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Abstract

Case Report

IntroductIon

Tuberculosis (TB) of thewrist accounts for only 1%–3%ofallTBcases.It ischaracterizedbyosteomyelitis in thecarpal bones,metacarpals, and phalanges.[1] Tubercular osteomyelitis can also occur in the mandible.[2] Theories of pathogenesis include direct inoculation and hematogenous dissemination from a primary focus.[3] It presents as synovitis that can progress and mimic other forms of arthritis. Isolated lytic bone lesions in the ulnar have also been reported.[4] Diagnosisrequiresacombinationofclinical, radiological,andhistopathologicalfindings.Aprolongedcourseofanti‑TBtreatmentisneeded.Whenthereisdestructionofthebones,surgical debridement is performed to further eradicate the infection.We report a patientwith a rare presentation oftuberculous osteomyelitis of the carpal bone. The diagnosis wasmadefromhistopathologicalandradiologicalfindings,despite failure to demonstrate the culture of Mycobacterium tuberclosis (MTB)andXpertMTP/Rifampicin(RIF)assayfromtheselesions.Thepatientmadefullrecoveryfollowingsurgerywith9monthsofantituberculoustreatment.

case rePort

A50‑year‑oldmalewithnoknownmedicalillnesspresentedwith a 1‑monthhistoryof leftwrist pain and swelling.Hedenied any history of preceding fall or trauma and had no historyofTBcontactnorhigh‑riskbehavior.Heworkedinapig abattoir. He had no constitutional symptoms.

On initial examination, the leftwristwas swollenwith areducedrangeofmovement.Otherjointswerenormal.LeftwristX‑ray[Figure 1a]revealedintactcarpalbones.Amagneticresonance imaging (MRI) of the leftwrist performedwassuggestive of erosive arthropathy [Figure 1b and c]. Serum uric acid levelwas 412μmol/L.Basedon the presence ofoligoarthropathy onMRI and elevated uric acid, hewas

Tuberculosis(TB)isthemostprevalentinfectiousdiseaseinSoutheastAsia.Itcausesbothpulmonaryandextrapulmonarydiseases.TBofthewristisrareandpresentsasosteomyelitisortenosynovitis.Wereportamiddle‑agedmalewithcarpalbonetuberculousosteomyelitis.Hepresentedwithleftwristpaininitiallytreatedasgoutyarthritis.Within2weeks,hedevelopedseropurulentdischargewithosteomyeliticchangesonimaging.Heunderwentdebridement,andintraoperatively,therewasdestructionofmostcarpalbones.Histopathologicalexaminationrevealedchronicgranulomatousinflammationwithabscessformation.Anti‑TBmedicationwasinitiated,andhemadeacompleterecoverywithalmostfullrangeofwristmovementafter9monthsoftreatment.ThiscaseservesasareminderthatTBisagreatmimicker,andahighindexofsuspicionisrequiredtomakeadiagnosisofTBofthewrist.Earlyinitiationofanti‑TBispivotaltopreventcomplicationsanddeteriorationofjointfunctions.

Keywords:Carpalbonetuberculosis,extrapulmonary,osteomyelitis

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DOI: 10.4103/ijmy.ijmy_97_20

Address for correspondence: Dr. Andrea Ban Yu‑Lin, Respiratory Unit, Department of Medicine, Faculty of Medicine,

Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000, Kuala Lumpur, Malaysia.

E‑mail: [email protected]

ORCID: 0000‑0003‑3788‑4789

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How to cite this article: HamidMF, Rajandiran SR,Yu‑LinAB,Sapuan J.A rare presentation of isolated carpal bone tuberculousosteomyelitismimickinggoutyarthritis.IntJMycobacteriol2020;9:325‑8.

A Rare Presentation of Isolated Carpal Bone Tuberculous Osteomyelitis Mimicking Gouty Arthritis

Mohamed Faisal Abdul Hamid1, Suvindran Raj Rajandiran1, Andrea Ban Yu‑Lin1, Jamari Sapuan2

1Respiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, 2Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Submitted: 21‑May‑2020 Revised: 01‑Jul‑2020 Accepted: 02‑Jul‑2020 Published:28‑Aug‑2020

[Downloaded free from http://www.ijmyco.org on Thursday, September 24, 2020, IP: 62.193.78.199]

Hamid, et al.: Carpal bone tuberculous osteomyelitis

International Journal of Mycobacteriology ¦ Volume 9 ¦ Issue 3 ¦ July‑September 2020326

hand physiotherapy, hemade a complete recovery after 9monthsof treatment.Thewoundcompletelyhealedandhecouldcarryabout20kgofweightwithhislefthand.Hehadalmost full rangeofmovementof the leftwrist [Figure 4]. Comparedwith previouswrist X‑ray [Figure 5a], latestimaging [Figure 5b and c] revealed a stable height of the distal rowofthecarpalbones.

dIscussIon

TBofthewristcommonlypresentsastenosynovitisandisaslowlyprogressivedisease.Thediagnosisisusuallydelayeddue to its insidious and indolent symptoms. The common presentationislocalswellingandpainonmovementofthe

diagnosed and treated as gouty arthritis.Therewas initialreductionofwristpainwithtabletcolchicine,however5weekslater,hedevelopedseropurulentdischarge from thepalmaraspect of the leftwrist [Figure 2a].X‑rayof the leftwristshowed a new disruption of carpal bones’ alignmentwith proximalmetacarpal bony resorption suggestive ofosteomyelitis[Figure2b]comparedtotheearlierMRIwhichshowedintactcarpalbones.

Other investigations revealed a raisedwhite cell count:13.1×109/Lwithlymphocytecount:2.9×109/L,hemoglobin:15.9g/dL,andplatelets:349×109/L.Renalandliverprofileswerenormal.ChestradiographwasnormalandtheMantouxtestreadingwas10mm.

He underwent surgery, and intraoperatively, there wasunhealthy soft‑tissue of the synovium and dorsal interossei muscle.Wound debridement, synovectomy, carpectomyof most carpal bones, and arthrotomy washout weredone [Figure 3aandb].XpertMTB/RIFassay and acid‑fast bacilliwerenegative.Histopathologicalexamination(HPE)of tissue and bone biopsies revealed multinucleated and Langhanstypegiantcellwithfocalareaofnecrosis.Therewasgranulomatousinflammationandmicroabscesses[Figure3c].TheHPEwashighlysuggestiveofTBdifferentiatingitfromother granulomatous/rheumatological diseases.Wemade adiagnosis of tuberculous osteomyelitis of the carpal bone. The patientwasstartedonanti‑TBtreatment,andwithintensive

Figure 3: Intraoperative findings revealed unhealthy soft tissue of the synovium and dorsal interossei muscle (a). Carpectomy performed (b) Histopathological examination revealed multinucleated giant cells (black arrow) and granuloma (blue arrow)(c)

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Figure 1: Left wrist X‑ray (a) revealed intact carpal bones. Magnetic resonance imaging (b) and (c) showed soft‑tissue swelling with erosive arthropathy changes of the left wrist. There was presence of bony resorption at proximal metacarpals and subchondral cysts in the remaining carpal bones and distal radius

a b c

Figure 2: Seropurulent discharge (a) from the palmar aspect of the left wrist. X‑ray of the left hand (b) showed disruption of carpal bones’ alignment (mainly proximal row) with the collapse of the distal row and bony resorption at the proximal metacarpal suggestive of osteomyelitis

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Figure 4: Functional outcome 9 months post treatment. Well‑healed wound with full finger grip.(a) Improvement in wrist flexion and extension (b‑e)

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International Journal of Mycobacteriology ¦ Volume 9 ¦ Issue 3 ¦ July‑September 2020 327

wrist.Duetothenonspecificsymptoms,thetreatmentisoftendelayed as it can mimic other more common rheumatological ororthopedicconditionssuchasgoutyarthritis,septicarthritis,rheumatoidarthritis,anddeQuervain’stenosynovitis.[5,6]

Our patient’s diagnosiswas challenging.The initialMRIshowed nonspecific changes of erosive arthropathywhichcouldalsobeseeninrheumatoidandgoutyarthritis.However,after 2weeks, his condition progressedwith radiologicalchangesofcarpalbonedestructionseenontheX‑raywhicheventuallyledtothediagnosisofTBofthewrist.Beinginthemeathandlingindustry,hewasalsoatriskofcontractingcutaneous diseases due to a variety of bacterial diseases such as to Staphylococcus aureus,Streptococcus pyogenes,Escherichia coli,Clostridium perfringens, Erysipelothrix rhusiopathiae, and cutaneous atypical Mycobacterium.[7,8] These bacterial organismswere excluded in our patient astissueandbonecultureswerenegative.

Inanearly stage, radiological signsare less specific.As thediseaseprogresses,therewouldbearticulardestruction,multiplegeodes(subchondralcysts),narrowedarticularjointspaces,andnibbled and deformed bones.[9]Ourpatient’sX‑rayshowedthesefindings.Rheumatoidarthritishassimilarradiologicalfindings,butitisusuallypolyarticular,andourpatientdidnotfulfilltheAmericanCollegeofRheumatology/EuropeanLeagueAgainstRheumatism 2010 criteria for rheumatoid arthritis.

The positive rates in detectingMTB in the joint throughTB polymerase chain reaction (PCR), Ziehl–Neelsenacid‑fast staining, andTBculture are 82.65%, 6.12%, and17.34%, respectively. Demonstrating a positive cultureacid‑fast Mycobacterium isdifficult asosteoarticularTB ispaucibacillary.[10]Therefore,aHPEis required tomake thediagnosisofosteoarticularTB.Theexpectedfindingsaregiantcellsforminggranulomatousinflammation,caseousnecrosis,orthepresenceofLanghanscells,asinthecasepresentedhere.

Late diagnosis leads to poor functional outcome despite initiatinganti‑TBtreatment.ThetreatmentforTBofthewristisessentiallyanti‑TBtherapywithsurgicalproceduresreservedfor certain situations or complications such as excision of the diseasedwrist synovium, abscess formation, carpal tunnelsyndromeneedingdecompressionofjoint,orpoorresponsetoanti‑TB.[11]

The classical long‑term 1‑year of anti‑TB treatment hasbeenreplacedwithaprogressivelyshortertreatmentof6–9months.TheAmericanThoracic Society and InfectiousDiseases Society ofAmerica joint guideline recommends6–9‑month regimens of anti‑TB containing rifampicin forthetreatmentofboneandjointTB.[12] Our patient received 9monthsoffixed‑dosecombinationanti‑TBtreatmentandrecoveredwell.

concLusIon

This case report highlights the need for a high index of suspicion for thediagnosisofTBof thewrist and that thediagnosis should be supported by histopathological and radiologicalexaminations.Earlyinitiationofanti‑TBtreatmentand surgical debridement and complete excision of the infected synovium may be required to prevent complications and deteriorationofjointfunctions.

Declaration of patient consentThe authors certify that they have obtained all appropriate patientconsent forms. In the form, thepatienthasgivenhis consent for his images and other clinical information tobereportedinthejournal.Thepatientunderstandsthatname and initialswill not be published and due effortswillbemadetoconcealidentity,butanonymitycannotbeguaranteed.

AcknowledgmentTheauthorswould like to thank thedeanof theFacultyofMedicine,UniversitiKebangsaanMalaysia,Prof.Dr.RajaAffendiRajaAliforallowingustopublishthiscase.

Financial support and sponsorshipNil.

Conflicts of interestTherearenoconflictsofinterest.

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Figure 5: Comparison of wrist X‑ray before surgery (a) and after completion of antituberculous treatment (b and c) which showed that the distal row of the carpal bone maintained its height

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