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TUBERCULOUS
ARTHRITIS
PGI CALLEJAS, JEANETTE
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CC: Mass, Left Knee
EE57/M/M
Brgy. Don Esteban, Lapuz, Iloilo City
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History of Present Illness:
2 years ptc:
(+) pain on the left knee, on and off
(+) mass, lateral aspect of L knee non
tender, non erythematous,non movable, doughy in char.
(+) swelling left knee
(+) difficulty walkingtook pain relievers which provided temp.
relief
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(+) on and off non productive cough
(-) fever
(-) night sweats
(-) anorexia
(-) vomiting
(-) previous injury to the knee
No consult done
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11 months ptc (December 15, 2009)
sought consult in the Surgery OPD of this
institution because of the persistent pain,
swelling and progression in size of the mass
on his left knee. A: Mass, Lateral aspect of L knee
P: Lagaflex 1 tab TID
S.Uric Acid, Creatinine
L knee APL
Refer to Ortho Dept.
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(December 16, 2009)
the patient underwent fine needle biopsy
performed by ortho resident which showed negative
result. He was then referred to IM Dept.
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(December 21, 2009)
Chest PA was requested by Ortho Dept. whichshowed suspicious densities in the R upper lungand haziness in the R paracardiac area. PPD wasdone which showed reactive results with an
induration of 23mm at 48 h.A: T/C TB arthritis
10 months ptc: (January 2010)
Anti-Kochs medications was started by IM Dept,despite negative results of sputum.
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PAST MEDICAL HISTORY
(-) previous hospitalization
(-) BA
(-) FDA
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FAMILY HISTORY
(+) HPN mother
(-) CA
(-) DM
(-) TB
(-) joint diseases
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PERSONAL HISTORY:
Non smoker
(+) alcoholic beverage drinker started atthe age of 20, drinks almost everyday 2
beers/day, stopped december last year. Seafarer but stopped working 7 years ago
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Physical Examination
PPE findings: Minimal swelling in the
left knee, nonerythematous, nontender
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L Knee APLThere are marginal
erosions, lytic and
blastic changes in the
condyles of the Lfemur and tibia as
well as the apex of
the L fibula with
surrounding softtissue swelling.
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Multiple ovoid cystic
lucencies are seen in
the medial aspect of
the condyles of the L
femur and tibia.
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There is an irregularity in
the inf. portion of the L
patella with narrowing ofthe femur patellar aspect
joint space
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There are no fracture lines noted
The rest of the findings and osseousstructures are unremarkable.
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CHRONIC PYOGENIC ARTHRITIS
RHEUMATOID ARTHRITIS
TUBERCULOUS ARTHRITIS
DIFFERENTIAL DIAGNOSIS:
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PYOGENIC ARTHRITIS
(+) history of antecedent infection
Source of infection may be hematogenous from otherinfections of the skin, respiratory tract or urinary system, adirect extension from a focus of adjacent osteomyelitis or aconsequence of a bacterial contamination
(+) positive synovial fluid cultures of S. aureus, Streptococcus,
S. Epidermidis
Progression usually is measured in hours and days.
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Pathologic Features Usually involves portions of the articular cartilage that
are weight bearing or in close apposition.
Purulent organisms excrete proteolytic enzymes thatdestroy articular cartilage resulting in a decrease in thewidth of the joint space (joint narrowing).
As the cartilage is destroyed, granulation tissue from the
subchondral bone attempts to bridge the joint and iseventually replaced by bone, resulting in bony ankylosis.
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Radiographic Features First sign is soft-swelling
Joint space narrowing may occur early and aid indifferentiating it from tuberculous arthritis
The first changes are small erosions in the articular
cortex, with severe infections the entire outline is
lost.
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RHEUMATOID ARTHRITIS
Usually polyarticular
Disease begins in the peripheral joints, usuallyproximal IP and MCP joints of the hand and carpal
joints of the wrist.
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Radiologic Features
Earliest radiologic evidence of the disease is periarticularsoft tissue swelling characteristically symmetrical andfusiform.
Joint distention can also be identified in the knee, ankleand wrist.
Narrowing of the joint space results from degenerationof the articular cartilage as pannus spreads across thejoint spaces.
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The joint space is characteristically symmetrically
narrowed.
Bony erosions occur as a result of development of
granulation tissue (pannus)
Marginal erosions and joint destruction are more
common in the smaller peripheral than in the
proximal major joints.
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TUBERCULOUS ARTHRITIS
Monoarticular
Symptoms may be present for months or years with aninsidious clinical onset.
A doughy swelling of the joint, a limp, muscular atrophy or adraining sinus may be the first indications.
Pain and tenderness are late symptoms.
Slight or no temp elevation is the rule.
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Tuberculous Arthritis
There are four clinical stages: 1. invasion
2. tissue destruction
3. quiescence
4. healing
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Tuberculous Arthritis
Articular cartilage is most vulnerable to tuberculosis at
the free surfaces where the opposing articular cartilagesare not in close apposition.
Because the reaction is insidious, it may take years for
enough cartilage to be destroyed to cause jointnarrowing.
Exudate contains no proteolytic enzymes so that debris
may persist throughout the course.
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Tuberculous Arthritis
Initial feature is extensive osteopenia adjacent to thejoint.
Disuse
Hyperemia
Bacterial toxins Eventually, destruction of articular cartilage is
manifested by narrowing of the joint and erosion of
bone.
Earliest evidence of bone destruction is the appearanceof erosion at the margins of the joints
Radiologic Features
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Tuberculous Arthritis
Marginal erosions gradually extend across the joint
surface, with further progression, gross disorganizationof the joint may occur
The articular cartilage disappears, ragged destruction at
the articular ends of the bone occurs and separation ofdead fragments (sequestra) is noted.
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TUBERCULOUS ARTHRITIS
IMPRESSION:
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