A deceptive presentation of Tuberculosis hip as Staphylococcal infection, its successful management and literature review

Abstract

A 71-year-old man presented with septic arthritis of the hip with an initial culture growth of methicillin-sensitive Staphylococcus aureus (MSSA) masking the diagnosis of tuberculosis (TB). Based on joint aspirate culture and sensitivity results, the patient was first diagnosed with MSSA arthritis. He was started on intravenous antibiotics and underwent washout and debridement of hip. During the procedure, the surgeons observed characteristic tubercular changes and samples were sent for tubercular testing. The reports of cultures for acid-fast bacilli and synovial biopsies confirmed our intraoperative suspicion of TB. Antitubercular medication was started and it helped patient to improve quickly. He completed 9 months of tubercular treatment regimen and at completion total hip replacement was offered. At 8-year follow-up, the patient was doing fine with no recurrence of infection in his hip. High index of suspicion for skeletal TB was raised based on clinical and radiological signs especially if there was a delay or absence of response to appropriate therapy.

Keywords: Bone & Joint infection; septic arthritis; total hip arthroplasty; tuberculosis.

Figure 1

Plain radiographs showed right hip with features consistent with tubercular arthritis. A triad of radiological abnormalities (Phemister’s triad) include: periarticular osteoporosis, peripherally located osseous erosion and gradual diminution of the joint space.

Figure 2

MRI scan (T2) coronal image showing effusion of the hip and extension into the psoas.

Figure 3

CT scan coronal image showing pattern of bone destruction.

Figure 4

CT scan axial image showing pattern of bone destruction.

Figure 5

Plain radiographs of right hip after first stage revision with excision of the femoral head and insertion of a cement spacer.

Figure 6

Plain radiographs of right hip after second-stage revision with furlong hydroxyapatite-coated uncemented prosthesis.

Figure 7

Plain radiographs of right total hip replacement at 8-year follow-up.