Tuberculosis of Bones and Joints of the Foot: An Analysis of 22 Cases

Abstract

Skeletal tuberculosis constitutes 1% to 3% of extrapulmonary cases and involvement of foot bones is rare. Lack of awareness and a confusing clinical and radiological picture often lead to a delay in diagnosis. We reviewed 23 feet seen over a 3.5-year period. Most cases were children or young adults less than 40 years of age; isolated bony involvement was seen in 10 feet, with the calcaneus being involved in five cases. Articular involvement at presentation was seen in 13 cases and these cases had significantly higher delays in diagnosis. Twenty cases responded to antitubercular therapy alone while one case had to be operated (there was one fatal outcome). Complete resolution of sequestra was seen with antitubercular therapy alone. The results were better in cases with isolated bony involvement, while cases with joint involvement had residual sequelae in the form of stiffness or pain. Two patients were advised arthrodesis. Early diagnosis and antitubercular therapy is essential to prevent joint involvement from periarticular bony lesions; surgical intervention is rarely needed. A high index of suspicion has to be maintained in high risk groups like Asian immigrants. Concomitant extraskeletal lesions may not always be present.

Multifocal Tubercular Osteomyelitis Involving Bilateral Symmetrical Second Metacarpals

“…Clinically, pyogenic osteomyelitis tends to be acutely painful, swollen, and hot, with generalized fever.19 Tuberculous osteomyelitis is more often only mildly painful, pyrexia is minimal, and the whole condition is relatively benign.14 Isolation of the mycobacterium tubercle bacilli from the tissue or discharge is the gold standard diagnostic tool.1,16,17,20 Presence of granulomatous osteitis with caseous necrosis in histo-pathological examination of a biopsy specimen is essential for confirmation of the diagnosis. 1,3,5,8,12,13,18,28 Tubercular osteomyelitis of metacarpals has been reported either in single metacarpal5, 8,9,14,16,25 or multiple metacarpals of the same hand along with other skeletal tuberculosis and pulmonary tuberculosis. 1,3,5,21,28 Disseminated tuberculosis with involvement of fingers can be seen in patients with HIV/ AIDS.17 There are case reports on multifocal tuberculous dactylitis involving multiple phalanges of both hands18 and chronic osteomyelitis in the second and third metacarpals of the left hand and arthritis of the left carpal j oints.19 However, there has been no report in the literature, describing multifocal tubercular osteomyelitis lesion in bilateral symmetrical metacarpals in a child without any immune-compromise and primary pulmonary lesion.…”

“…13,14,15,16,20 However, there are recommendations that debridement of the lesion can be helpful both for prompt tissue diagnosis and rapid recovery with anti-tubercular treatment. 3,8,9,17,28 This was supported by our experience in our case, there was rapid recovery with anti-tubercular treatment after drainage of pus and granulation tissues.…”

“…9,13,14,15,16,18,20,26,28 Sometimes tubercular osteomyelitis can be masked by pyogenic osteomyelitis.23 Unlike in developed part of the world where there is lot of diagnostic dilemma due to rarity of the tubercular infection particularly when the presentation is unusual; tubercular dactylitis should be one of the probable differential diagnosis in any osseous pathology of hands and feet, particularly in countries where tuberculosis is endemic. 5,6,7,8,10,12,13,14,16 Blood examination may show mild increase in erythrocyte sedimentation rate.13 Mantaoux test is usually positive. 16 Radiographs are still the mainstay of evaluation of patients with bony lesions.12 "Spina Ventosa" is radiological characteristics of tuberculous osteomyelitis.1,3,4,9,10 ,11,12,14,28 It typically involves short tubular bones of the hands and the feet in children.…”

Tubercular osteomyelitis of the second metatarsal bone: case report

“…In fact, bones and joints are affected in 1%-3% of all cases [1,2], and the spine and the hip are most commonly involved. Localization in the foot is very rare, and accounts for only about 10% of all cases of skeletal tuberculosis.…”

Isolated Cuneiform Tuberculosis a Rare Case Report.

“…The spine ismost commonly affected, and foot and ankle involvement is rare, accounting for about 10% 1 in which Calcaneum is the most common boneinvolved. 2 Diagnosis of tuberculosis of the foot remains a dilemma because of its rarity in lower limb,especially when confined to a single bone with orwithout articular involvement. Hence, the chance ofmisdiagnosis and delay in diagnosis may add tomorbidity.…”