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Musculoskeletal Tuberculosis

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  • Authors: Michael K. Leonard Jr.1, Henry M. Blumberg2
  • Editor: David Schlossberg3
  • VIEW AFFILIATIONS HIDE AFFILIATIONS
    Affiliations: 1: Division of Infectious Diseases, Carolinas HealthCare System, Charlotte, NC 28209; 2: Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA 30303; 3: Philadelphia Health Department, Philadelphia, PA
    • Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
  • Received 17 January 2017 Accepted 13 February 2017 Published 14 April 2017
  • Michael K. Leonard, [email protected]
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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. Vertebral involvement (tuberculous spondylitis, or Pott’s disease) is the most common type of skeletal TB, accounting for about half of all cases of musculoskeletal TB. The presentation of musculoskeletal TB may be insidious over a long period and the diagnosis may be elusive and delayed, as TB may not be the initial consideration in the differential diagnosis. Concomitant pulmonary involvement may not be present, thus confusing the diagnosis even further. Early diagnosis of bone and joint disease is important to minimize the risk of deformity and enhance outcome. The introduction of newer imaging modalities, including MRI (imaging procedure of choice) and CT, has enhanced the diagnostic evaluation of patients with musculoskeletal TB and for directed biopsies of affected areas of the musculoskeletal system. Obtaining appropriate specimens for culture and other diagnostic tests is essential to establish a definitive diagnosis and recover for susceptibility testing. A total of 6 to 9 months of a rifampin-based regimen, like treatment of pulmonary TB, is recommended for the treatment of drug susceptible musculoskeletal disease. Randomized trials of tuberculous spondylitis have demonstrated that such regimens are efficacious. These data and those from the treatment of pulmonary TB have been extrapolated to form the basis of treatment regimen recommendations for other forms of musculoskeletal TB.

  • Citation: Leonard M, Blumberg H. 2017. Musculoskeletal Tuberculosis. Microbiol Spectrum 5(2):TNMI7-0046-2017. doi:10.1128/microbiolspec.TNMI7-0046-2017.

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2017-04-14
2020-10-20

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. Vertebral involvement (tuberculous spondylitis, or Pott’s disease) is the most common type of skeletal TB, accounting for about half of all cases of musculoskeletal TB. The presentation of musculoskeletal TB may be insidious over a long period and the diagnosis may be elusive and delayed, as TB may not be the initial consideration in the differential diagnosis. Concomitant pulmonary involvement may not be present, thus confusing the diagnosis even further. Early diagnosis of bone and joint disease is important to minimize the risk of deformity and enhance outcome. The introduction of newer imaging modalities, including MRI (imaging procedure of choice) and CT, has enhanced the diagnostic evaluation of patients with musculoskeletal TB and for directed biopsies of affected areas of the musculoskeletal system. Obtaining appropriate specimens for culture and other diagnostic tests is essential to establish a definitive diagnosis and recover for susceptibility testing. A total of 6 to 9 months of a rifampin-based regimen, like treatment of pulmonary TB, is recommended for the treatment of drug susceptible musculoskeletal disease. Randomized trials of tuberculous spondylitis have demonstrated that such regimens are efficacious. These data and those from the treatment of pulmonary TB have been extrapolated to form the basis of treatment regimen recommendations for other forms of musculoskeletal TB.

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Musculoskeletal Tuberculosis
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Citation: Leonard M, Blumberg H. 2017. Musculoskeletal tuberculosis. microbiolspec 5(2): doi:10.1128/microbiolspec.TNMI7-0046-2017
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FIGURE 1
TB of the rib. Shown is a postero-anterior radiographic view of the chest of a man after 3 months of successful anti-TB 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.
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FIGURE 1

TB of the rib. Shown is a postero-anterior radiographic view of the chest of a man after 3 months of successful anti-TB 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.

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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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 .
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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 .

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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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 .
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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 .

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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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 findings are suggestive of tuberculous spondylitis. A CT-directed biopsy was performed to obtain material for cultures, which yielded .
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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 findings are suggestive of tuberculous spondylitis. A CT-directed biopsy was performed to obtain material for cultures, which yielded .

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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FIGURE 5
CT evaluation of patients with tuberculous spondylitis. CT demonstrated 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 .
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FIGURE 5

CT evaluation of patients with tuberculous spondylitis. CT demonstrated 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 .

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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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.
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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.

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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FIGURE 7
Radiographs of the knee of a patient with tuberculous arthritis. Plain radiograph of the knee shown in Fig. 3 . Marginal erosions are visible, along with soft tissue swelling.
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FIGURE 7

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

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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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).
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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).

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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FIGURE 9
TB of the hip. Plain radiograph of a 12-year-old girl who presented with an abnormal gait for several months. The left femoral head is completely destroyed. Operative specimen of the destroyed femoral head.
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FIGURE 9

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

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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FIGURE 10
CT imaging of the knee of a patient with tuberculous arthritis, showing extensive marginal destruction as well as erosions.
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FIGURE 10

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

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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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.
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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.

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
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Tables

Musculoskeletal Tuberculosis
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Citation: Leonard M, Blumberg H. 2017. Musculoskeletal tuberculosis. microbiolspec 5(2): doi:10.1128/microbiolspec.TNMI7-0046-2017
/content/microbiolspec/10.1128/microbiolspec.TNMI7-0046-2017.T1
TABLE 1
Numbers and proportions of musculoskeletal TB cases in the United States, 1993 to 2015
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TABLE 1

Numbers and proportions of musculoskeletal TB cases in the United States, 1993 to 2015

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
/content/microbiolspec/10.1128/microbiolspec.TNMI7-0046-2017.T2
TABLE 2
Anatomic sites of musculoskeletal TB reported in Los Angeles County from 1990 to 1995
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TABLE 2

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

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
/content/microbiolspec/10.1128/microbiolspec.TNMI7-0046-2017.T3
TABLE 3
Radiographic characteristics of tuberculous spondylitis
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TABLE 3

Radiographic characteristics of tuberculous spondylitis

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
/content/microbiolspec/10.1128/microbiolspec.TNMI7-0046-2017.T4
TABLE 4
Imaging features associated with tuberculous spondylitis
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TABLE 4

Imaging features associated with tuberculous spondylitis

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
/content/microbiolspec/10.1128/microbiolspec.TNMI7-0046-2017.T5
TABLE 5
Radiologic characteristics in the differential diagnosis of tuberculous arthritis
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TABLE 5

Radiologic characteristics in the differential diagnosis of tuberculous arthritis

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
/content/microbiolspec/10.1128/microbiolspec.TNMI7-0046-2017.T6
TABLE 6
Differential diagnosis of cystic bone lesions
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TABLE 6

Differential diagnosis of cystic bone lesions

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
/content/microbiolspec/10.1128/microbiolspec.TNMI7-0046-2017.T7
TABLE 7
Differential diagnosis of primary myositis
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TABLE 7

Differential diagnosis of primary myositis

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017
/content/microbiolspec/10.1128/microbiolspec.TNMI7-0046-2017.T8
TABLE 8
Etiologies of a psoas muscle abscess
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TABLE 8

Etiologies of a psoas muscle abscess

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0046-2017

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