Multifocal skeletal tuberculosis in nonimmunocompromised patient: Thumb infection as the tip of an iceberg

Raju Karuppal; Sreehari Sreedhar; Asif Kasim

doi:10.4103/jotr.jotr_30_20

CASE REPORT

Year : 2021 | Volume : 13 | Issue : 2 | Page : 149-151

Multifocal skeletal tuberculosis in nonimmunocompromised patient: Thumb infection as the tip of an iceberg

Raju Karuppal¹, Sreehari Sreedhar¹, Asif Kasim²
¹ Departments of Orthopaedics, Government Medical College, Kozhikode, Kerala, India
² Department of Orthopaedics, Government Medical College, Manjeri, Kerala, India

Date of Submission	01-May-2020
Date of Acceptance	11-Apr-2021
Date of Web Publication	27-Dec-2021

Correspondence Address:
Dr. Raju Karuppal
Karuppal House, Post Mukkam, Kozhikode - 673 602, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jotr.jotr_30_20

Abstract

Tuberculosis (TB) of the musculoskeletal system is not an uncommon clinical condition. Multifocal osseous involvement is often rare and difficult to recognize. Because of the diverse and atypical clinical manifestations, it is easily misdiagnosed in many situations. The present study reports a case of multifocal skeletal TB masquerading as septic arthritis of the interphalangeal joint of the thumb. Because of the high prevalence of TB in developing countries, chronic osteoarticular infective lesions are to be considered as TB unless proved otherwise. The importance of clinical suspicion, systematic investigation, and the role of a biopsy in the diagnosis of skeletal TB is emphasized in this study.

Keywords: Multifocal tuberculosis, osteolytic lesion, osteomyelitis, skeletal tuberculosis, small bone tuberculosis

How to cite this article:
Karuppal R, Sreedhar S, Kasim A. Multifocal skeletal tuberculosis in nonimmunocompromised patient: Thumb infection as the tip of an iceberg. J Orthop Traumatol Rehabil 2021;13:149-51

How to cite this URL:
Karuppal R, Sreedhar S, Kasim A. Multifocal skeletal tuberculosis in nonimmunocompromised patient: Thumb infection as the tip of an iceberg. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jan 22];13:149-51. Available from: https://www.jotr.in/text.asp?2021/13/2/149/333559

Introduction

Tuberculosis (TB) remains a major cause of mortality and morbidity world over particularly in developing countries.^[1],[2] Multifocal skeletal TB is defined as osteoarticular lesions that occur simultaneously at two or more locations in the skeletal system. Multifocal osseous involvement is usually rare, often difficult to recognize, and makes up <5% of all skeletal TB cases.^[3],[4],[5] A high index of clinical suspicion and systematic investigation has a pivotal role in the diagnosis of multifocal skeletal TB. Radiological examinations, including X-rays and magnetic resonance imaging (MRI), can be used to help the diagnosis.^[6] However, the diagnosis of multifocal skeletal TB is often missed or delayed due to its rarity and vague symptoms of the disease, thus allowing it to progress to functional deficits and severe deformities.^[4],[5],[6] In the present study, the importance of clinical suspicion, systematic investigation, and the role of a biopsy in the diagnosis of multifocal skeletal TB is emphasized.

Case Report

A 20-year-old female patient presented in April 2019 with complaints of throbbing pain, swelling, and a discharging wound over the right thumb of 2-month duration. She was treated as a case of soft-tissue infection from a primary care center. Detailed history revealed a history of low-grade continuous fever along with the sudden onset of pain, swelling, and excruciating pain confined to the left forearm for about 3 months before. She was treated with indigenous medicines for the same for about a fortnight. She also had significant fatiguability and had lost about 3 kg of body weight during these months.

She did not give any history of chronic cough, decreased appetite, night sweats, or any definite history of contact with any TB patients. Local examination of the right thumb showed a diffuse swelling around the interphalangeal region. There was an ulcer of 10-mm size over it with minimal slough and yellowish purulent pus. The examination of the left forearm showed a tense cystic ovoid swelling over the left distal forearm. It was tender but with no local rise of temperature. She was nonimmunocompromised and with normal pulmonary findings.

Blood investigation showed hemoglobin – 9.8 g/dl, total count – 11,500, polymorphs 37%, lymphocytes 42%, erythrocyte sedimentation rate (ESR) – 100, C-reactive protein (CRP) – 52.82, and Mantoux test was positive.

X-ray of right thumb [Figure 1] showed multiple small lytic areas with rarefaction of surrounding bones of both first and second phalanx. X-ray of distal metaphysical region of both left radius and ulna [Figure 2] showed definite lytic areas with geographic borders. Ultrasonogram of the left forearm showed heteroechoic collection with mobile internal echoes noted involving left forearm, deep to muscular plain.

Figure 1: Shows multiple small lytic areas with rarefaction of surrounding bones of both first and second phalanx. Interphalangeal joint articular surface appears to be eroded

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Figure 2: Distal metaphysical regions of both left radius and ulna shows definite lytic areas with geographic borders

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MRI of the left forearm showed shreds of evidence of osteomyelitis with intraosseous abscess with extension to intermuscular and subcutaneous planes. Needle aspiration showed yellow-colored frank pus which was drained and sent for culture and microscopic evaluation. The patient was started on parenteral broad-spectrum antibiotics. Drainage of abscess and debridement of left forearm swelling was done under general anesthesia. An organized collection of pus was found at intramuscular and submuscular planes with the pronator quadratus found completely destroyed. Postoperative X-rays [Figure 3] were taken to rule out any iatrogenic fractures.

Figure 3: Post operative Xray shows curetted lesions of both radius and ulna

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The histopathological study [Figure 4] showed the presence of well-organized granulomas which were characterized by a central group of epitheloid histiocytes, Langhan's giant cells, a mantle of lymphocytes, and fibrous tissue. Adenosine deaminase (ADA) value in the aspirated fluid was 250 IU/L. Acid-fast bacilli culture came as positive with no anti-TB drug resistance. Rifampicin-sensitive TB was detected in the Gene-Xpert study.

Figure 4: shows presence of well-organised chronic granulomatous inflammation at 40 x magnification

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Based on all these results, she was diagnosed as multifocal tuberculous osteomyelitis and was put on standard multidrug anti-TB treatment (ATT) regimen for 9 months. Close follow-ups were maintained, and she tolerated the ATT well. Regular physiotherapy was done for regaining the movements of her left wrist and right thumb. By the end of 9 months, she had regained her body weight, osseous lesions were healed, and blood values normalized.

Discussion

The multifocal skeletal form is usually seen as associated with pulmonary TB. Vertebrae are the most commonly affected site, constituting 50% of all multifocal skeletal TB cases.^[4],[5] Multifocal skeletal TB has rarely been reported in nonimmunocompromised patients and in those with normal pulmonary findings.^[6]

Our patient was nonimmunocompromised and with normal pulmonary findings, which is quite uncommon. Our patient presented to us for the soft-tissue infection of her right thumb, which was misdiagnosed by many as septic arthritis of the interphalangeal joint of the right thumb. This was probably because she had highlighted and prioritized the symptoms of her right thumb alone. However, after a proper detailed history, clinical examination, systematic investigation, and biopsy, we could make the final diagnosis of multifocal skeletal TB. Looking back at this case, we found several points that should have been considered by the clinicians to reach the correct diagnosis. Pain is the main symptom of bone TB.^[7] Fever and systemic symptoms may not present in the early stages of musculoskeletal TB. Hence, one should always keep in mind the possibility of musculoskeletal TB when patients have had long-term musculoskeletal swelling or pain even without fever or any other systemic symptoms. As shown in this case, increased CRP and ESR serum levels were reported as potential TB markers.^[8] Serum ADA level is proposed as a proper index for TB diagnosis; in a cutoff point of 14, its sensitivity and specificity are calculated as 92.7% and 88.1%, respectively.^[9] For the final diagnosis of TB, it is advisable to use these specific and sensitive methods, before reporting the negative results.

Conclusion

This article highlights the importance of clinical suspicion, proper history taking, systematic investigation, and biopsy in the diagnosis of multifocal skeletal TB. Due to the high prevalence of TB in developing countries, chronic osteoarticular infective lesions which may present as septic arthritis are to be considered as TB unless proved otherwise.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. Consensus statement. Global burden of tuberculosis: Estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA 1999;282:677-86.
2.	Moon MS, Moon YW, Moon JL, Kim SS, Sun DH. Conservative treatment of tuberculosis of the lumbar and lumbosacral spine. Clinical Orthopaedics and Related Research. 2002;398:40-9.
3.	Agarwal A, Khan SA, Qureshi NA. Multifocal osteoarticular tuberculosis in children. J Orthop Surg (Hong Kong) 2011;19:336-40.
4.	Yilmaz MH, Kantarci F, Mihmanli I, Kanberoglu K. Multifocal skeletal tuberculosis. South Med J 2004;97:785-7.
5.	Marudanayagam A, Gnanadoss JJ. Multifocal skeletal tuberculosis: A report of three cases. Iowa Orthop J 2006;26:151-3.
6.	Hong L, Wu JG, Ding JG, Wang XY, Zheng MH, Fu RQ, et al. Multifocal skeletal tuberculosis: Experience in diagnosis and treatment. Med Mal Infect 2010;40:6-11.
7.	Hammoudeh M, Khanjar I. Skeletal tuberculosis mimicking seronegative spondyloarthropathy. Rheumatol Int 2004;24:50-2.
8.	Sahin F, Yıldız P. Distinctive biochemical changes in pulmonary tuberculosis and pneumonia. Arch Med Sci 2013;9:656-61.
9.	Afrasiabian S, Mohsenpour B, Bagheri KH, Sigari N, Aftabi K. Diagnostic value of serum adenosine deaminase level in pulmonary tuberculosis. J Res Med Sci 2013;18:252-4.