The Great Imitator - Disseminated Tuberculosis Presenting as Baker’s Cyst: A Case Report

@#Tuberculosis is known to be a great mimicker, and it can present in a myriad of ways, which often result in an incorrect diagnosis. In a country that is endemic to tuberculosis, the presentation can take many forms ranging from tumour to trauma. We present a case of Baker’s cyst that was provisionally diagnosed as pigmented villonodular synovitis (PVNS) of the knee and eventually turned out to be tuberculous arthritis. A 46-year-old male presented with an insidious swelling on the posterior aspect of his knee for one year. Magnetic resonance imaging was suggestive of PVNS as the likely diagnosis. The patient presented 21 days later with a foot drop. On following-up with further investigations, he was found to have a lesion at the level of the L4-L5 spine. Chest radiograph changes were suggestive of tuberculosis. A synovial biopsy of the knee was done, and the tuberculosis culture report was positive. The patient was started on anti-tubercular treatment and then operated on, with arthroscopic synovectomy and posterior open cyst excision. The histology report was positive for tuberculous synovitis. The patient completed the course of antitubercular drugs and had physiotherapy. He demonstrated a clinically and radiologically healed disease at the final follow-up with a good functional outcome. Clinicians must have a high index of suspicion for tuberculosis, especially in endemic areas. Getting a chest radiograph is recommended in every case. Early diagnosis with the appropriate treatment will give a good functional outcome for the patient.

Multimodal Diagnostic Approach for Synovitis of the Wrist / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to suggest a multimodal diagnostic approach to determine the cause of the disease in patients diagnosed with synovitis of the wrist and who underwent synovectomy. MATERIALS AND METHODS: Twenty-nine patients, who underwent contrast magnetic resonance imaging (MRI) preoperatively and synovectomy from January 2000 to December 2013, were reviewed retrospectively. Among them, 17 patients underwent a Tc99m white blood cell (WBC) scan preoperatively. In patients who met the diagnostic criteria of rheumatoid arthritis (RA), the diagnosis was confirmed as RA if the MRI finding or histology was compatible with RA. If the MRI finding and histology were disparate, the final diagnosis was made based on the histologic finding. RESULTS: Of the nine patients who met the diagnostic criteria of RA, seven patients were finally diagnosed as RA and two patients as tuberculous arthritis. Of the 20 patients who did not meet the diagnostic criteria of RA, the MRI findings and histology were consistent with the same disease in 12 patients. In the remaining eight patients, five were diagnosed with nonspecific chronic synovitis, one with RA, and two with tuberculous arthritis based on the clinical findings, MRI, and histology findings. CONCLUSION: MRI and a WBC scan are very useful imaging modalities for diagnosing the causative condition of the wrist synovitis. A histology evaluation after synovectomy can also be useful in cases with a difficult diagnosis or are refractory to medications.

Elbow pain proven to be tuberculous arthritis: A case report / 대한마취과학회지

Elbow tuberculosis is a rare disease which accounts for 1-3% of all cases of osteoarticular tuberculosis. The diagnosis of tuberculous arthritis is very difficult in most clinical situations because of the insidious onset, indolent process, and mild and non-specific local or systemic symptoms. Thus, the confirmatory diagnosis and effective treatment for tuberculous arthritis are delayed until the disease progresses to an advanced stage in many clinical settings. Herein we report a case of septic arthritis of the elbow due to Mycobacterium tuberculosis as a result of misdiagnosis and delayed treatments.

Elbow pain proven to be tuberculous arthritis: A case report / 대한마취과학회지

Elbow tuberculosis is a rare disease which accounts for 1-3% of all cases of osteoarticular tuberculosis. The diagnosis of tuberculous arthritis is very difficult in most clinical situations because of the insidious onset, indolent process, and mild and non-specific local or systemic symptoms. Thus, the confirmatory diagnosis and effective treatment for tuberculous arthritis are delayed until the disease progresses to an advanced stage in many clinical settings. Herein we report a case of septic arthritis of the elbow due to Mycobacterium tuberculosis as a result of misdiagnosis and delayed treatments.

Operative Treatment of the Tuberculous Arthritis on the Sternoclavicular Joint: A Report of Two Cases

Tuberculous arthritis on the sternoclavicular joint is an uncommon disease and a delayed diagnosis can be due to the obscure clinical symptoms. We should suspect tuberculous arthritis in patients with slowly progressive pain, swelling, mild fever and a previous history of tuberculosis. Early diagnosis is important through conducting a thorough physical examination and performing laboratory tests and radiologic study. Tuberculous arthritis on the sternoclavicular joint should be treated with a combination of systemic antituberculous agents and thorough surgical debridement in marked damaged joints. When performing this operation, it is important not only to minimized the injury of the costoclavicular ligament, but also to avoid injury to the surrounding the vital structures such as the mediastinum and pleura after aggressive resection or radical debridement. We describe here 2 cases of the tuberculous arthritis on the sternoclavicular joint: one case had a good result after surgical debridement with using an anti-tuberculous agent, and the other had fatal complications such as mediastinal abscess and pleural effusion after the operation.

Tuberculous Arthritis in Peripheral Joints / 대한류마티스학회지

OBJECTIVE: We evaluated the clinical characteristics of tuberculous arthritis in peripheral joints and their relationship with rheumatologic disorders or other chronic illnesses. METHODS: One hundred and sixty seven patients who had suffered from skeletal tuberculosis were treated at Hanyang university medical center from January 1993 to December 2000. We retrospectively analyzed 39 patients who were diagnosed as tuberculous arthritis in peripheral joints. RESULTS: Thirty-nine (21 males, 18 females) patients with tuberculous arthritis in peripheral joints, aged 38.13+/-15.28, were found. All except one had a mono-articular feature. Affected joints were knee in 22 (56.4%), hip in 7 (17.9%), and wrist in 3 (7.7%). Extra-articular tuberculosis was noticed in 18 (46.2%) patients: lung involvement in 13 (33.3%), spine involvement in 4 (10.3%) and epididymis involvement in 1 (2.6%). One or more predisposing factors were found in 13 (33.3%) patients: 10 patients had a previous trauma history and 3 patients with previous intra-articular injections. Predisposing systemic conditions were present in 12 (30.8%) patients: 4 rheumatoid arthritis, 2 systemic lupus erythematosus, 1 juvenile rheumatoid arthritis, 4 liver cirrhosis, 2 breast cancer and 1 diabetes mellitus. CONCLUSION: Tuberculous arthritis in peripheral joints were evident in weight bearing joints, such as knee and hip, and were frequently associated with predisposing local or systemic factors. It is most important for the physician to make an early diagnosis and perform adequate treatments to prevent further complications.

Growth Changes of Lower Extremities after Pyogenic or Tuberculous Knee Joints in Children / 대한정형외과학회잡지

It is well-known that the infection of bone and joints could produce the shortening by destroying the articuiar cartilage and growth plate, or the lengthening hy increased hlood circulation to the epiphyseal and metaphyseal regions of long bone. Since 1985, we have treated total l7 cases of children s pyogenic or tuberculous children s knee with early arthrotomy and continuous irrigation etc. and followed their long hone growth for average 53 months after surgical intervention. Five patients (group I ) were early treated within 2 weeks and twelve patients(group 3 ) were delayed to treat their knees for more than 2 weeks of symptom development. Total 11 patients out of 17 cases(64.7%) (2 cases of group 1 pyogenic arthritis, and 1 case of group l and 8 cases of group II tuberculous arthritis) revealed growth acceleration. Femoral lengthening was much more greater than that of tibial growth, and the size of patella, distal femoral and proximal tibial epiphysis which were measured by computerized digitizer were also significantly larger than that of opposite knee. The total limb length was increased hy average 7mm in 6 months, l4mm in 1 year and 3mm in 2 years after operation. These results suggest the pyogenic and tuberculous arthritis in children s knee should he treated as early as possible after symptoms developed, and followed them to trace their limh inequality for at least 2 years after surgery. That means the early arthrotomy for tuberculous knee or even in pyogenic arthritis can preserve normal articular cartilage and can also prevent the early epiphyseal closure hy infection. and can get the limh lengthening by increased blood circulation around the knee joint.

Tuberculous Arthritis of the Hip in Children / 대한정형외과학회잡지

Although the incidence of the skeletal tuberculosis is being decreased with improvement of the socioeconomic status, tuberculous arthritis of the hip in children has many problems in fact that there is a relatively high incidence comparing to that of adult, that it is difficult to early detection for its variable clinical feature, and that there are many controversies in its treatment. From Aug. 1981 to Apr, 1988, 14 cases treated at Busan Paik Hospital were analyzed, and the following conclusions were obtained. 1. Surgical treatment of tuberculous arthritis of the hip with early lesion was better than conservative treatment in that it could be made early diagnosis, removed the infected focus, lessened the recurrence rate, and preserved the hip function. 2. A relatively good result in preserving the hip function was obtained with surgical treatment in tuberculous arthritis of the hip with late lesion.

Total Hip Replacement Arthroplasty in Tuberculous Arthritis of the Hip / 대한정형외과학회잡지

Although the incidence of tuberculous arthritis of the hip is being decreased with improvement of hygiene, preventive measures and chemotherapy, it remains as important disease in orthopedic surgery. In the tuberculous arthritis of the hip, eradication of the disease with improvement of joint function is ideal treatment. But classical treatment of anti-tuberculous chemotherapy, synovectomy, and especially hip fusion which was done in most cases in adults, have their own limitation in functional results. Recently the methods of total hip replacement arthroplasty done in tuberculous arthritis with treatment of infection by antituberculous chemotherapy reported good results. During the period from January 1970 to December 1984, total hip replacement arthroplasty were done in 55 patients of tuberculous arthritis of the hip in Seoul National University Hospital. The average follow-up period was 3 years and 1 months. And, the following results were obtained. l. of the 55 cases, 50 cases(90.9%) were resulted in success without reactivation of tuberculosis, and 5 cases(9.1%) were resulted in failure. In those cases, the follow-up period were more than 1 year. 2 . The average period of immediate preoperative anti-tuberculous chemotherapy was higher in the success cases with 10.0 weeks than in the failure cases with 4.5 weeks. 3 . The average preoperative ESR was lower in the success case with 12.4mm/ hr than in the failure cases with 28mm/hr. 4 . Failure cases were restricted to active cold abscess in operative finding. 5. The positive bacteriology was fewer in the success cases with 4% than in the failure cases with 60%. 6. Follow-up functional results of the success cases were superior to any other methods of treatment. It is our conclusion that preoperative anti-tuberculous chemotherapy is important to reduce inflammatous reaction, and although granulation or caseation necrosis is found in operation field, total hip replacement can be successful if there is no active cold abscess.