Bone And Joint Tuberculosis 24

BONE AND JOINT TUBERCULOSIS

INTRODUCTION The prevalence of tuberculosis has been rising in the Western world over the last decade Osteoarticular infection accounts for about 1-3% of all tuberculosis. Approximately 50% of osteoarticular cases are associated with concurrent pulmonary disease.

Awareness Timely recognition and management is essential to prevent loss of integrity and function of joints, and to reduce long-term morbidity.

AETIOLOGY Three species of mycobacteria are recognised as causing tuberculosis in humans Mycobacterium tuberculosis (the commonest), spread by unpasteurised milk

Osteoarticular tuberculosis may occur following ： haematogenous spread contiguous spread (for example from a lymph node) a reactivation of previous infection.

Major clinical features of osteoarticular tuberculosis Malaise, weight loss Fever, lethargy Insidious onset Gradual progression Localised joint or bone pain Cold abscess/cold joint effusion formation Later, radiologic and inflammatory changes

DIAGNOSIS A history of residence in an endemic area, or contact with tuberculosis, The definitive diagnosis follows the recognition of M. tuberculosis from any skeletal site. Biopsy is therefore the most useful procedure, for obtaining either bone or synovial tissue for histology and culture, and ideally both should be positive.

Aspiration of joint fluid, or drainage of a cold abscess, may also provide evidence of infection with positive cultures being found in about 85% of cases where a joint is involved.

Although there are no specific radiological features for osteoarticular tuberculosis, suggestive findings may include associated erosion, cyst formation, narrowing of the affected joint space and joint destruction occurring in the late stages

A raised ESR （ erythrocyte sedimentation rate) or plasma viscosity, an abnormal chest x-ray and evidence of pyrexia on temperature recording may assist in the diagnosis of tuberculosis.

Diagnosis of osteoarticular tuberculosis History of contact with tuberculosis Abnormal laboratory tests (e.g. raised ESR,) Abnormal chest x-ray Suggestive radiologic findings

Isolation of M. tuberculosis from sputum/early morning urine specimen/gastric lavage/synovial fluid Biopsy with isolation of M. tuberculosis from any skeletal site and/or typical histology

Differential diagnosis. Pyogenic infections Rheumatoid arthritis Malignant osteoma

General Treatment The patient’s general condition should be improved by high protein and nutritious diet including milk, eggs, vitamins and hamatenics.

Chemotherapy Rifampicin per day Isoniazid per day

10mg/kg. 5 - 19 mg/kg

Upto 600 mg in single dose Upto 300mg in single dose

Ethambutol

15 mg/kg

Upto 800 mg per day

Steptomycin

15/20 mg/kg

Upto 0.75 g per day

Pyrazinamide

20-30 mg/kg

Upto 2 gm per day

Side effects Rifampicin is noted for its hepatotoxicity and hence liver function must be monitored during therapy. Peripheral neuritis is the common toxic symptom while using Isoniazid . Ethambutol can cause optic neuritis. One must watch for vertigo, tinnitus and deafness while using Streptomycin. arthralgia and hepatitis are the toxic effects of Pyrazinamide.

Local Treatment The aim of local treatment is to correct deformities due to muscle spasm, minimise destruction of articular surface and preserve the maximum mobility in the affected joint. It includes plastic fix or traction.

Role of Surgery The aim of surgery in skeletal tuberculosis is clearance of the lesion wherever possible and the preservation of function of the joint. Surgery can be done safely and much earlier, if efficient conservative treatment is carried out in the first instance with rest and chemotherapy.

In lesions like caries of the rib, excision of the affected bone is done. It is possible to excise or curette a tuberculous focus in joints in the active stage of the disease under cover of antituberculous drugs. Surgery is done to manage the complications of the disease. It is also indicated to treat the end results of the disease, like deformity and ankylosis in the peripheral joints.

Quiescence of the lesion 1. General : Disappearance of toxaemia with improvement in appetite and weight. 2. Local : muscle spasm.

Absence of local warmth, tenderness and

3. Radiological : Evidence of clarity of the margin and sclerosis of the lesion. 4. Laboratory : Consistently low E.S.R.

Follow up An efficient follow up programme is very important as this will ensure detection of the early signs of recrudescence of the disease. The patient is re-examined periodically for any clinical evidence of pain, muscle spasm, tenderness and loss of weight. A radiograph is taken and E.S.R. done at the same time. If the lesion remains quiescent for one year after completion of chemotherapy the patient is taken as clinically cure