- Tuberculosis of bones and joints - symptoms
- Four periods of osteoarticular tuberculosis
- Tuberculosis of bones and joints - differentiation
- Tuberculosis of bones and joints - diagnosis
- Tuberculosis of bones and joints - treatment
Tuberculosis of bones and joints occurs when tuberculosis mycobacteria from their original location are spread. Initial symptoms tend to be non-specific, which makes diagnosis difficult. Which bones and joints are most often affected by the disease? How is bone tuberculosis treated?
Bone and joint tuberculosisusually develops as a seed of primary tuberculosis localized in the lungs, lymph nodes, and the gastrointestinal tract, or as a relapse or re-infection in immunocompromised patients.
Interestingly, about 5% of tuberculosis patients have disease outbreaks in the locomotor system. The most common locations are vertebral bodies and joints with a large amount of synovium.
In addition, disease outbreaks can be present in the hip joint, sacroiliac joint, pubic symphysis, greater trochanter of the femur, knee joint, ankle joint, foot, shoulder joint, elbow joint, wrist, and also in shafts of small and long bones as well as flat and variously shaped bones.
Tuberculosis is an infectious disease caused by mycobacteriaMycobacterium tuberculosisorMycobacterium bovis , which still causes significant mortality worldwide. Sub-Saharan Africa has the highest proportion of infections and deaths, while Southeast Asia has the highest proportion of new cases.
After exposure to Mycobacterium tuberculosis, the infection may be eliminated, develop into a primary infection, or may reactivate in the future.
Tuberculosis of bones and joints - symptoms
Bone and joint tuberculosis usually develops as a seed of primary tuberculosis localized in the lungs, lymph nodes, and the gastrointestinal tract, or as a relapse or reinfection in immunocompromised patients.
The infection usually occurs through the bloodstream or through the pathological process of abscesses, from the kidneys, or through the lymphatic vessels. Most often, tuberculosis is found in the spine, hip and knee joints.
In the bones it takes the form of a focal infection (the so-calledosteitis tuberculosa ) or osteomyelitis ( osteomyelitis tuberculosa ), and in the joints, synovitis (the so-calledsynovitis tuberculosa ), which can become inflammatory in bothbony articular ends when it passes into the lumen of the joint.
Patients may report symptoms such as
to their doctor- general malaise
- weight loss
- loss of appetite
- sometimes cough
Interestingly, gradually developing pain may be initially misdiagnosed as joint degeneration or aseptic arthritis.
Tuberculosis of the spine usually occurs in the thoracic-lumbar region and begins in the anterior corner of the vertebral body. The gradual development of the disease contributes to the fact that at the time of diagnosis there may already be a paravertebral abscess.
Moreover, the increasing destruction of the anterior part of the vertebral body leads to an abnormal curve of the spine and the formation of a hump.
Four periods of osteoarticular tuberculosis
Based on clinical symptoms and pathological changes, four periods of osteoarticular tuberculosis are distinguished. These include the period of initial changes, destruction, renewal and the period of deformation.
The first period of the disease isthe period of initial changesusually lasting from 2 to 6 months, during which outbreaks develop. Patients' symptoms are periodic local pain and swelling when the limb joints are involved.
In the second stage of the disease ( destruction period ), foci spread and abscess formation occurs. It lasts from 6 months to 1 year (or even longer). The general condition of patients worsens, they feel weak, motor functions may be impaired, and sometimes neurological symptoms are present.
Blood laboratory tests may show increased ESR, as well as decreased plasma protein levels.
The third period of the disease is therecovery periodwhich lasts from 6 to 12 months. It heals disease foci, reduces the symptoms of local inflammation and thus improves the general condition of patients.
The last period of osteoarticular tuberculosis wasdeformation period . It is characterized by the disappearance of clinical symptoms of the disease with a constant progression of structural deformities. It is worth remembering that the lack of symptoms of inflammation in a patient does not mean that the outbreak heals - there is still a possibility of the disease process returning.
Tuberculosis of bones and joints - differentiation
Tuberculosis of the osteoarticular system is differentiated from other nonspecific osteoarthritis, aseptic necrosis, post-traumatic lesions, neoplasms, rheumatoid arthritis lesions, and vascular disorders.
Tuberculosis of bones and joints - diagnosis
Recognitionosteoarticular tuberculosis is based on X-rays of the affected areas or other sites suspected of being the primary focus (e.g. x-ray of the lungs).
The photo may show, for example, various degrees of joint damage or periarticular osteopenia (reduction of the density of periarticular bone tissue).
The so-called new generation IGRA (Interferon Gamma Release Assay) tests.
They are based on the measurement of gamma interferon, which is secreted by T cells stimulated in vitro with specific antigens for Mycobacterium tuberculosis.
There are also Real Time PCR genetic tests that check the collected material (e.g. synovium of joints, bone scrapings) for the presence of mycobacterial DNA and the gene for resistance to rifampicin (one of the basic drugs used in the treatment of tuberculosis).
Mycobacterial culture can also be carried out from material collected from the patient (e.g. synovial fluid, bone scrapings), but it takes about 6 weeks.
Tuberculosis of bones and joints - treatment
In the treatment of tuberculosis of the osteoarticular system, the so-called multi-drug therapy - it uses oral antibiotics with chemotherapeutic agents.
The main drugs include rifampicin, pyrazinamide and hydrazide, supplements with streptomycin and ethambutol, and additional drugs include ethionamide, cycloserine, para-aminosalicylic acid, viomycin and kanamycin.
Usually 4 to 5 of these medications are taken over a period of 6 to 18 months. It is worth mentioning here that the therapy may turn out to be ineffective as resistance to the medications is increasing.
Surgical treatment complements pharmacotherapy and is usually used to cleanse the disease focus in the bone and perform synovectomy of the joint with its subsequent immobilization and relief.
Spine abscesses sometimes require drainage and stabilization of the spine with implants. It also happens that it is necessary to perform arthroplasty of diseased joints.