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Multifocal skeletal tuberculosis in an immunocompetent patient: a case report
© Araujo et al. 2015
Received: 13 January 2015
Accepted: 15 June 2015
Published: 20 June 2015
The occurrence of multifocal skeletal involvement in immunocompetent patients is rare, even in countries where tuberculosis is endemic. Multifocal skeletal lesions may occur as a result of hematogenous dissemination from another primary focus such as cervical lymph nodes, lungs, tonsils or gastrointestinal tract.
We present a 59 year-old man with a history of intermittent and disabling pain in his left knee for 2 years. The patient in this case presented with lung infection with bilateral skeletal dissemination in the knees and femurs. Immunological examination for the HIV was negative.
Diagnosis of this condition is not always easy because of the disease’s insidious character, and it can be confused with other diseases such as osteoarthritis, especially in middle-aged individuals.
Skeletal tuberculosis represents less than 2 % of all tuberculosis cases and may affect one or more joints. Joints that support greater weight loads, such as the knees and hips, are the most affected in cases of skeletal tuberculosis . The involvement of multiple joints is rare in immunocompetent patients [2, 3]. The symptoms are nonspecific, and the disease often presents with an indolent clinical course, usually leading to a delayed diagnosis as well as bone and joint destruction. A substantial number of patients report symptoms including pain and discomfort for over a year with reports of unsuccessful treatments for osteoarthritis [4, 5].
The patient in this case presented with lung infection with bilateral skeletal dissemination in the knees and femurs. In such cases, the diagnosis must be made the basis of the isolation of Mycobacterium tuberculosis in Lowenstein–Jensen culture medium and susceptibility testing using bone and/or synovial biopsy. Molecular methods such as real-time polymerase chain reaction (PCR) are much more sensitive and specific.
Treatment should preferably be drug-based with a combination of 4 anti-tuberculosis drugs for 6 months. This period may be extended in cases of poor response. As these drugs do not penetrate the bone or fibrous tissue deeply, some guidelines recommend extended treatment up to 12–18 months; treatment durations as long as 4 years have been reported [6–9]. Here, we present a case of multifocal skeletal tuberculosis affecting the knees in an immunocompetent individual, which progressed with a slow therapeutic response to a fixed-dose combination regimen of anti-tuberculosis drugs.
Multifocal skeletal tuberculosis, one of the various forms of extrapulmonary tuberculosis, is uncommon. Diagnosis of this condition is not always easy because of the disease’s insidious character, and it can be confused with other diseases such as osteoarthritis, especially in middle-aged individuals. Delayed diagnosis may result in the disease spreading to adjacent bone structures, leading to difficulty in clinical management.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
- Sampaio RF, Fádel SG, Santos VML, Ferreira MCL, Torres FP. Tuberculose articular multifocal acometendo pequenas articulações. Rev Bras Med. 2010;67(8):274-6.Google Scholar
- Marudanayagam A, Gnanadoss JJ. Multifocal skeletal tuberculosis: a report of three cases. Iowa Orthop J. 2006;26:151–3.PubMedPubMed CentralGoogle Scholar
- Zaki SA, Bhongade S. Multifocal skeletal tuberculosis. Sultan Qaboos Univ Med J. 2012;12(4):531–3.View ArticlePubMedPubMed CentralGoogle Scholar
- Gardam M, Lim S. Mycobacterial osteomyelitis and arthritis. Infect Dis Clin N Am. 2005;19:819–30.View ArticleGoogle Scholar
- Pandey AS, Surana A. The appropriate DOTS regimen greatly reduces the disabilities in polyarticular EPTB. J Clin Diagn Res. 2013;7(3):529–31.PubMedPubMed CentralGoogle Scholar
- Agarwal A, Khan SA, Qureshi NA. Multifocal osteoarticular tuberculosis in children. J Orthop Surg. 2011;19(3):336–40.View ArticleGoogle Scholar
- Thawani M, Hale E, Habte-Gabr E. Multifocal tubercular osteomyelitis: a case with atypical manifestations. Tuberc Res Treat. 2011;Article ID 483802:3. doi:10.1155/2011/483802.Google Scholar
- Hong L, Wu J-G, Ding J-G, Wang X-Y, Zheng M-H, Fu R-Q, et al. Multifocal skeletal tuberculosis: experience in diagnosis and treatment. Med Mal Infect. 2010;40:6–11.View ArticlePubMedGoogle Scholar
- Sebben AL, Dotta G, Oliveira AEL, Lima R, Schneider M, Sebben MA, et al. Tuberculose de articulação coxofemoral: a propósito de um caso. Rev Assoc Med Bras. 2012;58(1):15–7.PubMedGoogle Scholar
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