Tubercular Osteomyelitis of Navicular Bone: A Rare Site for Bone Tuberculosis.

Introduction: Tuberculosis (TB) is a global public health problem, endemic to India. Osteoarticular TB uncommonly presents in the foot, navicular osteomyelitis is an extremely rare entity. Case Report: We report a rare case of navicular osteomyelitis caused by TB in a 37-year-old man who presented to OPD with swelling and dull aching pain over the dorsum of his left foot. A radiograph of the foot showed a lytic lesion in the navicular bone. Further investigations in the form of aspiration cytology, cartridge-based nucleic acid amplification test, and acid-fast bacilli culture confirmed TB. Category-1 anti-tubercular therapy was started immediately and the patient was treated conservatively. Four drugs (HRZE) were given for 2 months and 3 drugs (HRE) for 9 months, after which the patient stopped his medications on his own. Radiographs and CEMRI at 14-month follow-up showed a healed lesion. Conclusion: This case illustrates an exceptional location of osteoarticular TB and shows that Navicular TB can be treated conservatively with near-complete function and recovery if diagnosed early.

Incidence and Patterns of Drug Resistance in Patients with Spinal Tuberculosis: a Prospective, Single-Center Study from a Tuberculosis-Endemic Country.

Background: There is paucity of data on incidence and pattern of drug resistance in spinal TB. This prospective observational study was conducted to document the incidence and drug-resistance pattern among primary and presumptive resistant cases. Methods: 59 consecutive cases diagnosed clinico-radiologically (imaging) were grouped into Group A (n = 51, primary cases) and Group B (n = 8, presumptive resistant cases) based on pre-defined criteria (INDEX-TB guidelines). Tissue samples obtained percutaneously (37.29%, 22/59) and on surgery (62.71%, 37/59) were subjected to genotypic DST (CBNAAT, LPA) and phenotypic DST (BACTEC MGIT 960 culture and sensitivity using fixed critical concentration of drugs). Results: Etiological diagnosis was ascertained in all. 13/51 (25.49%) in Group A, while 3/8 (37.5%) in Group B and 16/59 (27.12%) overall demonstrated drug resistance. 12/16 (75%) had no prior history of ATT intake. 4 demonstrated INH (Isoniazid) mono-resistance. 12 polydrug resistance demonstrated: 5MDR, 3pre-XDR, while RIF + FQ (fluoroquinolones), FQ + Lz (linezolid), only SLID (second-line injectable drugs), and only FQ resistance observed in 1 case each. Isolated RIF (Rifampicin) resistance and XDR pattern were not observed. Overall frequency of RIF resistance was 16.4% (9/55) and INH was 25% (12/48) with low-(n-2) and high-level INH resistance (n-10). Among second-line drugs, FQ resistance was more than SLID resistance and within FQ, levofloxacin resistance was more frequent than moxifloxacin. MGIT demonstrated positive growth in 16/59 samples, out of which 1 sample was positive for nontuberculous mycobacteria (M. chelonae) but on genotypic testing demonstrated MTB resistant to RIF and FQ. Conclusion: This is the first report on incidence and drug-resistant pattern in culture-positive/negative cases. High (25.49%) primary drug resistance is worrisome. This being the first study in  spinal TB cases which document prevalent drug-resistant pattern as evaluated for consecutive culture-positive/negative cases. The tissue obtained must be submitted for AFB culture and molecular tests to ascertain drug resistance in culture-positive/negative cases. However, in the presence of insufficient tissue sample histology and CBNAAT can ascertain etiological diagnosis in 100% cases. INH resistance is more than RIF with isolated RIF resistance unreported.

Intradural Conus Medullaris Lipoma With Neurological Deficit: A Rare Occurrence.

Intradural lipoma without spinal dysraphism is a rare occurrence. Most of them are asymptomatic but can also present with neurological deficits. A 54-year-old male patient presented to us with progressive weakness in both lower limbs for six months. On physical examination and radiological workup, intradural lipoma was diagnosed. Due to progressive neurological deficit, the patient was treated surgically. On 2.5 years of follow-up, the patient showed complete neurological recovery. Intradural lipomas can also present with the neurological deficit at any age and should be managed surgically if the deficit is progressive in nature. Surgical management has a good outcome if done within two years of onset of symptoms.