Flint, Julia D

Saravana, Shanmugam

English

PubMed

Springer - Publisher Connector

Case report
Open Access
Tuberculous osteomyelitis of the midfoot: a case report
Julia D Flint* and Shanmugam Saravana
Address: Department of Rheumatology, City Hospital, Birmingham, UK
Email: JDF* - juliaflint@cantab.net; SS - adersh555saravana@doctors.org.uk
*Corresponding author
Received: 24 March 2009 Accepted: 11 June 2009 Published: 7 July 2009
Cases Journal 2009, 2:6859 doi: 10.4076/1757-1626-2-6859
This article is available from: http://casesjournal.com/casesjournal/article/view/6859
© 2009 Flint and Saravana; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Introduction: The prevalence of tuberculosis is increasing and musculoskeletal tuberculosis,
although currently rare, may become an important problem.
Case presentation: We report the case of a 20-year-old Somalian man, who presented with an
inversion injury to his ankle. When further history was taken, it transpired that he had sustained
trauma to his ankle in Somalia 4 years previously, complicated by a non-healing wound. His foot pain
and swelling had been present ever since. Diagnosis of tuberculosis was made by bone biopsy,
histology of which demonstrated caseating granulomas. Tissue culture yielded growth of tuberculous
bacilli. The patient made a full recovery on anti-tuberculous treatment.
Conclusion: Musculoskeletal tuberculosis can be difficult to diagnose as only about one third of
patients have respiratory symptoms. Synovial fluid aspirate is relatively unlikely to lead to definitive
diagnosis, and a bone biopsy should always be taken for culture and histological examination.
Introduction
Tuberculosis is a major global health problem, with an
estimated incidence of 9.2 million cases worldwide in
2006 [1]. Prevalence of TB in the UK has increased from
9/100000 in 1990 to 12/100000 in 2001 [1]. Musculo-
skeletal tuberculosis accounts for 1-2% of all cases of
tuberculosis in the Western World [2]. The spine is most
commonly affected, and foot involvement is rare [3].
Case presentation
We report the case of a 20-year-old Somalian man, who
presented with an inversion injury of his ankle, sustained
during a fall downstairs. He had subsequent pain in the
foot and difficulty walking. The history on admission was
limited due to language difficulties, but he felt otherwise
generally well.
Examination demonstrated tenderness over the base of
the 1st and 5th metatarsals, cuboid and navicular, with
swelling of the dorsal lateral aspect of the right foot. Ankle
movements were normal, although limited by pain. There
was warmth of the overlying skin, but no rash was seen.
No abnormalities were detected in other joints, and
systemic examination was normal with no lymphadeno-
pathy or fever and unremarkable respiratory, cardiovas-
cular and abdominal examinations. He had a slightly
raised CRP of 10, normal ESR of 10, and an x-ray of the
right foot and ankle showed abnormal lucent lesions at the
Page 1 of 3
(page number not for citation purposes)
base of the 3rd, 4th and 5th metatarsals but no recent
fracture (Figure 1).
Further history was finally obtained through an inter-
preter. The patient had come to the UK 2 years previously,
but had sustained trauma to his foot during a road traffic
accident in Somalia about 4 years previously. Following
this he had persistent foot pain and a non-healing wound.
He had not sought medical attention until 2 years later
when he had presented to an orthopaedic outpatient
clinic. An x-ray performed on this occasion demonstrated
deformities at the bases of the lateral four metatarsal bones
and of the lateral cuneiform bone. These deformities were
well corticated and attributed to old fractures. He reported
no contacts with TB and on direct questioning had no
respiratory symptoms, fevers, night sweats or weight loss,
and no other past medical history. Although bloods
revealed a concomitant hepatitis B infection, an HIV test
was negative.
An MRI scan showed prominent bone marrow oedema
with destruction of the navicular, medial and lateral and
cuneiform bones (Figure 2). Marked degenerative changes
were seen in the naviculo-cuneiform joint with associated
joint effusion extending to dorsal aspect of mid foot
causing a prominent localised teno-synovitis around the
anterior tibialis tendon. The overall appearances were
suggestive of either osteomyelitis with associated septic
arthritis, bony tumour or neuropathic joint. There was
insufficient fluid to aspirate under ultrasound guidance,
and the patient underwent a bone biopsy. Histology of the
bone core demonstrated multiple granulomas, some of
which showed ‘a hint of caseation’. Although ZN and
fungal stains were negative, subsequent tissue culture grew
mycobacterium tuberculosis.
The patient was started on quadruple anti-tuberculous
therapy for 2months: rifampicin 720mg, isoniazid 300 mg,
pyrizinamide 1800 mg (in combination as ‘Rifater’), and
ethambutol 300 mg. He was given prophylactic vitamin B6
(pyridoxine 10 mg), and after 2 months ethambutol and
pyrizinamide were discontinued in line with the standard
treatment regime.Within 4months of starting treatment the
patient was pain free, fully weight bearing on the affected
foot, and x-rays showed no further bony destruction.
Discussion
Musculoskeletal tuberculosis is difficult to diagnose. The
classic presentation with localised pain, together with fever
and weight loss is rarely seen. Blood tests may show a
raised ESR [4]. Only about one third of patients with
Figure 2. MRI scan right foot, T2 weighted, 5 days after
admission. Marked degenerative changes are seen in the
naviculo-cuneiform joint. There is an associated joint effusion
extending to dorsal aspect of mid foot causing a prominent
localised teno-synovitis around the anterior tibialis tendon.
Figure 1. Right foot x-ray on day of admission - 2 views.
Abnormal lucent lesions are seen at the base of the 3rd, 4th
and 5th metatarsals.
Page 2 of 3
(page number not for citation purposes)
Cases Journal 2009, 2:6859 http://casesjournal.com/casesjournal/article/view/6859
musculoskeletal tuberculosis have pulmonary involve-
ment [5], making chest x-ray screening less useful.
Radiological features of musculoskeletal tuberculosis
are non specific, but may include bone marrow oedema,
osteoporosis or lytic lesions. The surrounding tissue
may show synovitis, joint effusions, tenosynovitis, soft
tissue collections, or myositis [6,7]. MRI appearances are
non-specific and may be consistent with osteomyelitis,
bony tumour, avascular necrosis or a neuropathic joint,
but if tuberculosis is a possibility, a tissue diagnosis
should be sought. Synovial fluid aspirate is relatively
unlikely to lead to definitive diagnosis, and a bone
biopsy should also be taken for microscopy, culture
and histology [3]. Tuberculous bacilli are rarely seen
(with Ziehl-Neelsen staining) or grown in culture, and
the diagnosis often has to be made based on the
granulomatous appearance histologically along with
high clinical suspicion.
Drug therapy is usually sufficient to treat tubercular
osteomyelitis, although surgery is very occasionally
required [7]. Isolated osteomyelitis can be seen in the
early stages of the disease, but early treatment is required
to prevent possible sequelae, such as septic arthritis of
adjacent joints [8]. Quadruple anti-tuberculous therapy
should be commenced as soon as the diagnosis is made.
The usual regime is 2 months daily treatment with
rifampicin, isoniazid, pyrazinamide and ethambutol.
Rifampicin and isoniazid are continued for a further
4 months. Notification of every new diagnosis of tubercu-
losis must be sent to the health protection agency.
This patient was diagnosed with tuberculous osteomyelitis
of the mid foot. The history of inversion injury was in fact
a red-herring in this case as the tuberculosis had
presumably been contracted following the trauma and
open wound sustained 4 years previously. The importance
of getting a full history, through an interpreter where
necessary is clearly demonstrated by this case.
Conclusion
Tuberculosis is on the rise and it is important to recognise
the less common presentations of this condition to enable
early diagnosis and successful treatment. In inner city areas
with a high prevalence of TB, there may be no history of TB
contact, or any ‘typical’ symptoms or signs. Radiological
features are non-specific and so a high index of suspicion is
required. In patients with risk factors, or any suspicion of
TB, a biopsy should be performed to make the diagnosis
and initiate treatment.
Abbreviations
TB, Tuberculosis; MRI, Magnetic resonance imaging;
ZN, Zeil Neelson stain.
Consent
Written informed consent was obtained from the patient
for the publication of this case report. A copy of the written
consent is available for review by the Editor-in-Chief of
this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
JF principally authored the manuscript. SS was a major
contributor to data collection. Both authors have read and
approved the final manuscript.
Acknowledgements
Dr SR Elamanchi, Consultant Rheumatologist, City
Hospital, Birmingham. JF is affiliated with the University
of Birmingham.
References
1. World Health Organisation: Report on Global Tuberculosis
Control, 2008.
2. Shah BA, Splain S: Multifocal osteoarticular tuberculosis.
Orthopedics 2005, 28:329.
3. Watts HG, Lifeso RM: Current Concepts Review - Tuberculosis
of Bones and Joints. J Bone Joint Surg Am 1996, 78:228.
4. Vohra R, Kang HS, Dogra S, Saggar RR, Sharma R: Tuberculous
osteomyelitis. J Bone Joint Surg Br 1997, 79-B:562-566.
5. Daniel TM, DeBanne SM: The serodiagnosis of tuberculosis and
othermycobacterial diseases by enzyme-linked immunosor-
bent assay. Am Rev Resp Dis 1987, 135:1137-1151.
6. Parmar H, Shah J, Patkar D, Singrakhia M, Patankar T, Hutchinson C:
Tuberculous arthritis of the appendicular skeleton: MR
imaging appearances. Eur J Radiol 2004, 52:300-309.
7. Dhillon MS, Sharma S, Gill SS, Nagi ON: Tuberculosis of bones and
joints of the foot: an analysis of 22 cases. Foot and Ankle 1993,
14:505-513.
8. Dhillon MS, Nagi ON: Tuberculosis of the foot and ankle.
Clin Orthop Relat Res 2002, 398:107-113.
Page 3 of 3
(page number not for citation purposes)
Cases Journal 2009, 2:6859 http://casesjournal.com/casesjournal/article/view/6859
Do you have a case to share?
Submit your case report today
• Rapid peer review
• Fast publication
• PubMed indexing
• Inclusion in Cases Database
Any patient, any case, can teach us
something
www.casesnetwork.com


Tuberculous osteomyelitis of the midfoot: a case report

file:///data/core-remote/dit/data/Springer-OA/pdf/560/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjQwNzYvMTc1Ny0xNjI2LTItNjg1OS5wZGY=.pdf

Tuberculous osteomyelitis of the midfoot: a case report

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector