Osteoarticular Tuberculosis:Osteoarticular Tuberculosis:Challenges in DiagnosisChallenges in Diagnosis

G. Omondi Oyoo FRCP(Edin), FACRG. Omondi Oyoo FRCP(Edin), FACRCONSULTANT PHYSICIAN AND RHEUMATOLOGIST,CONSULTANT PHYSICIAN AND RHEUMATOLOGIST,

SENIOR LECTURER ,DEPARTMENT OF CLINICAL MEDICINESENIOR LECTURER ,DEPARTMENT OF CLINICAL MEDICINEAND THERAPEUTICS, AND THERAPEUTICS,

SCHOOL OF MEDICINE;UNIVERSITY OF NAIROBI,SCHOOL OF MEDICINE;UNIVERSITY OF NAIROBI,NAIROBI, KENYA..NAIROBI, KENYA..

Chairman AARDChairman AARD(Association for Arthritis and Rheumatic Diseases of Kenya ),(Association for Arthritis and Rheumatic Diseases of Kenya ),

President-elect, AFLAR(African League of Associations for Rheumatology).

Country coordinator, Bone and Joint Decade (BJD), Kenya.

ASSUMPTIONS ASSUMPTIONS IN PREPARING THE TALKIN PREPARING THE TALK

ll AUDIENCE IS PREDOMINANTLY PHYSICIANSAUDIENCE IS PREDOMINANTLY PHYSICIANS

ll SINCE THE TALK IS IN THE MORNING, THE SINCE THE TALK IS IN THE MORNING, THE AUDIENCE IS PHYSICALLY STRONG AND AUDIENCE IS PHYSICALLY STRONG AND MENTALLY ALLERTMENTALLY ALLERT

ll TALK WILL BE MORE QUALITATIVE AND WILL TALK WILL BE MORE QUALITATIVE AND WILL STRESS KEY CONCEPTSSTRESS KEY CONCEPTS

Incidence of TBIncidence of TB

llWorld populationWorld population 6 billion6 billion

ll Latent TBLatent TB 2 billion2 billion

ll Incidence of TBIncidence of TB 144 / 100 000 144 / 100 000 GlobalGlobal

205 / 100 000 205 / 100 000 AfricaAfrica

introductionintroduction

ll TB cases have risen due to HIV infectionTB cases have risen due to HIV infection

ll Extra pulmonary TB on the rise ( now 16Extra pulmonary TB on the rise ( now 16--18% compared to 7.8% in 1964)18% compared to 7.8% in 1964)

ll Osteoarticular involvement is 1Osteoarticular involvement is 1--3 %3 %

Who is at Risk factorsWho is at Risk factors

ll AlcoholicsAlcoholics

ll HIV HIV ––positive patientspositive patients

ll Immigrants from endemic countriesImmigrants from endemic countries

ll Drug abusersDrug abusers

ll ElderlyElderly

ll Immunosuppressed patientsImmunosuppressed patients

Dissemination of TB to bone and Dissemination of TB to bone and jointjoint

ll Haematogenous SpreadHaematogenous Spread

ll Lymphatic spread from distant focusLymphatic spread from distant focus

ll Contagious spread from infected areasContagious spread from infected areas

TB ARTHRITIS (CLINICAL TB ARTHRITIS (CLINICAL PRESENTATIONS)PRESENTATIONS)

ll Spinal TBSpinal TB

ll Peripheral TBPeripheral TBll MonoarthritisMonoarthritis

ll PolyarthritisPolyarthritis

ll Oligoarticular (Poncets Disease)Oligoarticular (Poncets Disease)

ll Soft tissue TBSoft tissue TB

ll Reactive Arthritis 2o to BCGReactive Arthritis 2o to BCG

ll Arthritis due to Tropical MycobacteriaArthritis due to Tropical Mycobacteria

ll Faceitis / Polyarthritis due to anti TB therapyFaceitis / Polyarthritis due to anti TB therapy

ll TB associated to Collagen DiseaseTB associated to Collagen Disease

Risk of Infection in Rheumatic Risk of Infection in Rheumatic DiseasesDiseases

ll Conflicting reportsConflicting reports

ll Most studies show greater risk in RA / Most studies show greater risk in RA / SLESLE

ll Types of infection include UTI, Types of infection include UTI, respiratory, skin and septic arthritis respiratory, skin and septic arthritis

Infections and DMARDSInfections and DMARDS

ll High dose MTX High dose MTX –– clearly immunosuppressiveclearly immunosuppressive

ll Low dose MTX Low dose MTX –– decreases Ig production, decreases Ig production, cytokine secretion, cell mediated immunity and cytokine secretion, cell mediated immunity and neutrophil functionneutrophil function

ll Oppurtunistic infections reportedOppurtunistic infections reported

ll Leucopaenia not a featureLeucopaenia not a feature

ll Any stage of treatment Any stage of treatment

ll Overall risk is smallOverall risk is small

Corticosteroids and InfectionCorticosteroids and Infection

ll Inhibit neutrophil migrationInhibit neutrophil migration

ll Adherence to vascular endothelium decreaseAdherence to vascular endothelium decrease

ll Monocyte antimicrobial activity decreaseMonocyte antimicrobial activity decrease

ll Impaired lymphocyte activation, cytokine Impaired lymphocyte activation, cytokine stimulation and Ig productionstimulation and Ig production

ll Risk of infection increases with steroids, higher Risk of infection increases with steroids, higher dose, longer duration dose, longer duration

Commonly involved bones/jointsCommonly involved bones/joints

ll Spine (PottSpine (Pott’’s Disease)s Disease)

ll 50% of cases50% of cases

ll Frequently in thoracolumbar spineFrequently in thoracolumbar spine

ll Peripheral jointsPeripheral joints

llWeight bearing jointWeight bearing joint

llHip, knee, ankleHip, knee, ankle

ll Mono articularMono articular

ll 30% of cases30% of cases

Commonly involved bones/jointsCommonly involved bones/joints

ll Osteomyelitis Osteomyelitis

ll DactylitisDactylitis

ll TenosynovitisTenosynovitis

ll BursitisBursitis

ll PoncetPoncet’’s diseases disease

Spinal TuberculosisSpinal Tuberculosis

ll Involves anterior vertebral border and discInvolves anterior vertebral border and disc

ll Progresses to disc narrowing,vertebral Progresses to disc narrowing,vertebral collapse and kyphosiscollapse and kyphosis

ll Complications:Complications:ll Psoas abscessPsoas abscess

ll Sinus tract formationSinus tract formation

ll Neurologic compromiseNeurologic compromise

ll Sacroiliac joint rarely involved (unilateral if Sacroiliac joint rarely involved (unilateral if it occursit occurs

Spinal Tuberculosis: presentationSpinal Tuberculosis: presentation

ll Back painBack pain

ll SpasmSpasm

ll Local tendernessLocal tenderness

ll KyphosisKyphosis

ll Cord compressionCord compression

ll Mycotic aneurysm of aortaMycotic aneurysm of aorta

Frequency and location on spinal lesions in POTT`S disease

50 cases

Thoracolumbar XrayThoracolumbar Xray

Wedge collapse Wedge collapse T6T6--T7T7

Thoracolumbar x ray Thoracolumbar x ray

Fusiform opaque mass over Fusiform opaque mass over the thoracic spinethe thoracic spine

THORACOLUMBAR THORACOLUMBAR radiographradiograph

Wedge collapse of T11 Wedge collapse of T11 --T12 T12

Peripheral joints: presentationPeripheral joints: presentation

ll Hip: pain in the thigh, groin or knee; limp, Hip: pain in the thigh, groin or knee; limp, muscle atrophymuscle atrophy

ll Knee: insidious pain, swelling, limp, Knee: insidious pain, swelling, limp, stiffness,stiffness,

ll Hand / wrist: carpal tunnel syndrome, Hand / wrist: carpal tunnel syndrome, swelling, painswelling, pain

OsteomyelitisOsteomyelitis

ll pain,pain,

ll Lytic lesions on radiographLytic lesions on radiograph

ll DactylitisDactylitis

Constitutional symptoms often are not Constitutional symptoms often are not presentpresent

PoncetPoncet’’s diseases disease

ll Acute polyarthritis( ? Reactive) in patients Acute polyarthritis( ? Reactive) in patients with visceral or pulmonary tuberculosiswith visceral or pulmonary tuberculosis

ll Tuberculous organisms are not cultured Tuberculous organisms are not cultured from involved jointsfrom involved joints

ll Commonly involves knees, ankles and Commonly involves knees, ankles and elbowselbows

Osteoarticular tuberculosis: diagnosisOsteoarticular tuberculosis: diagnosis

ll Demonstration of Demonstration of mycobacterium mycobacterium tuberculosistuberculosis in tissue or synovial fluidin tissue or synovial fluid

ll Diagnostic yield:Diagnostic yield:

ll Synovial fluid smearSynovial fluid smear 20%20%

ll Synovial fluid cultureSynovial fluid culture 80%80%

ll Synovial biopsy and cultureSynovial biopsy and culture > 90%> 90%

Osteoarticular tuberculosis: diagnosisOsteoarticular tuberculosis: diagnosis

ll Synovial fluid analysis:Synovial fluid analysis:ll Elevated proteinsElevated proteins

ll Low glucose in 60%Low glucose in 60%

ll Variable cell counts (10,000Variable cell counts (10,000--20,000) mostly 20,000) mostly polymorphonuclear cellspolymorphonuclear cells

ll Synovial membrane biopsy: caseating Synovial membrane biopsy: caseating granulomasgranulomas

ll Osteomyelitis: needle biopsy reveals Osteomyelitis: needle biopsy reveals granulomas (granulomas (±± caseating necrosis)caseating necrosis)

Osteoarticular tuberculosis: diagnosisOsteoarticular tuberculosis: diagnosis

ll Purified protein derivative (PPD) skin Purified protein derivative (PPD) skin testing ? :testing ? :

ll Positive in virtually all patientsPositive in virtually all patients

ll Difficult to interpret if anergy is presentDifficult to interpret if anergy is present

RANGERANGE MEDIANMEDIAN No.No. %%

ESRESR 18 18 -- 6565 4242 1616 100100

WBCWBC 4,6 4,6 –– 13,413,4 8,58,5

PPD (+) > PPD (+) > 10MM10MM

3/43/4 7575

CHEST X RAY CHEST X RAY ABNORMALABNORMAL

77 5454

TB ARTHRITIS LABORATORYTB ARTHRITIS LABORATORY

Osteoarticular tuberculosis: Osteoarticular tuberculosis: Radiographic featuresRadiographic features

ll Spine:Spine:

ll Narrowing of joint space with vertebral Narrowing of joint space with vertebral collapsecollapse

ll Anterior vertebral scallopingAnterior vertebral scalloping

ll Extensive vertebral destruction with relative Extensive vertebral destruction with relative preservation of disc spacepreservation of disc space

Osteoarticular tuberculosis: Osteoarticular tuberculosis: Radiographic featuresRadiographic features

ll Peripheral jointPeripheral joint

ll Destructive lessions near joints with little Destructive lessions near joints with little periosteal reactionperiosteal reaction

ll SoftSoft--tissue swelling and osteopeniatissue swelling and osteopenia

ll Subchondral erosionsSubchondral erosions

ll Joint destruction ( late finding)Joint destruction ( late finding)

““AtypicalAtypical”” mycobacteriamycobacteria

ll Propensity to involve tendons and joints of Propensity to involve tendons and joints of the handsthe hands

ll 50% affect hands50% affect hands

ll 20% affect knees20% affect knees

ll Polyarticular disease much lessPolyarticular disease much less

““AtypicalAtypical”” mycobacteriamycobacteria

ll Mycobacterium aviumMycobacterium avium--intracellulare (MAI)intracellulare (MAI)ll sytemic mycobacterial infection in 25% of sytemic mycobacterial infection in 25% of

AIDS patientsAIDS patients

ll Tenosynovitis,bursitis, and osteomyelitis Tenosynovitis,bursitis, and osteomyelitis

ll Mycobacterium kansasiiMycobacterium kansasiill Tenosynovitis,bursitis, and osteomyelitisTenosynovitis,bursitis, and osteomyelitis

ll Mycobacterium marinumMycobacterium marinumll Tenosynovitisof hands and wrists (typical )Tenosynovitisof hands and wrists (typical )

ll bursitis, and osteomyelitisbursitis, and osteomyelitis

AtypicalAtypical”” mycobacteria: predisposing mycobacteria: predisposing conditionsconditions

ll Prior surgery or traumaPrior surgery or trauma

ll IntraIntra-- articular steroid injectionarticular steroid injection

ll Open wounds in the hands or fingersOpen wounds in the hands or fingers

ll immunosuppressionimmunosuppression

Treatment of Osteoarticular TBTreatment of Osteoarticular TB

ll Derived from therapy of pulmonary Derived from therapy of pulmonary diseasedisease

ll Most therapy as in pulmonary diseaseMost therapy as in pulmonary disease

ll Some authors recommend long term Some authors recommend long term therapy (1therapy (1--2 years)2 years)

ll Surgery to debried abscess in extensive Surgery to debried abscess in extensive bone involvement to hasten recoverybone involvement to hasten recovery

ll Regimens commonly involve RHZERegimens commonly involve RHZE

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WHO/CDS/TB/2003.313 TREATMENT OF TUBERCULOSIS: GUIDELINES FOR NATIONAL PROGRAMMES, THIRD EDITION, REVISION APPROVED BY STAG, JUNE 2004

RESERVE ANTITUBERCULOSIS DRUGS

AMINOGLYCOSIDES

1. Kanamycin and amikacin

2. Capreomycin (polypeptide)

THIOAMIDES

1. Ethionamide

2. Protionamide

FLUROQUINOLONES

1. Ofloxacin

2. Ciprofloxacin

CYCLOSERINE (AND TERIZIDONE)

P-AMINOSALICYCLIC (PAS)

EXTENSIVELY DRUGEXTENSIVELY DRUG--RESISTANT TB RESISTANT TB (XTR(XTR--TB)TB)

ll Resistant to isoniazid and Rifampin, any fluroquinolone Resistant to isoniazid and Rifampin, any fluroquinolone and at least one of the 3 injectable 2nd line drugs:and at least one of the 3 injectable 2nd line drugs:

ll AmikacinAmikacin

ll Kenamicyn Kenamicyn

ll CapreomycinCapreomycin

XTR TB + HIV = XTR TB + HIV = LETALLETAL

CDC ATLANTA Ga. March 2006CDC ATLANTA Ga. March 2006

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AFLAR: African League of AFLAR: African League of Associations for RheumatologyAssociations for Rheumatology

ll 44thth regional regional Rheumatology Rheumatology symposium and symposium and workshops :workshops :

ll October 11October 11--15, 2010 15, 2010 Nairobi, Kenya.Nairobi, Kenya.

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