Paediatric osteoarticular tuberculosis: A review

Abstract

Objective: Tuberculosis (TB) is endemic in Indian subcontinent. The paediatric osteoarticular (OA) TB is frequently confused with suppurative etiology as both can have similar clinical, radiological and laboratory presentation. It has become a health hazard due to its association with immunosuppression diseases such as HIV, chronic renal and liver diseases and use of immunosuppressive drugs. Furthermore, there is much dilemma regarding the drug choice and duration of anti tubercular treatment among practicing clinicians. This mini review briefs the reader to the classical regional and atypical tubercular clinical presentations, imaging and laboratory investigations and management for bone and joint TB.

Methods: The article details both common and atypical clinical tubercular presentations, the approach to diagnosis, drug treatment and surgical indications in paediatric OA TB.

Results: OA TB in the paediatric age group is uncommon. Diagnosis is often delayed because of diseases' nonspecific symptoms, non-characteristic imaging findings and lack of awareness of the condition. Multidrug antitubercular chemotherapy remains the anchor sheet of tubercular treatment in children. Surgery is needed in select cases to obtain tissue, to ensure better joint movement, prevent deformities and restore neurological function.

Conclusions: TB can have varied presentation and therefore it is essential to keep tubercular infection in differential diagnosis while working up for any infective pathology. Conservative treatment produces good results in vast majority of cases. Surgery is reserved for select indications.

Keywords: Bone and joint; Children; Pediatric; Tuberculosis.

Fig. 1

“Ice cream scoop” appearance in TB elbow. A) The clinical presentation. B) The proximal ulnar involvement with formation of above radiological sign.

Fig. 2

TB lumbar spine (L4, L5) in a 4 year child. A) Collapse of vertebra along with large pre and para vertebral collections. The patient was managed conservatively with rest and multidrug ATT. No surgical procedure was done. B) Post completion of ATT, bone marrow oedema reduced, the prevertebral and paravertebral collections resolved. The collapsed vertebrae and growth plates can produce spinal deformities during the growth of the child and therefore the child needs to be kept in supervised follow up.

Fig. 3

TB osteomyelitis of left tibia in a 2 year old female child. A) Inflammation and swelling of the leg. B) Plain radiographs showing a diaphyseal involvement with sclerotic cortex on both sides and onion peel appearance. Common differential diagnosis included chronic osteomyelitis and malignancy. C) The MRI delineated the extent of the pathology, showed the soft tissue component. The tubercular diagnosis was however established by histopathology only.