Diagnosis of Osteoarticular Tuberculosis: Perceptions, Protocols, Practices, and Priorities in the Endemic and Non-Endemic Areas of the World-A WAIOT View

Abstract

There has been a major resurgence of tuberculosis (TB) and drug-resistant tuberculosis in the last few decades. Although it has been brought under control in most Western countries, it is still a major cause of death in endemic regions like India. Osteoarticular tuberculosis (OA TB) forms a small proportion of the total cases of tuberculosis. Perceptions and practices of orthopedic surgeons are entirely different in endemic and non-endemic regions around the world, due to the vast difference in exposure. Literature from endemic areas puts stress on clinico-radiological diagnosis and empirical anti-tubercular treatment (ATT). Such practices, although non-invasive, simple to implement, and economical, carry a significant risk of missing TB mimics and developing drug resistance. However, OA TB is still perceived as a "diagnostic enigma" in non-endemic regions, leading to a delay in diagnosis. Hence, a high index of suspicion, especially in a high-risk population, is needed to improve the diagnosis. Evolving drug resistance continues to thwart efforts to control the disease globally. This review article discusses the perceptions and practices in different parts of the world, with India as an example of the endemic world, and lays down priorities for overcoming the challenges of diagnosing osteoarticular TB.

Keywords: GeneXpert; clinico-radiological diagnosis; culture; drug sensitivity; drug-resistant tuberculosis; endemic; osteoarticular tuberculosis.

Figure 8

A simplified management algorithm to follow in suspected cases of OA TB [41,80].

Figure 9

The hierarchy of investigative modalities for the diagnosis of TB. AFB, acid-fast bacilli; HPE, histopathological examination.

Figure 1

The pathogenesis of osteoarticular tuberculosis (OA TB).

Figure 2

(a) An 18-year-old female presents with a gradually progressive soft to firm swelling over her mid-upper forearm for 2 months, suggestive of a cold abscess. (b) X-rays suggestive of lytic lesion in the diaphysis of the ulna with significant soft tissue swelling around it, suggestive of infective pathology. Final diagnosis: pan-sensitive TB.

Figure 3

(a) An 11-month-old boy presents with discharging sinus over right anterior axillary fold with restricted and painful movement of his right shoulder. (b) Magnetic resonance imaging (MRI) reveals infective lesion crossing the physeal plate of the proximal humerus.

Figure 4

A characteristic tuberculous ulcer in the foot of a 60-year-old male. It is characterized by thin, reddish-blue undermined edges. There is pale granulation tissue with scanty serosanguinous discharge in the floor and slight induration at the base.

Figure 5

The characteristic Phemister’s triad of peripheral osseous erosions, joint space narrowing, and juxta-articular osteopenia/osteoporosis in a case of tuberculosis of the knee in a 30-year-old man.

Figure 6

(a) A 6-year-old girl presents with scoliosis noticed by parents 4 months previously. (b) X-ray of the dorsal spine showing collapse of the D8 vertebra and a fusiform-shaped soft tissue shadow suggestive of an abscess. (c) MRI of the dorsal spine showing collapse of the D8 vertebral body with marrow edema, prevertebral and paravertebral collection with subligamentous and epidural extension, and epidural involvement (canal encroachment).

Figure 7

(a) A 28-year-old man presents with pain, gradually progressive swelling in his left knee and restricted left knee movements since the past 3 months. (b) MRI left knee shows synovitis, bone marrow edema with erosions, osteomyelitis with para-articular abscess, and tenosynovitis.

Figure 10

OA TB practices in endemic and non-endemic areas of the world.