, Glover GW. Facial palsy due to tuberculosis: the value of CT. J
Laryngol Otol 1995; 109:1010.
52. Gothwal S, Varshney P, Mathur S, Songra B. Tuberculosis of the pubic symphysis. BMJ
Case Rep 2014; 2014.
53. Ormerod LP, Grundy M, Rahman MA. Multiple tuberculous bone lesions simulating
metastatic disease. Tubercle 1989; 70:305.
54. Muradali D, Gold WL, Vellend H, Becker E. Multifocal osteoarticular tuberculosis: report
of four cases and review of management. Clin Infect Dis 1993; 17:204.
55. Lynn MM, Kukanesen JR, Khan AW. Troublesome Tuberculosis: A Case Report on Multi-
focal Tuberculous Osteomyelitis in An Immunocompetent Patient. J Clin Med Res 2012;
4:73.
56. Marais S, Roos I, Mitha A, et al. Spinal Tuberculosis: Clinicoradiological Findings in 274
Patients. Clin Infect Dis 2018; 67:89.
57. Yao DC, Sartoris DJ. Musculoskeletal tuberculosis. Radiol Clin North Am 1995; 33:679.
58. Phemister, DB, Hatcher, CH. Correlation of pathological and roentgenological findings in
the diagnosis of tuberculous arthritis. Am J Roentgenol 1933; 29:736.
59. Choi JA, Koh SH, Hong SH, et al. Rheumatoid arthritis and tuberculous arthritis:
differentiating MRI features. AJR Am J Roentgenol 2009; 193:1347.
60. Shanley DJ. Tuberculosis of the spine: imaging features. AJR Am J Roentgenol 1995;
164:659.
61. Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: patterns of

bone destruction. Clin Radiol 1993; 47:196.
62. Kim NH, Lee HM, Suh JS. Magnetic resonance imaging for the diagnosis of tuberculous
spondylitis. Spine (Phila Pa 1976) 1994; 19:2451.
63. Desai SS. Early diagnosis of spinal tuberculosis by MRI. J Bone Joint Surg Br 1994; 76:863.
64. Pui MH, Mitha A, Rae WI, Corr P. Diffusion-weighted magnetic resonance imaging of
spinal infection and malignancy. J Neuroimaging 2005; 15:164.

65. Jung NY, Jee WH, Ha KY, et al. Discrimination of tuberculous spondylitis from pyogenic
spondylitis on MRI. AJR Am J Roentgenol 2004; 182:1405.
66. Hart JT. The inverse care law. Lancet 1971; 1:405.
67. Davidson PT, Horowitz I. Skeletal tuberculosis. A review with patient presentations and
discussion. Am J Med 1970; 48:77.
68. Broderick C, Hopkins S, Mack DJF, et al. Delays in the diagnosis and treatment of bone
and joint tuberculosis in the United Kingdom. Bone Joint J 2018; 100-B:119.
69. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This
official statement of the American Thoracic Society and the Centers for Disease Control
and Prevention was adopted by the ATS Board of Directors, July 1999. This statement
was endorsed by the Council of the Infectious Disease Society of America, September
1999. Am J Respir Crit Care Med 2000; 161:1376.
70. Colmenero JD, Ruiz-Mesa JD, Sanjuan-Jimenez R, et al. Establishing the diagnosis of
tuberculous vertebral osteomyelitis. Eur Spine J 2013; 22 Suppl 4:579.
71. Merino P, Candel FJ, Gestoso I, et al. Microbiological diagnosis of spinal tuberculosis. Int
Orthop 2012; 36:233.
72. Mondal A. Cytological diagnosis of vertebral tuberculosis with fine-needle aspiration

biopsy. J Bone Joint Surg Am 1994; 76:181.
73. Versfeld GA, Solomon A. A diagnostic approach to tuberculosis of bones and joints. J
Bone Joint Surg Br 1982; 64:446.
74. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic
Society/Infectious Diseases Society of America/Centers for Disease Control and
Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children.
Clin Infect Dis 2017; 64:e1.
75. Allali F, Mahfoud-Filali S, Hajjaj-Hassouni N. Lymphocytic joint fluid in tuberculous

arthritis. A review of 30 cases. Joint Bone Spine 2005; 72:319.
76. Patwardhan SA, Joshi S. Laboratory diagnosis of spinal tuberculosis: Past and present.
ArgoSpine News & Journal 2011; 23:120.
77. Sun Q, Wang S, Dong W, et al. Diagnostic value of Xpert MTB/RIF Ultra for osteoarticular
tuberculosis. J Infect 2019; 79:153.
78. Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for
Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice
Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147.
79. Blumberg HM, Leonard MK Jr, Jasmer RM. Update on the treatment of tuberculosis and
latent tuberculosis infection. JAMA 2005; 293:2776.

80. Suárez-García I, Noguerado A. Drug treatment of multidrug-resistant osteoarticular

tuberculosis: a systematic literature review. Int J Infect Dis 2012; 16:e774.
81. A controlled trial of six-month and nine-month regimens of chemotherapy in patients

undergoing radical surgery for tuberculosis of the spine in Hong Kong. Tenth report of
the Medical Research Council Working Party on Tuberculosis of the Spine. Tubercle
1986; 67:243.
82. Upadhyay SS, Saji MJ, Yau AC. Duration of antituberculosis chemotherapy in conjunction
with radical surgery in the management of spinal tuberculosis. Spine (Phila Pa 1976)
1996; 21:1898.
83. A controlled trial of anterior spinal fusion and débridement in the surgical management
of tuberculosis of the spine in patients on standard chemotherapy: a study in two
centres in South Africa. Seventh Report of the Medical Research Council Working Party
on tuberculosis of the spine. Tubercle 1978; 59:79.
84. Five-year assessment of controlled trials of short-course chemotherapy regimens of 6, 9

or 18 months' duration for spinal tuberculosis in patients ambulatory from the start or
undergoing radical surgery. Fourteenth report of the Medical Research Council Working
Party on Tuberculosis of the Spine. Int Orthop 1999; 23:73.
85. Controlled trial of short-course regimens of chemotherapy in the ambulatory treatment

of spinal tuberculosis. Results at three years of a study in Korea. Twelfth report of the
Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg
Br 1993; 75:240.
86. Ramachandran S, Clifton IJ, Collyns TA, et al. The treatment of spinal tuberculosis: a
retrospective study. Int J Tuberc Lung Dis 2005; 9:541.
87. Wang Z, Shi J, Geng G, Qiu H. Ultra-short-course chemotherapy for spinal tuberculosis:
five years of observation. Eur Spine J 2013; 22:274.
88. Nene A, Bhojraj S. Results of nonsurgical treatment of thoracic spinal tuberculosis in

adults. Spine J 2005; 5:79.
89. Upadhyay SS, Sell P, Saji MJ, et al. Surgical management of spinal tuberculosis in adults.
Hong Kong operation compared with debridement surgery for short and long term
outcome of deformity. Clin Orthop Relat Res 1994; :173.
90. Wang LJ, Zhang HQ, Tang MX, et al. Comparison of Three Surgical Approaches for
Thoracic Spinal Tuberculosis in Adult: Minimum 5-Year Follow-Up. Spine (Phila Pa 1976)
2016.
91. Wang ST, Ma HL, Lin CP, et al. Anterior debridement may not be necessary in the
treatment of tuberculous spondylitis of the thoracic and lumbar spine in adults: a
retrospective study. Bone Joint J 2016; 98-B:834.

92. Alam MS, Phan K, Karim R, et al. Surgery for spinal tuberculosis: a multi-center
experience of 582 cases. J Spine Surg 2015; 1:65.
93. Oguz E, Sehirlioglu A, Altinmakas M, et al. A new classification and guide for surgical
treatment of spinal tuberculosis. Int Orthop 2008; 32:127.
94. Garg N, Vohra R. Minimally invasive surgical approaches in the management of

tuberculosis of the thoracic and lumbar spine. Clin Orthop Relat Res 2014; 472:1855.
95. Jutte PC, Van Loenhout-Rooyackers JH. Routine surgery in addition to chemotherapy for
treating spinal tuberculosis. Cochrane Database Syst Rev 2006; :CD004532.
96. Zhang X, Ji J, Liu B. Management of spinal tuberculosis: a systematic review and meta-
analysis. J Int Med Res 2013; 41:1395.
97. Hoffman EB, Allin J, Campbell JA, Leisegang FM. Tuberculosis of the knee. Clin Orthop
Relat Res 2002; :100.
98. Boxer DI, Pratt C, Hine AL, McNicol M. Radiological features during and following
treatment of spinal tuberculosis. Br J Radiol 1992; 65:476.
99. Kalita J, Misra UK, Mandal SK, Srivastava M. Prognosis of conservatively treated patients
with Pott's paraplegia: logistic regression analysis. J Neurol Neurosurg Psychiatry 2005;
76:866.
Topic 7658 Version 32.0

GRAPHICS
Pott disease in a young child
A gibbous deformity has occurred as a consequence of collapse of the 8th, 9th,

and 10th thoracic vertebral bodies with sparing of the posterior vertebral
elements. The paravertebral abscess is extensive projecting laterally and
anteriorly (arrows). Bony debris is present in the abscess.
Courtesy of Charles E Putnam, MD.
Graphic 60628 Version 8.0

Pott disease in an adult
Posterioanterior thoracic spine film from a patient with Pott disease

shows the contours of a tuberculous paraspinal mass (arrows) with
destruction of the T7-8 disc space and adjacent vertebral bodies.

Tuberculous arthritis
Tuberculous arthritis of the left wrist with destructive changes in the

carpal bones (arrow) and radius and prominent soft tissue swelling
(arrowhead).

Tuberculosis of the right hip
Plain film of the right hip in a 28-year-old woman with painful joints
and a productive cough demonstrates complete loss of the joint
space and destruction of the cartilage and adjacent joint surfaces
with severe periarticular bony demineralization (arrows).
Courtesy of Jonathan Kruskal, MD.

Tuberculosis of the spine (Pott disease)
Magnetic resonance imaging with T1-weighted fat-saturated image

showing anterior vertebral body destruction with relative sparing of
adjacent discs and an abscess spreading beneath the anterior
longitudinal ligament.
Courtesy of Denis Spelman, MBBS, FRACP, FRCPA, MPH.

Magnetic resonance imaging of 17-year-old fisherman showing

tuberculous infection of adjacent thoracic vertebrae with intervening
disc destruction and an anterior paraspinal abscess.
Courtesy of Malcolm McDonald, PhD, FRACP, FRCPA.

Magnetic resonance imaging of 17-year-old fisherman (coronal

section) showing a large tuberculous paraspinal abscess and pleural
involvement.

Postsurgical drainage and fixation of spinal

tuberculosis (Pott disease)
Plain film of 17-year-old fisherman following surgical drainage and

spinal fixation.

Contributor Disclosures
Jason Stout, MD Nothing to disclose John Bernardo, MD Nothing to disclose Elinor L Baron, MD,
DTMH Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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17/11/21 23:05 Bone and joint tuberculosis - UpToDate

Official reprint from UpToDate®

Worldwide, skeletal TB accounts for 10 to 35 percent of cases of extrapulmonary TB (9.6

During primary M. tuberculosis infection, bacillemia may lead to seeding of organisms in

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Spondylitis (Pott disease) — Tuberculous spondylitis (Pott disease) most commonly affects

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Inflammatory (Poncet disease) — Poncet disease is an acute symmetric polyarthritis

Prosthetic joint infection — Rarely, M. tuberculosis can cause infection at the site of a

Osteomyelitis — In addition to tuberculous vertebral osteomyelitis (Pott disease),

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Other clinical manifestations — Musculoskeletal TB can occur as an abscess in the

Radiography — Radiographic imaging can be useful to identify and establish the anatomy

In the setting of tuberculous spondylitis (Pott disease), radiographic abnormalities are

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General principles — The greatest challenge in diagnosis of skeletal TB is to consider the

The diagnosis of musculoskeletal TB is established by microscopy and culture of infected

Biopsy and culture — The diagnosis of musculoskeletal TB is established by microscopy and

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Differential diagnosis — The differential diagnosis of skeletal TB includes subacute or

General approach — Treatment of musculoskeletal TB consists of antimicrobial therapy. In

Antimicrobial therapy — The approach to selection of antituberculous therapy for

● A large prospective cohort study in Hong Kong demonstrated that 6 months of

● In three randomized trials of short-course chemotherapy for spinal TB in Hong Kong,

● In a randomized trial of 203 Korean patients comparing four different treatment

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Surgery — Surgical intervention is warranted for patients in the following circumstances

● Patients with spinal disease and advanced neurological deficits

The role of surgery in treatment of other presentations of musculoskeletal TB is not always

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Monitoring clinical response — The response to therapy may be monitored by clinical

For patients on antituberculous therapy for skeletal TB in the setting of antiretroviral

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Skeletal tuberculosis (TB) refers to TB involvement of the bones and/or joints.

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adjoining intervertebral disc space, leading to vertebral collapse. Subsequent kyphosis

● The diagnosis of musculoskeletal TB is established by microscopy and culture of

● Treatment of musculoskeletal TB consists of antituberculous therapy. The approach to

● The optimal duration of therapy for treatment of musculoskeletal TB is uncertain. For

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Use of UpToDate is subject to the Subscription and License Agreement.

3. Arriaza BT, Salo W, Aufderheide AC, Holcomb TA. Pre-Columbian tuberculosis in

8. Fanning A. Tuberculosis: 6. Extrapulmonary disease. CMAJ 1999; 160:1597.

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14. Trecarichi EM, Di Meco E, Mazzotta V, Fantoni M. Tuberculous spondylodiscitis:

18. Held MFG, Hoppe S, Laubscher M, et al. Epidemiology of Musculoskeletal Tuberculosis in

20. Lenaerts A, Barry CE 3rd, Dartois V. Heterogeneity in tuberculosis pathology,

https://www.uptodate.com/contents/bone-and-joint-tuberculosis/print?search=Mal de Pott&source=search_result&selectedTitle=1~20&usage_t… 13/27

45. Rubinstien EM, Lehmann T. Sternal osteomyelitis due to Mycobacterium tuberculosis

https://www.uptodate.com/contents/bone-and-joint-tuberculosis/print?search=Mal de Pott&source=search_result&selectedTitle=1~20&usage_t… 14/27

61. Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: patterns of

https://www.uptodate.com/contents/bone-and-joint-tuberculosis/print?search=Mal de Pott&source=search_result&selectedTitle=1~20&usage_t… 15/27

72. Mondal A. Cytological diagnosis of vertebral tuberculosis with fine-needle aspiration

75. Allali F, Mahfoud-Filali S, Hajjaj-Hassouni N. Lymphocytic joint fluid in tuberculous

https://www.uptodate.com/contents/bone-and-joint-tuberculosis/print?search=Mal de Pott&source=search_result&selectedTitle=1~20&usage_t… 16/27

80. Suárez-García I, Noguerado A. Drug treatment of multidrug-resistant osteoarticular

81. A controlled trial of six-month and nine-month regimens of chemotherapy in patients

84. Five-year assessment of controlled trials of short-course chemotherapy regimens of 6, 9

85. Controlled trial of short-course regimens of chemotherapy in the ambulatory treatment

88. Nene A, Bhojraj S. Results of nonsurgical treatment of thoracic spinal tuberculosis in

https://www.uptodate.com/contents/bone-and-joint-tuberculosis/print?search=Mal de Pott&source=search_result&selectedTitle=1~20&usage_t… 17/27