Faktor Tuberculosis remains a major problem despite advances and antituberculous

therapy. Musculoskeletal tuberculosis is difficult to diagnose and can go unnoticed

for a long time because sign and symptoms are very nonspecific and can include
insidious onset of pain, swelling, weight loss, night sweats and difficulty in walking.
During initial stage of disease laboratory tests like raised erythrocyte sedimentation
rate, complete blood count are inconclusive and moreover radiologic appearance
depend upon stage of disease on presentation. Primary diaphyseal TB of tibia
without articular involvement is extremely rare and only few cases have been
reported9. Jacob9 in a series of 30 cases of atypical TB in immigrants reported only 2
cases involving tubular bones. Carino(5) in his series of 15 cases reported 80%
cases involving primarily the long bones(femur=7, tibia=3, humerus=2). Another
case of diaphyseal TB of tibia was reported in 1983 by Richter 7 in a study of 27
years. Chattopadhyay10 reported one male patient with primary diaphyseal TB of
tibia. In our patient there was no previous history of pulmonary tuberculosis while in
the literature one third of patients with

Any part of the skeleton may be involved but the sites most
commonly affected are spine, femur, tibia, humerus and
fibula. Incidence of lesion in proximal ulna is relatively rare
in literature review. As compared with pyogenic
osteomyelitis, tuberculosis of the bones in infants and
children tends to occur in the vascularised metaphyses where
it produces an endarteritis. The factors that influence
localization of skeletal tuberculosis to a specific bone are
unidentified. As in other forms of extrapulmonary
tuberculosis, the respiratory tract is the primary portal of
entry of mycobacteria. Tuberculous osteomyelitis is thought
to occur secondary to lymphohematogenous dissemination
to the bone at the time of initial pulmonary infection, with
local reactivation at a later date.
Our aim was to draw attention to Tuberculous osteomyelitis
which is rare compared with skeletal tuberculosis involving
spine or joints. The low index of suspicion for diagnosis due
to its rarity and the subtle nature of the symptoms in early
lesions leads to neglection. The diagnosis is delayed until the
process is advanced and destruction has been carried out.
The repeated use of NSAIDs in such neglected cases of early
lesion creates a false sense of security, until it become
apparent that their continued use had failed to provide
complete relief. Mild pain and swelling of bone, with slight warmth and
tenderness, and overlying swelling of soft tissue should alert
clinicians to the possibility of skeletal tuberculosis.
Enlargement of regional lymph nodes and the presence of an
abscess is also of great diagnostic significance clinically.
Normal plain radiographs in cases of suspicion require more
sensitive investigations such as Montaux test, MRI and CT
scan to detect and localise the lesion. Biopsy is mandatory to
confirm the diagnosis. Antituberculous drugs remain the
mainstay of treatment and in our experience, judicious
surgical intervention (debridement and curettage) help to
promote early healing. Bone grafting can be considered in

treating larger healed bony defects after tuberculous culture

reports were negative.

(jurnal 13-10-14)
In acute presentations, surgery may be required to drain pus. In chronic
osteomyelitis, areas of dead bone may need to be resected. Both need to be
accompanied by specific antibiotic therapy depending on culture results. This is
most often carried out intravenously, initially. In some cases, where the disease
is too extensive to fully resect, the patient is too unfit for surgery or a device is
retained, long term oral antibiotics may be required. Organisms need to be
tested against a wide variety of antibiotic options as patients commonly are
intolerant of one or more antibiotics. In acute presentations, surgery may be
required to drain pus. In chronic osteomyelitis, areas of dead bone may need to
be resected. Both need to be accompanied by specific antibiotic therapy
depending on culture results. This is most often carried out intravenously,
initially. In some cases, where the disease is too extensive to fully resect, the
patient is too unfit for surgery or a device is retained, long term oral antibiotics
may be required. Organisms need to be tested against a wide variety of
antibiotic options as patients commonly are intolerant of one or more antibiotics.