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Copyright: © 2017 Lamine S, et al.

Research Article Journal of Orthopedics, Rheumatology and Sports Medicine Open Access

Extra-Spinal Tuberculosis Arthritis: Diagnosis and Treatment Patterns


Sarr Lamine*, Soulama Massadiami, Sane A. Daniel, Niane M. Moustapha, Kinkpe C. Alain Valerie, Daffe Mohamed, Dembele Badara,
Gueye A. Badara, Diouf A. Badara, Coulibaly NdeyeFatou, Dieme C. Bertin and Sane A. Daniel
BP 3001 Avenue Pasteur Dakar, Senegal

Received Date: March 21, 2017, Accepted Date: May 26, 2017, Published Date: June 03, 2017.
*Corresponding author: Lamine Sarr, BP 3001 Avenue Pasteur Dakar, Senegal, Tel: 221-776-528-823, E-mail: drlaminesarr@yahoo.fr.

Patients and Methods


Abstract
Introduction: Among Extra-Pulmonary Tuberculosis (EPTB), extra- It is a retrospective study conducted in the Department of
spinal tuberculosis arthritis is second to spine; hence a large number of Orthopedics and Traumatology of Aristide Le Dantec University
cases are visiting the medical facilities every year. However, diagnosing Teaching Hospital between January 2010 and December 2013. The
and treating tuberculosis arthritis remain challenging since it affects study includes all patients followed and treated for at least one joint
children and young adults. The aim of management is to have a painless, tuberculosis confirmed by bacteriologically and/or histologically.
mobile joint and return the anatomy of the joint as normal as possible. We excluded patients with suspected tuberculosis arthritis but not
Objective: In this article, we review clinical features and principles confirmed by tuberculosis diagnostic tests. We studied for each
of treatment of extra-spinal tuberculosis arthritis. patient social and demographic data, medical and surgical history,
Patients and Methods: It is a retrospective study of all patients clinical, biological and radiological signs, diagnostic patterns,
followed for at least one joint tuberculosis confirmed bacteriologically principles of treatment and evolution. Anatomical and functional
and/or histologically. We report 13 patients and among them one has results were analyzed based on X-rays and specific scores for the
bilateral involvement. affected joint.
Results: The mean follow-up time was 33 months. The most affected Results
joint was the hip which accounted for seven cases and among them one
has bilateral involvement, followed by the knee joint (three cases). The Our study included 13 patients with one patient having bilateral
shoulder, elbow, wrist and ankle joints accounted for one case each. All involvement. There were eight men and five women. The mean
cases were diagnosed by culture or biopsy, or both. All patients received age was 28.8 years (interval: 18 years and 37 years). The Bacillus
anti-tuberculosis chemotherapy in accordance with the National
Calmette-Guérin (BCG) vaccine status was unknown. No history
protocol. Surgery was performed depending on the joint involved and
the radiological and clinical features. We performed three Total Hip
of tuberculosis contact was found. The mean time between the
Replacement (THR) in two patients, nine debridements associated in onset of symptoms and the outpatient consultation was 33 months
one patient with arthrodesis of the ankle joint and immobilization in (interval: 1 month and 84 months). Our patients consulted for
the reminder of cases. The mean follow-up time of 11 patients was 43 joint pain associated or not with swelling (Figure 1,2). There was
months while two patients disappeared. The anatomical and functional a restriction of movement of the affected area in all our patients.
results were excellent in cases of THR, however there was a limited Tuberculosis arthritis primarily involved the large weight-bearing
range of motion in conservative treatment. joints, in particular the hip (7 cases) followed by knee joint (3 cases)
Discussion: Tuberculosis arthritis remains a major health problem and occasionally smaller nonweight-bearing joints like shoulder,
worldwide and it can impair the joint functions. There is usually long elbow, wrist and the ankle accounted one (1 case) case each (Table
delayed consultation of patients thus challenging treatment. The THR is 1,2). Six patients had lymph nodes. No sign of active pulmary
often required as a therapeutic option under circumstances to deal with tuberculosis was noted at the diagnosis time. Tuberculin skin test
complications or sequelae arising from the disease. was positive in all patients. Lymphocytosis was found in all patients.
Test Level: IV; retrospective study. The mean hemoglobin was 10.33 g/dl (interval: 8.3 and 11.8).
There was an increase in C - reactive protein with the mean value of
Keywords: Tuberculosis arthritis; Chemotherapy; Surgery
116.4 (interval: 6 and 192). HIV test was performed in five patients
and it was negative in all patients. X-rays were done systematically
Introduction to all patients. The classic triad of radiologic characteristic
tuberculosis arthritis is juxta-articular osteoporosis; peripheral
The new data of the World Health Organisation (WHO) osseous erosion and gradual narrowing of the intra articular
confirmed that tuberculosis is the most life-threatening infectious space. The outcomes in the hip were subluxation in three cases,
disease accounting 1.3 million deaths in 2013 [1]. In our countries, dislocation in one case, bilateral femoral head and neck necrosis in
the mainstay treatment of pulmonary tuberculosis is supervised one case (Figure 3) and one case of coxarthosis (Figure 4). The CT-
by anti-tuberculosis national programs. However, for extra-
pulmonary tuberculosis, it implies the specialist who may not be Localisation Number of cases
experienced in treating the disease. In extra-spinal tuberculosis Shoulder 1 (pseudo tumor appearance)
arthritis, tuberculosis arthritis primarily involves the large Elbow 1
weight-bearing joints, in particular the hip, knee and ankle and
Wrist 1
occasionally involves smaller nonweight-bearing joints. However
Hip 7 (in which 1 case is bilatéral)
diagnosing and treating tuberculosis arthritis remain challenging.
Knee 3 (verycow brand abscess in one case)
It affects mainly children and young adults and their treatment
Ankle 1
should aim at restoring good functions and pain free joints. We
will describe clinical patterns and principles of treatment of Table 1: Distribution of patients according to the joint localisation of
tuberculosis arthritis. tuberculosis.

J Orth Rhe Sp Med ISSN: 2470-9824 Page 1 of 6


J Orth Rhe Sp Med ISSN: 2470-9824 Vol. 2. Issue. 2. 35000116

Figure 1: Knee TB with lateral gastrocnemius muscle cold abscess (A) Gonarthrosis SAZAKI stage IV in a 23 years old un patient (B).

Figure 2: TB Arthritis of the wrist.

Figure 3: TB Arthritis of the Hip with bilateral head of femur necrosis (A) Treated by chemotherapy and bilateral Total Hip Prosthesis (B).

Scan was performed in three patients. It helped in defining further with the national protocol and adjuvant analgesic therapy. In
extent of joint destruction. The ultrasound was performed in four eleven patients, in addition to anti-tuberculosis chemotherapy,
patients. The diagnosis was confirmed bacteriologically and/or surgery was performed. In six patients, it consisted in debridement
histologically in all cases. A confirmation of acid fast bacillus (AFB) accompanied with plaster of Paris (POP) immobilization or soft
from any body fluid or tissue is the gold standard for the diagnosis immobilization with removable splints (Figures 2,3,5). In case of
of tuberculosis. A Ziehl-Nelsen stain revealed AFB in six patients. ankle tuberculosis, external fixation after debridement has been
Different culture methods such as Lowenstein-Jensen medium can used. In three cases, a joint replacement therapy was performed;
be used for confirming diagnosis of mycobacterium tuberculosis. that is the Total Hip Replacement (Figures 3,4). In one female
In nine patients, cytological examination of the samples showed patient, the joint replacement therapy was done concomitantly
the existence of typical epithelioïd giant cell granuloma. The with the debridement (Figure 4). All patients were declared healed
Chest X-ray was systematically requested in all patients and three of tuberculosis. The mean follow-up time for eleven patients was 44
patients presented tuberculosis caverns. One patient presented months (interval: 17 and 127). Anatomical results were different.
active miliary tuberculosis and one had a spine localization. All In the shoulder joint, we had a joint space narrowing with humeral
patients received anti-tuberculosis chemotherapy in accordance head necrosis at persistence of multiples metaphyseal lacunar

Citation: Lamine S, Massadiami S, Daniel SA, Moustapha NM, Valerie KCA, et al. (2017) Extra-Spinal Tuberculosis Arthritis: Page 2 of 6
Diagnosis and Treatment Patterns. J Orth Rhe Sp Med 2(2): 116.
J Orth Rhe Sp Med ISSN: 2470-9824 Vol. 2. Issue. 2. 35000116

Circumstances Type of Final


Time
Number of Age and Joint Diagnostic Antitubercular Treatment or indications surgical functional
before
Patient Sex involved criteria drugs course duration for surgical intervention status of
diagnosis
intervention performed the joint
complete lysis of
1111 RHZE 2 m Total hip
28/F 60 months Hip L and R histology 8 months femoral heads and excellent
1 RH 6 m Prosthesis
collars
Residual
12222 2 RHZE 2 m
22/M 60 months Knee L histology 8 months arthritis septic Arthrotomy Pain
2 RH 6 m
+stiffness
3 Ankle R and RHZE 2 m arthrosis painful Arthrotomy+
18/M 84 months bacterio 10 months Good
3 Spine RH 8 m ankle arthrodesis
4 RHZE 2 m
18/M 32 months Hip L bacterio 8 months _ _ Good
4 RH 6 m
5 discovery per-
Hip L and histology+ RHZE 2 m Total hip
25/F 6 months 8 months operatoire of the excellent
chest bactério RH 6 m Prosthesis
5 caseum
biopsy of the
6 RHZE 2 m
34/F 12 months Shoulder R histology 8 months pseudo-tumor Arthrotomy Bad
6 RH 6 m
mass
7 RHZE 2 m average
23/M 4 months Knee L histology 8 months arthritis septic Arthrotomy
7 RH 6 m result
88888 8 RHZE 2 m
25/M 2 months Hip L bactério 8 months _ _ Good
8 RH 6 m
9 histology+ RHZE 2 m hip arthritis
16/M 18 days Hip L 8 months Debridement Good
9 bactério RH 6 m assessment
10
persistence of the
Knee RHZE 2 m average
25/M 12 months bacterio 8 months collection despite Debridement
L+chest RH 6 m result
the treatment
10
11 histology+ RHZE 2 m arthritis septic
37/F 18 months Hip R+ chest 10 months Arthrotomy Bad
11 bactério RH 8 m fistulis
12 biopsy of the
RHZE 2 m
22/F 40 months Elbow histology 8 months pseudo-tumor Arthrotomy
RH 6 m _
12 mass
biopsy of the
13 RHZE 2 m
35/M 22 months wrist histology 8 months pseudo-tumor Arthrotomy
13 RH 6 m _
mass

Table 2: Summary table of patients (R: Rifampicin ; H: Isoniazid ; Z: Pyrazinamide ; E: Ethambutol)

Figure 4: THP on coxalgia.

lesions (Figure 6). In three cases of Total Hip Replacement, the Murley Shoulder outcome Score has been used as the measure for
implants were in place without any sign of prosthetic loosening nor assessing the outcomes of the treatment of shoulder tuberculosis.
tuberculosis reactivation. Four remaining cases of hip tuberculosis It is the recommended scoring system of the European Society
were at the stage of coxarthrosis (3 cases) and septic dislocation of Shoulder and Elbow Surgery (ESSE). It is poor with the score
of the hip (1 case). In case of knee tuberculosis, we had globally at 65 (Figure 6). The Postel-Merle d’Aubigné (PMA) score in case
joint space narrowing. In the ankle joint, we had bone fusion with of Total Hip replacement therapy was excellent. In case of knee
tibio-talar joint arthrodesis. At the function level, the Constant- tuberculosis, there is persistence of residual mechanic pain with

Citation: Lamine S, Massadiami S, Daniel SA, Moustapha NM, Valerie KCA, et al. (2017) Extra-Spinal Tuberculosis Arthritis: Page 3 of 6
Diagnosis and Treatment Patterns. J Orth Rhe Sp Med 2(2): 116.
J Orth Rhe Sp Med ISSN: 2470-9824 Vol. 2. Issue. 2. 35000116

Figure 5: TB Arthritis of the elbow.

Figure 6: TB Arthritis of the shoulder (A: TB Arthritis with humeral head necrosis; B: Intra-operative Caseum; C and D: Shoulder fonctions after healing)

different movement restriction of the joint. In the ankle, the the agent or history of trauma should undergo microbiological or
painless plantigrade walk is possible without limbing. The patient histological tests for tuberculosis which remains the gold standard in
with elbow and wrist localisation disappeared. the diagnosis of tuberculosis. Tuberculosis, once a disease confined
to undeveloped or developing nations is currently in resurgence,
Discussion which is attributable to pandemic human immunodeficiency virus
Our study of fourteen cases in thirteen patients seems to make (HIV) infection and immigration from endemic areas [5]. It is an
the extra-spinal tuberculosis arthritis rare. However, these are infection of the hip and knee joints essentially of the young adult
visible parts of the iceberg [2–4]. The diagnosis of tuberculosis joint male. This observation was confirmed in the literature [2,3,5,6]. The
arthritis is delayed due to lack of awareness, insidious in onset, diagnosis of a Tuberculous arthritis is difficult because it can mimic
lack of characteristic early radiographic findings and often lack of an early mono-articular chronic inflammatory rheumatism, a form
constitutional or pulmonary involvement. A high index of suspicion of torpide bacterial arthritis of banal germ, a fungal arthritis, other
is necessary, especially in the context of persistent mono-arthritis in granulomatous synovitis and pigmented villo-nodular synovitis.
a susceptible host. The immunocompromised individuals, elderly or [3,7–9]. The shoulder tuberculosis had a pseudo-tumor aspect. We
children in close contact to tuberculosis or patient who underwent often dispose an x-ray image of lytic bone without any reaction thus
treatment with corticoid and /or immunosuppressive and biologic also revealing an infection with the bacillus of Hansen or a tumor.

Citation: Lamine S, Massadiami S, Daniel SA, Moustapha NM, Valerie KCA, et al. (2017) Extra-Spinal Tuberculosis Arthritis: Page 4 of 6
Diagnosis and Treatment Patterns. J Orth Rhe Sp Med 2(2): 116.
J Orth Rhe Sp Med ISSN: 2470-9824 Vol. 2. Issue. 2. 35000116

All our cases had a bacteriological or histological confirmation surgeon to pay attention to diagnosis and therapy and make
after the diagnosis was suspected on the basis of chronic and them more effective even at higher costs associated with total hip
destructive osteo-articular lesions; classical features on medical replacement in tuberculosis or post-tuberculosis patients in order
imaging (radiography, CT), increased CRP, phlyctenular standard to maintain or restore joint function.
tuberculin skin test (TST) [5,7,10]. The suspicious diagnosis has
often been intra-operative (case of arthritis tuberculosis of the Conflict of Interest
shoulder and one case of coxalgia) by the discovery of the caseum None declared.
during the debridement. The diagnosis of arthritis tuberculosis
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Citation: Lamine S, Massadiami S, Daniel SA, Moustapha NM, Valerie KCA, et al. (2017) Extra-Spinal Tuberculosis Arthritis: Page 5 of 6
Diagnosis and Treatment Patterns. J Orth Rhe Sp Med 2(2): 116.
J Orth Rhe Sp Med ISSN: 2470-9824 Vol. 2. Issue. 2. 35000116

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*Corresponding author: Lamine Sarr, BP 3001 Avenue Pasteur Dakar, Senegal, Tel: 221-776-528-823, E-mail: drlaminesarr@yahoo.fr.
Received Date: March 21, 2017, Accepted Date: May 26, 2017, Published Date: June 03, 2017.
Copyright: © 2017 Lamine S, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Lamine S, Massadiami S, Daniel SA, Moustapha NM, Valerie KCA, et al. (2017) Extra-Spinal Tuberculosis Arthritis: Diagnosis and Treatment Patterns.
J Orth Rhe Sp Med 2(2): 116.

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Citation: Lamine S, Massadiami S, Daniel SA, Moustapha NM, Valerie KCA, et al. (2017) Extra-Spinal Tuberculosis Arthritis: Page 6 of 6
Diagnosis and Treatment Patterns. J Orth Rhe Sp Med 2(2): 116.

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