Tuberculous Osteomyelitis

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Tuberculous Osteomyelitis:

Tuberculous Osteomyelitis Becky Bulen , Lindsay Cale , Drew Kayser 6/19/11

Tuberculous Osteomyelitis:

Tuberculous Osteomyelitis Osteomyelitis is an acute or chronic bone infection that can be caused by: Bacteria Fungi Infection elsewhere in the body Risk factors include ( but are not limited to ): Diabetes, hemodialysis, intravenous drug use, decreased blood supply, recent trauma & tuberculosis In the case of tuberculous osteomyelitis the infection starts as tuberculosis in the lungs, and travels to the bone. (1,2)

Signs and Symptoms:

Signs and Symptoms A physical exam will usually demonstrate bone tenderness as well as swelling and redness Patients may present with: Bone Pain Fever Malaise Chills Excessive sweating Low back pain Excessive swelling of ankles, feet, and legs Enlarged lymph nodes (2)

Incidence:

Incidence In 2010, The World Health Organization estimated that approximately 270,000 people in the Americas were living with tuberculosis Incidents of tuberculosis are higher in third world countries without adequate healthcare, children and the elderly 1%-2% of people with tuberculosis develop tuberculous osteomyelitis (3)

Diagnosis:

Diagnosis Bone pain that does not respond to analgesic medication is often due to infection or neoplasia Tests performed may include: Blood cultures Bone biopsy Bone scan X-ray Complete blood count MRI Needle aspiration of the area around affected bones (4)

Prognosis:

Prognosis The prognosis for tuberculous osteomyelitis is variable and has many different determinants Acute cases have a better outcome than chronic cases Co-morbidities, such as diabetes, resulting in decreased circulation negatively affect prognosis Autoimmune diseases such as HIV/AIDS also negatively affect prognosis In nations with strong healthcare services available, the diagnosis of TB is often secondary to some form of autoimmune disease if the patient is not a young child or elderly. (5)

Impact of Function:

Impact of Function In children, it can cause impaired growth of the affected bone Can lead to leg length discrepancy Compensatory patterns due to disuse or musculoskeletal dysfunction Skeletal lesions can lead to: Spinal instability Neurologic damage Gibbus deformity due to vertebral body collapse Arthritis Severe cases can lead to loss of limb or death (6,7,8,9)

Role of Imaging:

Role of Imaging Plain film radiograph Joint effusion, periarticular osteopenia, cortical irregularity, lytic lesions, periosteal new bone formation Ultrasound Joint effusion – aids in aspiration of effusion CT Degree of bone destruction, sequestrum and surrounding soft tissue extension MRI Marrow changes, joint effusion, synovitis, pannus, cartilage and bone erosion (9)

Treatment:

Treatment Antituberculous drugs In severe cases surgery to drain pockets of pus is recommended Rehabilitation is aimed at restoring ROM, strength, flexibility, endurance, mobility, and function (4,10)

Best Imaging:

Best Imaging MRI Can identify lesions in early stages when plain film radiographs are normal Shows the extent and severity of the disease Provides detailed images of bones and surrounding soft tissue In spinal lesions it can give exact level of spinal cord involvement, which can aid in surgical interventions (4,6,7,10)

Slide 11:

©2000 by Radiological Society of North America (13)

ABC’s of Radiographs:

ABC’s of Radiographs A. Alignment: General appearance is consistent with that of a child.  Radiograph displays small carpal bones with normal shape and contour, which appear to be free floating with increased joint space.  Radius and ulna appear to be aligned properly with each other and relative to the carpal bones. B. Bone Density: Decreased bone density is noted at the distal lateral aspect of the radius with varying amounts of sclerosis and bone destruction.  The radius, aside from the distal lateral aspect, appears to have increased bone density compared to ulna and carpal bones. C. Cartilage: Because this is an AP/non-weight-bearing radiograph of a juvenile’s left wrist the cartilage space appears greater than that of a fully formed adult wrist.  The subchondral bone at the distal radial head appears increased due to the sclerotic lesion at the lateral aspect.  The epiphyseal plates are present at the distal radius, distal ulna, and at the CMC joint of the first digit. S. Soft Tissues: Not remarkable.

Functional Limitations:

Functional Limitations Decreased ability to weight bear through the wrist Decreased bone growth due to lesion crossing epiphyseal plate Possible residual deformity of the radius Arm length discrepancy Decreased strength and ROM at the wrist due to pain and swelling

Evaluation of MRI:

Evaluation of MRI High T2 signal indicates bony involvement of both vertebrae Disc space involvement in center of image White arrow indicates normal disc Possible involvement of nerve root below level of lesion Increased pain with movement (flexion > extension) due to location of lesion Compensatory hypermobility or instability at levels above and below lesion (14)

Questions:

Questions What areas of the body are most often affected by the bony lesions associated with tuberculous osteomyelitis? How would bone destruction in those areas affect your plan of care or treatment approach with your patient?

References:

References 1. Watts HG, Lifeso RM. Current concepts review - tuberculosis of bones and joints. Journal of Bone and Joint Surgery. 1996, 78(2):288. 2. Dugdale DC, Vyas JM. Osteomyelitis. National Center for Biotechnology Information Website. 2011. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001473/#adam_000437.disease.causes . Accessed June 16, 2011. 3. Tuberculosis. World Health Organization Website. 2010. Available at http://www.who.int/mediacentre/factsheets/fs104/en/ . Accessed June 16, 2011. 4. Vohra R, Harinder K, Dogra S, et al. Tuberculous Osteomyelitis. Journal of Bone and Joint Surgery. 1997;79-B(4):562-566. 5. Mannepalli et al . Mycobacterium tuberculosis osteomyelitis in a patient with human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS): a case report. Cases Journal . 2010; 3(67):1-4. 6. Cervical Spine Infections. Desert Institute of Spine Care. 2008. Available at http://www.disclv.com/c_spine_infections.php . Accessed June 17, 2011. 7. Osteomyelitis. Mayo Clinic. 2010. Available at http://www.mayoclinic.com/health/osteomyelitis/DS00759 . Accessed June 17, 2011. 8. Osteomyelitis. University of Illinois Medical Center at Chicago. 2006. Available at http://uimc.discoveryhospital.com/main.php?id=360 . Accessed June 17, 2011. 9. Harvey E L Teo, Wilfred C G Peh. Skeletal tuberculosis in children . Pediatric Radiology. 2004;34:853-60. 10. Osteomyelitis. MD Guidelines. 2010. Available at http://www.mdguidelines.com/osteomyelitis . Accessed June 17, 2011. 11. Thawani M, Hale E, Habte-Gabr E. Multifocal tubercular osteomyelitis: A case with atypical manifestations. Tuberculosis Research and Treatment . 2011; 2011:1-3 12. Versfeld GA, Solomon A. A diagnostic approach to tuberculosis of bones and joints. Journal of Bone and Joint Surgery . 1982; 64(4):446-449. 13. Harisinghani M, et al. Tuberculosis from Head to Toe. RadioGraphics . 2000;20:449-470. 14. BMJ. 2011. Available at http://bestpractice.bmj.com/best-practice/monograph/189/resources/images/print/4.html . Accessed June 17, 2011.