Tuberculous osteo-arthritis unmasked through unusual elbow swelling: A case report

Abstract

Introduction and importance: Tuberculous osteoarthritis, a rare condition affecting the elbow in 1-5 % of cases, poses diagnostic challenges due to its subtle clinical presentation, often resulting in delayed diagnosis. Herein, we present a case of tuberculous osteoarthritis involving the elbow joint. Our aim is to underscore the complexities associated with diagnosing this condition and to emphasize the critical importance of early recognition and appropriate management strategies for optimal patient outcomes.

Case presentation: A 44-year-old Tunisian woman presented with a year-long history of painful right elbow swelling, systemic symptoms, and purulent drainage. Physical examination revealed a swollen, erythematous elbow with limited mobility. Radiographs showed periarticular osteolysis and subluxation, and Mycobacterium tuberculosis was cultured from the purulent drainage. The patient underwent open arthrotomy, synovectomy, joint irrigation, external fixation, and immobilization. Histopathology confirmed tuberculosis. She started a 12-month anti-tuberculous treatment and rehabilitation plan but was lost to follow-up due to socioeconomic difficulties.

Clinical discussion: This case underscores the intricate diagnostic challenges of tuberculous osteoarthritis, emphasizing the necessity of a comprehensive assessment for precision in diagnosis. Timely intervention plays a pivotal role in averting joint deterioration and securing favorable results, especially in regions with high endemicity.

Conclusions: Early recognition and management of tuberculous osteoarthritis are vital for preserving joint function. Maintaining a high suspicion for tuberculosis in cases of unusual joint symptoms is key to timely diagnosis and effective treatment, leading to improved patient care and outcomes.

Keywords: Elbow; Infection; Osteo-arthritis pathology; Tuberculosis.

Fig. 1A

Anteroposterior radiograph of the right elbow showing marginal periarticular osteolysis and elbow subluxation.

Fig. 1B

Lateral plain radiograph of the right elbow demonstrating marginal periarticular osteolysis and elbow subluxation.

Fig. 2

Intraoperative image showing the surgical exploration of the lateral aspect of the elbow. The image reveals osteocartilaginous and capsuloligamentous destruction in the anterolateral region, extending into the adjacent soft tissues. Additionally, there is hypertrophic synovium resembling a pseudotumor, accompanied by bone lysis and minimal purulent discharge.

Fig. 3A

Anteroposterior radiograph of the right elbow demonstrating the utilization of an external fixator for stabilization.

Fig. 3B

Lateral radiograph of the right elbow demonstrating successful stabilization achieved with an external fixator.

Fig. 4A

Histological examination showing granulomatous inflammation with caseous necrosis (asterisk), epithelioid cells, Langhans giant cells, and lymphocytic infiltration. (Hematoxylin and eosin, magnification × 40).

Fig. 4B

The image depicts the presence of caseating granulomas, characterized by central caseous necrosis (asterisk) surrounded by epithelioid cells, Langhans giant cells, and a dense infiltration of lymphocytes. (Hematoxylin and eosin, magnification × 100).

Fig. 4C

Epithelioid granuloma with multinucleated Langhans giant cells (Hematoxylin and eosin, magnification × 400).

Fig. 4D

Caseous necrosis (asterisk) surrounded by epithelioid cells (Hematoxylin and eosin, magnification × 400).