A CLINICAL PROFILE OF FIFTEEN CASES OF TUBERCULOUS

OSTEOMYELITIS SEEN AT THE PHILIPPINE ORTHOPEDIC CENTER

Amado Carino, MD
Carmelita Navarro, MD FPSP

Introduction

Extrapulmonary tuberculosis is more common in children than in adults,

and about one-third of children who have tuberculosis have extrapulmonary
manifestations.1 Tuberculosis of the skeletal system is generally the result of
hematogenous dissemination at the time of initial baccilemia, with the lung as the
primary focus in about 75% of cases. 2,3 Skeletal involvement usually presents as
an insidious monoarticular process. Weight-bearing joints are frequently affected,
with the hip, knee, or ankle being involved in 50% of cases. Peripheral
involvement occurs in 3% of all cases with skeletal involvement, usually
monoarticular and mainly affecting the hip and the knee. 4 Disseminated
tuberculous osteomyelitis makes up the remainder. The site of involvement is
primarily metaphyseal, although diaphyseal infection is also seen. 5 Virtually any
bone can be affected including those of the pelvis, the phalanges and the
metacarpals, the long bones, ribs, sternum, skull, patella, and the carpal and
tarsal regions.6,7

However, extra-articular skeletal tuberculosis involving the diaphyseal

portion of long bones is relatively rare. And if ever seen, are usually mistaken for
newgrowths of pathologic fractures. There are no incidence figures for this
particularly rare disease entity although there have been reports of its incidence.
Even in the local setting where tuberculosis is more common, it has been
considered a diagnostic challenge and requires a high index of suspicion and
requires additional diagnostic procedures compared to tuberculous arthritis.

Although foreign literature have cited cases of skeletal tuberculosis

involving long and flatbones, no local study has yet been found to report on this
uncommon disease entity.8,9 It is therefore the purpose of this report to review
cases of tuberculous osteomyelitis involving long and flatbones seen at the
Philippine Orthopedic Center.

Methodology

This is a descriptive, retrospective study covering a four-year period from

January 1993 to December 1996. Criteria for patient inclusion was a discharge
diagnosis of tuberculous osteomyelitis involving flatbones and diaphysis of long
bones, and a histopathologic finding of chronic granulomatous inflammation
consistent with tuberculosis on open biopsy. Excluded were cases with pure
spinal tuberculosis and those involving the joints. Data collected were analyzed
using the different measures of central tendency. Results of treatment was not
included in this study.

Results
A total of fifteen cases of tuberculous osteomyelitis were included for an
average of 3.7 cases per year from 1993 to 1996. There were 7 males and 8
females with a male:female ratio of 1:1.14. The overall mean age was 37 years,
36 for males and 21.5 for females. The youngest patients were three one-year
old girls all presenting with pain and swelling of involved parts. The oldest was a
75-year old male presenting with pain, swelling and deformity of right femur.
Eighty percent of patients belong to the less than 20-year age group.

Nine patients were hospitalized for less than thirty days while six patients
were confined at the hospital for more than one month. One
post-debridement/biopsy patient was discharged after only 12 days of hospital
stay. One 43-year old male was discharged after eight months and a series of
four surgical interventions.

It is very interesting to note that all patients had a different admitting

diagnosis from the diagnosis upon discharge. Seven patients were diagnosed as
Chronic Osteomyelitis while three were diagnosed as Newgrowths, two as
Pathologic Fractures, two as Eosinophilic Granulomas, and one as Aneurysmal
Bone Cyst (Table 2). No correct admitting diagnosis was noted.

Pain in the involved site was the most frequent local symptom, occurring
in 14(93%) of patients, the location depending on the site of involvement.
Swelling and limp were mentioned by 13 (87%) and 12(83%) patients
respectively. Joint stiffness was seen in 7(47%) patients while deformity of
involved extremity was noted in 5(33%). Systemic symptoms included weight
loss in 7(47%), fever in 3(20%), cough in 2(13%), and night sweats in 1(7%). Nos
systemic symptoms were noted on 2 patients (Table 3).

As to the duration of illness, 12(80%) patients had symptoms lasting for

less than 6 months while three had symptoms lasting for more than 6 months
(Table 4).

On chest x-ray, only 4(47%) showed lung lesions with one patient
showing concomitant segmental atelectasis and non-specific bronchitis. The rest
showed unremarkable chest findings (Table 5).

All patients underwent surgery, 14 as elective and one as an emergency

where debridement and open arthrotomy/biopsy was done. Tissue diagnosis was
established in all of these procedures. Not one patient has been clinically
diagnosed as tuberculosis prior to a biopsy procedure.
 Debridement and open biopsy was the most common procedure,
performed in 9(43%) patients. Two patients underwent trochar biopsy. A total of
22 procedures was done in 15 patients. All were given oral anti-tuberculosis
drugs upon diagnosis while one had chemotherapy initially but was immediately
discontinued once the biopsy result came in (Table 6).

Overall, the femur was the most common site, occurring in 7(47%),
followed by the tibia in 3(18%) cases. Two patients had involvement of the
humerus and two involve the ilium (Table 7).

Histological diagnosis of chronic granulomatous inflammation consistent

with tuberculosis was reported in all cases, all of which showed casseation, while
specimen of 7(47%) patients showed Langhan’s giant cells (Table 8). Aerobic
culture and sensitivity was done in 13 patients; no growth, however, was noted in
10(67%) patients. (Table 9)

Discussion

The declining clinical awareness of skeletal tuberculosis has resulted in

unnecessary destruction of bone. But more importantly, the failure to diagnose
skeletal tuberculosis causes further delay in definitive therapy resulting in further
destruction. Therefore, prompt recognition of the disorder is important. Previously
reported studies of tuberculous arthritis is compared with our patients.

In this study, 80% of the patients were less than 20 years of age. A 1985
study by Montalban of 49 patients with tuberculous arthritis reported 50% of
patients belonging to the more than 40 years age group. 10 This could likely mean
that the patients in this study had the onset of their disease at an earlier age and
had exposure to active tuberculosis cases.

Females were slightly more affected in our study with a ratio of 1:1.14.
This does not parallel the results of compared studies, with Montalban obtaining
a ratio of 1.7:1and Claudio, et al reported a ratio of 1.5:1. 11

The bones of the lower extremities were involved in 13(87%) patients, with
the femur being the most commonly involved followed by the tibia. It has been
postulated that the preference for the lower extremity skeleton is brought by the
daily microtrauma of bearing weight.

Pain and swelling were the most common complaint in this series,
duplicating the results of comparable studies.

The majority of skeletal tuberculous infection is no longer preceded by

overt pulmonary infection. In this study, only 4(27%) out of the 15 patients had
radiological evidence of active pulmonary tuberculosis on chest x-rays. Jocson
(1993) reported the presence of active pulmonary tuberculosis on chest x-ray in
42.8% of cases while Montalban reported 51% of cases. 12

The most definitive way of arriving at a diagnosis is by an open biopsy

and examination of the tissue by both histology and culture. In this study, only 2
cases turned out to be positive for acid-fast bacilli. No microbacterium was
isolated in all specimens sent for culture. Results obtained from specimen sent
for histology reported a histological diagnosis of casseating chronic
granulomatous inflammation consistent with tuberculosis in all cases.

All patients underwent surgery. Debridement and open biopsy were the
most common procedures performed.

References

1. Watts HG, Lifeso RM: Current Concepts Review: Tuberculosis of

Bones and Joints, Journal of Bone and Joint Surgery, 78-A, Feb 96,
pp288-298
2. World Health Statistics, 1988. World Health Organization, Geneva
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Pediatric Clinics of North America, 30, 1983 Pp. 333-348
4. Health Intelligence Service, Department of Health, Philippine Health
Statistics, Manila 1984
5. Benson, et al: Children’s Orthopedics and Fractures, London 1994, p.
210
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Tuberculosis of Bone: Report of a Case; Journal of Bone and Joint
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5 Dec. 1986
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Radiologic Profile non Tuberculous Arthritis, Philippine Journal of
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Journal of Orthopedics Vol. 12, Dec. 1993