tuberculous arthritis

8/3/2019 Tuberculous Arthritis

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TUBERCULOUS

ARTHRITIS

PGI CALLEJAS, JEANETTE


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CC: Mass, Left Knee

EE57/M/M

Brgy. Don Esteban, Lapuz, Iloilo City


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History of Present Illness:

2 years ptc:

(+) pain on the left knee, on and off

(+) mass, lateral aspect of L knee non

tender, non erythematous,non movable, doughy in char.

(+) swelling left knee

(+) difficulty walkingtook pain relievers which provided temp.

relief


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(+) on and off non productive cough

(-) fever

(-) night sweats

(-) anorexia

(-) vomiting

(-) previous injury to the knee

No consult done


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11 months ptc (December 15, 2009)

sought consult in the Surgery OPD of this

institution because of the persistent pain,

swelling and progression in size of the mass

on his left knee. A: Mass, Lateral aspect of L knee

P: Lagaflex 1 tab TID

S.Uric Acid, Creatinine

L knee APL

Refer to Ortho Dept.


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(December 16, 2009)

the patient underwent fine needle biopsy

performed by ortho resident which showed negative

result. He was then referred to IM Dept.


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(December 21, 2009)

Chest PA was requested by Ortho Dept. whichshowed suspicious densities in the R upper lungand haziness in the R paracardiac area. PPD wasdone which showed reactive results with an

induration of 23mm at 48 h.A: T/C TB arthritis

10 months ptc: (January 2010)

Anti-Kochs medications was started by IM Dept,despite negative results of sputum.


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PAST MEDICAL HISTORY

(-) previous hospitalization

(-) BA

(-) FDA


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FAMILY HISTORY

(+) HPN mother

(-) CA

(-) DM

(-) TB

(-) joint diseases


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PERSONAL HISTORY:

Non smoker

(+) alcoholic beverage drinker started atthe age of 20, drinks almost everyday 2

beers/day, stopped december last year. Seafarer but stopped working 7 years ago


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Physical Examination

PPE findings: Minimal swelling in the

left knee, nonerythematous, nontender


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L Knee APLThere are marginal

erosions, lytic and

blastic changes in the

condyles of the Lfemur and tibia as

well as the apex of

the L fibula with

surrounding softtissue swelling.


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Multiple ovoid cystic

lucencies are seen in

the medial aspect of

the condyles of the L

femur and tibia.


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There is an irregularity in

the inf. portion of the L

patella with narrowing ofthe femur patellar aspect

joint space


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There are no fracture lines noted

The rest of the findings and osseousstructures are unremarkable.


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CHRONIC PYOGENIC ARTHRITIS

RHEUMATOID ARTHRITIS

TUBERCULOUS ARTHRITIS

DIFFERENTIAL DIAGNOSIS:


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PYOGENIC ARTHRITIS

(+) history of antecedent infection

Source of infection may be hematogenous from otherinfections of the skin, respiratory tract or urinary system, adirect extension from a focus of adjacent osteomyelitis or aconsequence of a bacterial contamination

(+) positive synovial fluid cultures of S. aureus, Streptococcus,

S. Epidermidis

Progression usually is measured in hours and days.


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Pathologic Features Usually involves portions of the articular cartilage that

are weight bearing or in close apposition.

Purulent organisms excrete proteolytic enzymes thatdestroy articular cartilage resulting in a decrease in thewidth of the joint space (joint narrowing).

As the cartilage is destroyed, granulation tissue from the

subchondral bone attempts to bridge the joint and iseventually replaced by bone, resulting in bony ankylosis.


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Radiographic Features First sign is soft-swelling

Joint space narrowing may occur early and aid indifferentiating it from tuberculous arthritis

The first changes are small erosions in the articular

cortex, with severe infections the entire outline is

lost.


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RHEUMATOID ARTHRITIS

Usually polyarticular

Disease begins in the peripheral joints, usuallyproximal IP and MCP joints of the hand and carpal

joints of the wrist.


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Radiologic Features

Earliest radiologic evidence of the disease is periarticularsoft tissue swelling characteristically symmetrical andfusiform.

Joint distention can also be identified in the knee, ankleand wrist.

Narrowing of the joint space results from degenerationof the articular cartilage as pannus spreads across thejoint spaces.


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The joint space is characteristically symmetrically

narrowed.

Bony erosions occur as a result of development of

granulation tissue (pannus)

Marginal erosions and joint destruction are more

common in the smaller peripheral than in the

proximal major joints.


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Monoarticular

Symptoms may be present for months or years with aninsidious clinical onset.

A doughy swelling of the joint, a limp, muscular atrophy or adraining sinus may be the first indications.

Pain and tenderness are late symptoms.

Slight or no temp elevation is the rule.


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Tuberculous Arthritis

There are four clinical stages: 1. invasion

2. tissue destruction

3. quiescence

4. healing


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Articular cartilage is most vulnerable to tuberculosis at

the free surfaces where the opposing articular cartilagesare not in close apposition.

Because the reaction is insidious, it may take years for

enough cartilage to be destroyed to cause jointnarrowing.

Exudate contains no proteolytic enzymes so that debris

may persist throughout the course.


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Initial feature is extensive osteopenia adjacent to thejoint.

Disuse

Hyperemia

Bacterial toxins Eventually, destruction of articular cartilage is

manifested by narrowing of the joint and erosion of

bone.

Earliest evidence of bone destruction is the appearanceof erosion at the margins of the joints

Radiologic Features


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Marginal erosions gradually extend across the joint

surface, with further progression, gross disorganizationof the joint may occur

The articular cartilage disappears, ragged destruction at

the articular ends of the bone occurs and separation ofdead fragments (sequestra) is noted.


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IMPRESSION:


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tuberculous arthritis

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