Multifocal osteoarticular tuberculosis in children.

PURPOSE: To review records of 16 children with multifocal osteoarticular tuberculosis. METHODS: Records of 7 girls and 9 boys aged one to 14 (mean, 6) years with multifocal osteoarticular tuberculosis were reviewed. Haematological tests and radiographs of the chest, whole spine, pelvis, knees, elbows, hands, and feet were taken. The diagnosis was confirmed histologically. Patients were treated with standard 4-drug antitubercular chemotherapy (isoniazid, rifampicin, ethambutol, pyrazinamide) for 2 months, followed by a 2-drug regimen (isoniazid and rifampicin) for 10 months. Supportive treatment (deworming and nutritional advice) was also provided. RESULTS: All 16 patients were immunocompetent. Pain and swelling around the lesions were the main symptoms; fever was not common (2 cases only). No patient reported weight loss or night sweats. The mean number of bony lesions was 3.4 (range, 2-15) per patient. Appendicular (hands and feet) involvement was more common than axial (spinal) involvement. Radiological appearances of the lesions were cystic, irregular, lytic, and with or without sequestrum/ periosteal reaction. Some lesions were asymptomatic and detected incidentally on radiographs. Only one patient had active chest lesions. Five patients had spinal involvement but no neurological deficit. No patient underwent any surgical intervention, except for diagnostic biopsy. The mean follow-up period was 18 (range, 6-24) months. All patients showed complete healing within one year of chemotherapy. There were residual deformities and restriction of joint movement in patients with advanced articular and axial osteoarticular involvement. CONCLUSION: Children with multifocal osteoarticular tuberculosis were usually immunocompetent. Appendicular involvement was common, but concomitant chest involvement was uncommon. Standard multidrug antitubercular therapy and nutritional supplementation achieved good outcome.

Tuberculosis of the foot and ankle in children.

PURPOSE: To report manifestations and management of tuberculosis of the foot and ankle in 21 children. METHODS: Records of 12 girls and 9 boys aged 3 to 14 (mean, 7) years with tuberculosis of the foot and ankle were reviewed. The mean delay in presentation was 4.7 (range, 0.5-14) months. All the patients had local swelling, tenderness, and antalgic gait; 16 were limping; 5 had an antecedent trauma; 11 had an abscess; and 6 had a discharging sinus. The diagnosis was based on a smear positive for acid-fast bacilli (n=2), histopathology (n=15), or clinicoradiological findings (n=4). Nine patients had osteoarticular tuberculosis in other parts of the body. None had evidence of pulmonary tuberculosis. Lesions were classified into synovial (articular) and osseous. All 3 synovial lesions occurred in the ankle, 2 of which were at an advanced stage. Osseous lesions occurred in the calcaneus (n=5), metatarsal (n=5), talus (n=3), cuboid (n=3), medial cuneiform (n=1), and phalanx (n=1), and were sub-classified into stages 1 (n=3), 2 (n=5), and 3 (n=10) according to disease progression. All the patients were treated conservatively with splintage and chemotherapy. RESULTS: The mean follow-up period was 21 (range, 7-51) months. All the 3 patients with stage 1 osseous lesions showed healing within 6 weeks and had complete recovery of function. Four of the 5 patients with stage 2 lesions also showed complete recovery of function and reformation of bony trabeculations; radiological incorporation of sequestrum was obvious by 6 months in most patients. In patients with stage 3 lesions, healing was delayed and there was residual alteration in bony architecture and joint changes. Sclerotic changes and joint involvement also increased the likelihood of poor outcomes. However, none of our patients had any residual tenderness or foot deformity at the final follow-up. CONCLUSION: Outcome after non-operative treatment is good, provided the lesions are treated early.