Chemotherapy of osteoarticular tuberculosis

Abstract

Tuberculosis (TB) of the bones and joints is rampant in India with the dorsolumbar spine as the most common site of osseous involvement. For diagnosis, clinical suspicion needs to be confirmed through appropriate laboratory and imaging investigations, and increasingly nowadays, nucleic acid amplification techniques. Chemotherapy remains the cornerstone of management complemented by rest, nutritional support and splinting, as necessary. Operative intervention is required if response to chemotherapy is unsatisfactory and for spinal stabilization. The drugs and regimens are fundamentally similar to those for pulmonary TB. However, there is lack of consensus on the appropriate duration of treatment. The prevailing practice of extending treatment till radiological evidence of healing is complete, may be unnecessary in view of recent reports that 6-9 months of therapy is sufficient for the majority of cases. Relapse rates are not drastically improved by extending treatment to 12 months or even longer, except perhaps in pediatric cases. However, prolonged treatment may be required if surgical debridement is indicated but cannot be done. Multidrugresistant TB should be suspected if disease activity shows no signs of abating after 4-6 months of uninterrupted therapy. These cases are therapeutically challenging and will require second line or experimental antiTB drugs, supported by resistance testing where feasible. Coexistent HIV/AIDS may also necessitate prolonged treatment. Interactions between first line antiTB drugs and antiretroviral medication can complicate matters. Close monitoring is essential in all cases, with dechallenge and cautious reinstitution of drugs in the event of toxicity. While awaiting the arrival of long overdue new antiTB medication, existing drugs and regimens must be used in an informed manner with emphasis on patient compliance.

Spinal tuberculosis: A review

“…84 World Health Organization (WHO) recommends a category-based treatment for tuberculosis. Spinal tuberculosis falls under category-1 of the WHO treatment category.…”

Isolated tuberculous biceps tenosynovitis bicipitoradial bursitis: A case report

“…However, the duration has been reduced to 6 months in new regimens recommended by the World Health Organization. 6 In conclusion, this case illustrates that tubercular tenosynovitis of biceps tendon and bicipitoradial bursitis can be seen without involvement of the adjacent joint or any other primary focus in the body. Tuberculosis should be included in the list of possible causes where chronic tenosynovitis is suspected.…”

A Clinical Review of 40 Cases With Tuberculous Spondylitis in Adults

“…17,18,41 World Health Organization recommends that all cases with tuberculous spondylitis should be treated for a minimum period of 6 months whereas Centers For Diseases control and Prevention recommend that the duration of treatment for osteoarticular TB including spinal form should at least be 12 months. 17,18,39 However, duration of therapy may be prolonged due to immunosupression or lack of compliance with medication or in only medically treated patients who have no results of culture as seen in this study. 17,18,39,40 Treatment with second line drugs takes 2 years or longer as opposed to 6 to 12 months with isoniazid-rifampicin containing regimens.…”

“…17,18,39 However, duration of therapy may be prolonged due to immunosupression or lack of compliance with medication or in only medically treated patients who have no results of culture as seen in this study. 17,18,39,40 Treatment with second line drugs takes 2 years or longer as opposed to 6 to 12 months with isoniazid-rifampicin containing regimens. [39][40][41][42] Most of the patients in our study were treated for 12 to 18 months and mean treatment duration was 14.1 ± 4.2 months.…”

“…1,17,35,39 The management decision should be based on the goals of treatment for each individual case, depending on the stage of the disease. 17,35,39 Treatment of TB is curative regardless of site, if it is instituted early and if the organism remains sensitive to all first-line antituberculous drugs. 40 Tahaog˘lu et al concluded that beginning anti-TB therapy with at least 4 first-line drugs in TB therapy is mandatory in Turkey because of high rate of drug resistance.…”