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Chapter 21 : Musculoskeletal Tuberculosis

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Abstract:

Musculoskeletal tuberculosis (TB) accounts for approximately 10% of all extrapulmonary TB cases in the United States and is the third most common site of extrapulmonary TB after pleural and lymphatic disease. The majority of TB cases in the United States occur among foreign-born persons, reflecting the global TB epidemic. Tuberculous spondylitis begins with infection of the subchondral bone that then spreads to the cortex. This chapter also talks about pathophysiology and diagnosis of tuberculous osteomyelitis and arthritis, Poncet’s disease, tuberculous myositis, and tuberculous tenosynovitis. Early diagnosis and initiation of appropriate antituberculous therapy are important, as early treatment can prevent loss of function and mobility. The basic principles that underlie the treatment of pulmonary TB also apply to extrapulmonary forms of the disease. Based on experience from treating tuberculous spondylitis and the experience with treating other forms of extrapulmonary disease, it is recommended that treatment of drug-susceptible tuberculous arthritis and osteomyelitis be carried out using rifampin-based short-course regimens similar to those that are used for the treatment of pulmonary disease. Early diagnosis of bone and joint disease is important in order to minimize the risk of deformity and enhance outcome. The introduction of new imaging modalities, including CT and MRI, has enhanced the diagnostic evaluation of patients with musculoskeletal TB and for directed biopsies of affected areas of the musculoskeletal system.

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21

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Figures

Image of Figure 1.
Figure 1.

TB of the rib. Shown is a postero-anterior radiographic view of the chest of a man after 3 months of successful antituberculous chemotherapy. Note the mass in the left chest with destruction of a portion of the adjacent rib. A biopsy and culture confirmed TB. The mass resolved with continued therapy.

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 2.
Figure 2.

This photograph demonstrates a cold abscess of the chest wall in a patient with TB. Aspiration of this mass yielded material that was AFB smear positive, and the culture yielded .

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 3.
Figure 3.

Swollen knee of a patient with tuberculous arthritis. An HIV-infected patient presented with a painful, swollen knee. He had a recent history of trauma to the knee. On examination the knee was warm and an effusion was present. Culture of the synovial fluid following arthrocentesis grew .

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 4.
Figure 4.

Plain film radiograph of the lumbar spine of a patient with tuberculous spondylitis demonstrating anterior end plate destruction, sclerosis, loss of disk space, and evidence of bony debris. These finding are suggestive of tuberculous spondylitis. A CT-directed biopsy was performed to obtain material for cultures, which yielded .

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 5.
Figure 5.

CT evaluation of patients with tuberculous spondylitis. CT demonstrates a large right psoas abscess in an HIV-infected patient with tuberculous spondylitis of the lumbar spine. A percutaneous drain was placed into the psoas abscess, and the fluid culture yielded

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 6.
Figure 6.

MRI of a patient with multifocal tuberculous spondylitis who has both thoracic and lumbar spine involvement which is not contiguous (i.e., skip lesions). The thoracic lesion reveals anterior collapse of adjacent vertebrae and a gibbus formation leading to kyphosis. There is also evidence of lumbar disease in this patient.

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 7.
Figure 7.

Radiographs of the knee of a patient with tuberculous arthritis. (A) Plain radiograph of the knee shown in Fig. 3 . Marginal erosions are visible, along with soft tissue swelling.

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 8.
Figure 8.

TB of the knee. The radiograph shows findings of TB (left) and the normal knee (right). Note the narrowed joint space, lytic bone destruction in the distal femur and proximal tibia, and soft tissue swelling in the abnormal knee, which had shown clinical evidence of TB for more than 10 years (but the patient had not undergone treatment).

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 9.
Figure 9.

TB of the hip. (A) Plain radiograph of a 12-year-old girl who presented with an abnormal gait for several months. The left femoral head is completely destroyed. (B) Operative specimen of the destroyed femoral head.

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 10.
Figure 10.

CT of the knee of a patient with tuberculous arthritis. CT imaging of the knee shows extensive marginal destruction as well as erosions.

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Image of Figure 11.
Figure 11.

CT imaging of a psoas muscle abscess. The CT shows the lower extremities in a patient with lumbar tuberculous spondylitis who has a psoas abscess that extends into the right thigh.

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
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Tables

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Table 1.

Number and proportion of musculoskeletal TB cases in the United States, 1993 to 2008

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
Generic image for table
Table 2.

Anatomic site of musculoskeletal TB reported in Los Angeles County from 1990 to 1995

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
Generic image for table
Table 3.

Radiographic characteristics of tuberculous spondylitis

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
Generic image for table
Table 4.

Imaging features associated with tuberculous spondylitis

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
Generic image for table
Table 5.

Radiologic characteristics in the differential diagnosis of tuberculous arthritis

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
Generic image for table
Table 6.

Differential diagnosis of cystic bone lesions

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
Generic image for table
Table 7.

Differential diagnosis of primary myositis

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21
Generic image for table
Table 8.

Etiologies of a psoas muscle abscess

Citation: Leonard, Jr. M, Blumberg H. 2011. Musculoskeletal Tuberculosis, p 315-334. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Sixth Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817138.ch21

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