Tuberculosis Arthritis and Tenosynovitis

ABSTRACT

The incidence of extrapulmonary tuberculosis (TB) has been rising due to the increasing number of immunosuppressed patients. Musculoskeletal system accounts for 25% of extrapulmonary TB. Most of the musculoskeletal TB involves the spine. TB of peripheral joints and tendons occur infrequently, but if untreated, it can cause serious joint and tendon destruction as well as spread of the infection to the surrounding bursa, muscle, and other soft tissues. The diagnosis of TB of joints and tendons is difficult due to the nonspecific clinical manifestations and imaging features. Concurrent active pulmonary TB is present in <50% of the patients. A positive chest radiographic finding or a positive tuberculin test supports the diagnosis, but negative results do not exclude diagnosis. Although imaging features of TB of joints and tendons are nonspecific, certain findings such as relatively preserved joint space, juxta-articular osteoporosis, cold abscesses, para-articular soft tissue calcification, and rice bodies are suggestive of TB infection. Familiarity with these imaging features can help in making an early diagnosis and facilitating proper management.

KEYWORDS

Infective tenosynovitis - Mycobacterium tuberculosis - septic arthritis - tuberculosis - tuberculous arthritis

REFERENCES

• 1 World Health Organization. Global tuberculosis control: a short update to 2009 report. Available at: http://www.who.int/tb/publications/global_report/2009/update/en/index.html Accessed September 29, 2011
• 2 Golden M P, Vikram H R. Extrapulmonary tuberculosis: an overview.  Am Fam Physician. 2005;  72 (9) 1761-1768
• 3 Gonzalez O Y, Adams G, Teeter L D, Bui T T, Musser J M, Graviss E A. Extra-pulmonary manifestations in a large metropolitan area with a low incidence of tuberculosis.  Int J Tuberc Lung Dis. 2003;  7 (12) 1178-1185
• 4 Lin J N, Lai C H, Chen Y H et al.. Risk factors for extra-pulmonary tuberculosis compared to pulmonary tuberculosis.  Int J Tuberc Lung Dis. 2009;  13 (5) 620-625
• 5 Holty J E, Gould M K, Meinke L, Keeffe E B, Ruoss S J. Tuberculosis in liver transplant recipients: a systematic review and meta-analysis of individual patient data.  Liver Transpl. 2009;  15 (8) 894-906
• 6 Sayiner A, Ece T, Duman S et al.. Tuberculosis in renal transplant recipients.  Transplantation. 1999;  68 (9) 1268-1271
• 7 Choi S W, Ahn J J, Hwang Y T, Koh S H, Cho S D. A case of tuberculous arthritis following the use of etanercept.  Korean J Intern Med. 2009;  24 (4) 397-401
• 8 Gardam M A, Keystone E C, Menzies R et al.. Anti-tumour necrosis factor agents and tuberculosis risk: mechanisms of action and clinical management.  Lancet Infect Dis. 2003;  3 (3) 148-155
• 9 Sayarlioglu M, Inanc M, Kamali S et al.. Tuberculosis in Turkish patients with systemic lupus erythematosus: increased frequency of extrapulmonary localization.  Lupus. 2004;  13 (4) 274-278
• 10 Kumar S, Agarwal A, Arora A. Skeletal tuberculosis following fracture fixation. A report of five cases.  J Bone Joint Surg Am. 2006;  88 (5) 1101-1106
• 11 Nag H L, Neogi D S, Nataraj A R, Kumar V A, Yadav C S, Singh U. Tubercular infection after arthroscopic anterior cruciate ligament reconstruction.  Arthroscopy. 2009;  25 (2) 131-136
• 12 Gopal K, Raj A, Rajesh M R, Prabhu S K, Geothe J. Sternal tuberculosis after sternotomy for coronary artery bypass surgery: a case report and review of the literature.  J Thorac Cardiovasc Surg. 2007;  133 (5) 1365-1366
• 13 de Jong J W, van Altena R. Non-respiratory tuberculosis with Mycobacterium tuberculosis after penetrating lesions of the skin: five case histories.  Int J Tuberc Lung Dis. 2000;  4 (12) 1184-1187
• 14 Bryan W J, Doherty Jr J H, Sculco T P. Tuberculosis in a rheumatoid patient. A case report.  Clin Orthop Relat Res. 1982;  (171) 206-208
• 15 Hortas C, Ferreiro J L, Galdo B et al.. Tuberculous arthritis of peripheral joints in patients with previous inflammatory rheumatic disease.  Br J Rheumatol. 1988;  27 (1) 65-67
• 16 Tuli S M. General principles of osteoarticular tuberculosis.  Clin Orthop Relat Res. 2002;  398 (398) 11-19
• 17 Poppel M H, Lawrence L R, Jacobson H G, Stein J. Skeletal tuberculosis: a roentgenographic survey with reconsideration of diagnostic criteria.  Am J Roentgenol Radium Ther Nucl Med. 1953;  70 (6) 936-963
• 18 Heycock J B, Noble T C. Four cases of syringe-transmitted tuberculosis.  Tubercle. 1961;  42 25-27
• 19 Noordhoek G T, van Embden J D, Kolk A H. Reliability of nucleic acid amplification for detection of Mycobacterium tuberculosis: an international collaborative quality control study among 30 laboratories.  J Clin Microbiol. 1996;  34 (10) 2522-2525
• 20 Moore S L, Rafii M. Imaging of musculoskeletal and spinal tuberculosis.  Radiol Clin North Am. 2001;  39 (2) 329-342
• 21 Madariaga M G, Jalali Z, Swindells S. Clinical utility of interferon gamma assay in the diagnosis of tuberculosis.  J Am Board Fam Med. 2007;  20 (6) 540-547
• 22 Song K H, Jeon J H, Park W B et al.. Usefulness of the whole-blood interferon-gamma release assay for diagnosis of extrapulmonary tuberculosis.  Diagn Microbiol Infect Dis. 2009;  63 (2) 182-187
• 23 Mann K J. Lung lesions in skeletal tuberculosis; review of 500 cases.  Lancet. 1946;  2 (6430) 744-749
• 24 Muangchan C, Nilganuwong S. The study of clinical manifestation of osteoarticular tuberculosis in Siriraj Hospital, Thailand.  J Med Assoc Thai. 2009;  92 (Suppl 2) S101-S109
• 25 Gardam M, Lim S. Mycobacterial osteomyelitis and arthritis.  Infect Dis Clin North Am. 2005;  19 (4) 819-830
• 26 Davies P D, Humphries M J, Byfield S P et al.. Bone and joint tuberculosis. A survey of notifications in England and Wales.  J Bone Joint Surg Br. 1984;  66 (3) 326-330
• 27 Enarson D A, Fujii M, Nakielna E M, Grzybowski S. Bone and joint tuberculosis: a continuing problem.  Can Med Assoc J. 1979;  120 (2) 139-145
• 28 Valdazo J P, Perez-Ruiz F, Albarracin A et al.. Tuberculous arthritis. Report of a case with multiple joint involvement and periarticular tuberculous abscesses.  J Rheumatol. 1990;  17 (3) 399-401
• 29 Resnick D. Osteomyelitis, septic arthritis, and soft tissue infection: organisms. In: Resnick D, ed. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia, PA: WB Saunders; 2002: 2510-2624
• 30 Versfeld G A, Solomon A. A diagnostic approach to tuberculosis of bones and joints.  J Bone Joint Surg Br. 1982;  64 (4) 446-449
• 31 Wang M N, Chen W M, Lee K S, Chin L S, Lo W H. Tuberculous osteomyelitis in young children.  J Pediatr Orthop. 1999;  19 (2) 151-155
• 32 De Vuyst D, Vanhoenacker F, Gielen J, Bernaerts A, De Schepper A M. Imaging features of musculoskeletal tuberculosis.  Eur Radiol. 2003;  13 (8) 1809-1819
• 33 De Backer A I, Mortelé K J, Vanhoenacker F M, Parizel P M. Imaging of extraspinal musculoskeletal tuberculosis.  Eur J Radiol. 2006;  57 (1) 119-130
• 34 Akeson W H, Chu C R, Bugbee W. Articular cartilage: morphology, physiology, and function. In: Resnick D, ed. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia, PA: WB Saunders; 2002: 793-815
• 35 Popert J. Rice-bodies, synovial debris, and joint lavage.  Br J Rheumatol. 1985;  24 (1) 1-2
• 36 Cheung H S, Ryan L M, Kozin F, McCarty D J. Synovial origins of rice bodies in joint fluid.  Arthritis Rheum. 1980;  23 (1) 72-76
• 37 Popert A J, Scott D L, Wainwright A C, Walton K W, Williamson N, Chapman J H. Frequency of occurrence, mode of development, and significance or rice bodies in rheumatoid joints.  Ann Rheum Dis. 1982;  41 (2) 109-117
• 38 Nagasawa H, Okada K, Senma S, Chida S, Shimada Y. Tenosynovitis with rice body formation in a non-tuberculosis patient: a case report.  Ups J Med Sci. 2009;  114 (3) 184-188
• 39 Muirhead D E, Johnson E H, Luis C. A light and ultrastructural study of rice bodies recovered from a case of date thorn-induced extra-articular synovitis.  Ultrastruct Pathol. 1998;  22 (4) 341-347
• 40 Jaovisidha S, Chen C, Ryu K N et al.. Tuberculous tenosynovitis and bursitis: imaging findings in 21 cases.  Radiology. 1996;  201 (2) 507-513
• 41 Davidson P T, Le H Q. Musculoskeletal tuberculosis. In: Schlossberg D, ed. Tuberculosis and Nontuberculous Mycobacterium Infections. 4th ed. Philadelphia, PA: WB Saunders; 1999: 204-220
• 42 Dhillon M S, Nagi O N. Tuberculosis of the foot and ankle.  Clin Orthop Relat Res. 2002;  398 (398) 107-113
• 43 Phemister D B, Hatcher C H. Correlation of pathological and roentgenological findings in the diagnosis of tuberculous arthritis.  AJR Am J Roentgenol. 1933;  29 736-752
• 44 Sawlani V, Chandra T, Mishra R N, Aggarwal A, Jain U K, Gujral R B. MRI features of tuberculosis of peripheral joints.  Clin Radiol. 2003;  58 (10) 755-762
• 45 Chau C L, Griffith J F. Musculoskeletal infections: ultrasound appearances.  Clin Radiol. 2005;  60 (2) 149-159
• 46 Pookarnjanamorakot C, Sirikulchayanonta V. Tuberculous bursitis of the subacromial bursa.  J Shoulder Elbow Surg. 2004;  13 (1) 105-107
• 47 Coppola J, Müller N L, Connell D G. Computed tomography of musculoskeletal tuberculosis.  Can Assoc Radiol J. 1987;  38 (3) 199-203
• 48 Suh J S, Lee J D, Cho J H, Kim M J, Han D Y, Cho N H. MR imaging of tuberculous arthritis: clinical and experimental studies.  J Magn Reson Imaging. 1996;  6 (1) 185-189
• 49 Hong S H, Kim S M, Ahn J M, Chung H W, Shin M J, Kang H S. Tuberculous versus pyogenic arthritis: MR imaging evaluation.  Radiology. 2001;  218 (3) 848-853
• 50 Hsu C Y, Lu H C, Shih T T. Tuberculous infection of the wrist: MRI features.  AJR Am J Roentgenol. 2004;  183 (3) 623-628
• 51 Shah J, Patkar D, Parikh B et al.. Tuberculosis of the sternum and clavicle: imaging findings in 15 patients.  Skeletal Radiol. 2000;  29 (8) 447-453
• 52 Batra S, Ab Naell M, Barwick C, Kanvinde R. Tuberculous pyomyositis of the thigh masquerading as malignancy with concomitant tuberculous flexor tenosynovitis and dactylitis of the hand.  Singapore Med J. 2007;  48 (11) 1042-1046
• 53 Soler R, Rodríguez E, Remuiñán C, Santos M. MRI of musculoskeletal extraspinal tuberculosis.  J Comput Assist Tomogr. 2001;  25 (2) 177-183
• 54 Faure E, Souilamas R, Riquet M et al.. Cold abscess of the chest wall: a surgical entity?.  Ann Thorac Surg. 1998;  66 (4) 1174-1178
• 55 Morris B S, Maheshwari M, Chalwa A. Chest wall tuberculosis: a review of CT appearances.  Br J Radiol. 2004;  77 (917) 449-457
• 56 Kuzucu A, Soysal O, Günen H. The role of surgery in chest wall tuberculosis.  Interact Cardiovasc Thorac Surg. 2004;  3 (1) 99-103
• 57 Paik H C, Chung K Y, Kang J H, Maeng D H. Surgical treatment of tuberculous cold abscess of the chest wall.  Yonsei Med J. 2002;  43 (3) 309-314
• 58 Chung S Y, Yang I, Bae S H et al.. Tuberculous abscess in retromammary region: CT findings.  J Comput Assist Tomogr. 1996;  20 (5) 766-769
• 59 Teo T H, Ho G H, Chaturverdi A, Khoo B K. Tuberculosis of the chest wall: unusual presentation as a breast lump.  Singapore Med J. 2009;  50 (3) e97-e99
• 60 Khalil A, Le Breton C, Tassart M, Korzec J, Bigot J, Carette M. Utility of CT scan for the diagnosis of chest wall tuberculosis.  Eur Radiol. 1999;  9 (8) 1638-1642
• 61 Supe A N, Prabhu R Y, Priya H. Role of computed tomography in the diagnosis of rib and lung involvement in tuberculous retromammary abscesses.  Skeletal Radiol. 2002;  31 (2) 96-98
• 62 Choi J A, Koh S H, Hong S H, Koh Y H, Choi J Y, Kang H S. Rheumatoid arthritis and tuberculous arthritis: differentiating MRI features.  AJR Am J Roentgenol. 2009;  193 (5) 1347-1353
• 63 Zacharia T T, Shah J R, Patkar D, Kale H, Sindhwani V. MRI in ankle tuberculosis: review of 14 cases.  Australas Radiol. 2003;  47 (1) 11-16
• 64 Hassanpour S E, Gousheh J. Mycobacterium tuberculosis-induced carpal tunnel syndrome: management and follow-up evaluation.  J Hand Surg Am. 2006;  31 (4) 575-579