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Orthopedic Reviews 2009; volume 1:e24

Tuberculosis of the knee gin was referred by her general practitioner to

the orthopedic clinic with a painful right knee. Correspondence: Surjit Lidder, Department of
Her symptoms had gradually worsened over a Trauma and Orthopaedics, The Royal London
Surjit Lidder,1 Kathryn Lang,2 Hospital, Whitechapel Road, Whitechapel,
period of six months whereby now she had an
Mallick Haroon,1 Mitra Shahidi,2 London E1 1BB, UK. E-mail: surjitlidder@doc-
antalgic gait, found it difficult to climb stairs,
Magdi El-Guindi1
and had a limited range of movement of the
Department of Trauma and Ortho- knee. Courses of analgesics and physiotherapy Key words: tuberculosis, infectious arthritis,
paedics, Stoke Mandeville Hospital, had made no difference to her pain, and initial knee, arthroscopy.
Mandeville Road, Aylesbury, radiographs showed mild degenerative changes
Buckinghamshire; 2Department of in all three compartments of the right knee with Conflict of interests: the authors report no con-
Medicine, Wycombe Hospital, Queen gross preservation of the joint space. There was flicts of interest.
Alexandra Road, High Wycombe, no recent history of trauma, of respiratory,
Acknowledgments: the authors would like to
Buckinghamshire, England, UK infective, or joint disease, or of recent travel,
thank the patient for her kind permission to
and she immigrated to Britain from Vietnam report this case.
thirty years previously.
Examination of the right knee revealed a Received for publication: 23 September 2009.
Abstract swollen warm knee, a fixed flexion deformity of Revision received: 15 October 2009.
20°, flexion to 70°, and the knee was held in val- Accepted for publication: 15 October 2009.
gus of approximately 12°. Examination of the
Extrapulmonary manifestations of tubercu- This work is licensed under a Creative Commons
right hip, right ankle, and left knee were normal.
losis are reported in less than one in five Attribution 3.0 License (by-nc 3.0).
A chest radiograph was interpreted as normal,
cases with the knee affected in 8% after the
and right knee radiographs (Figures 1 and 2) ©Copyright S. Lidder et al., 2009
spine and hip. We report a case of isolated
demonstrated rapid progression of an erosive Licensee PAGEPress, Italy
highly erosive tuberculosis of the knee pre-
area over the lateral tibial plateau. A diagnosis Orthopedic Reviews 2009; 1:e24
senting in a previously fit Vietnamese
of erosive arthropathy was made and a slow-act- doi:10.4081/or.2009.e24
woman. The difficulties of diagnosis, modali-
ing infection was considered. Automated blood
ties of chemotherapeutic management, and
counts demonstrated a microcytic anaemia of
surgical treatment are discussed.
8.3 g/dL, total white cell count of 11.0x109/L, an
erythrocyte sedimentation rate prolonged to 89
mm/hr (normal 1-10 mm/hr), and a C-reactive
Introduction protein of 39 mg/L (normal 0-5 mg/L). Magnetic Discussion
resonance imaging (Figure 3) of the right knee
Tuberculosis (TB), once the romantic dis- showed a 1 cm depression of the lateral tibial TB is an ancient disease. Mummified
ease of poets and paupers, currently is undergo- plateau with associated bone edema on T2- remains of ancient Egyptians show evidence
ing a resurgence in the United Kingdom. In weighted sections. The appearances were sug- of tubercular disease, and the earliest docu-
2008, 8769 cases were diagnosed, representing gestive of an insufficiency collapse. There were mented case of tuberculosis spondylitis was
a 2.2% rise on the previous year’s figures and an multiple erosions at the inner aspect of the lat- written in Sanskrit dating back to 1500 BC.3
incidence of 14.2 cases per 100,000 population.1 eral femoral condyle and advanced loss of carti- TB proved the scourge of humankind in the
Reasons for the re-emergence of TB as a signif- lage with erosions in the patellar cartilage. In years preceding antitubercular drugs and the
icant illness in the UK include increased and addition, moderate joint effusion and a tear of mortality from tubercular disease reached
more widespread immigration, ease of exotic the posterior horn of the lateral meniscus were 60%. It is estimated that there are nine mil-
foreign travel for the native population, and seen. lion people worldwide infected with the active
increasing prevalence of immunosuppressed At further follow-up, an arthroscopic washout form of TB and it is the direct cause of around
HIV/AIDS patients. Extrapulmonary infection and biopsy were performed under general anes- two million deaths per year.4
with Mycobacterium tuberculosis has muscu- thesia. The degree of erosive change in the right Mycobacterium tuberculosis is a nonmotile,
loskeletal involvement in up to 19% of cases.2 knee was grade II for the patella, grade III for the strictly aerobic organism consisting of pleo-
We report a case of TB of a native knee medial femoral condyle and tibial plateau, and morphic rods lacking an outer cell membrane.
joint in a well Vietnamese lady who reported grade IV for the lateral tibial plateau. Specimens It is a slow-growing organism and humans
an indolent course of low-grade knee pain for were sent for microscopy, culture, and sensitivi- are its only reservoir in nature. The particular
six months prior to presentation. Although ties, and acid-fast bacilli specimens were virulence of the organism is, in part, a result
the knee is affected in approximately 8% of requested. After twelve days, synovial fluid cul- of its ability to enter cells, to grow intracellu-
cases,2 to our knowledge this is the first such tures were confirmed to have grown larly, and to interfere with the effects of toxic
case in the English literature of TB of the Mycobacterium tuberculosis. The organism was oxygen intermediates. Transmission is via
native knee with no other systemic signs or sensitive to all standard antituberculous med- droplet spread.5
symptoms. Although it is unlikely that this ication. The patient was referred to a specialist Pulmonary tuberculosis accounts for
represents a primary TB of the knee, it does in the management of TB. At further review fol- around 52%1 of tubercular infection but mus-
suggest in certain patients that we should lowing completion of a six-month course of TB culoskeletal involvement is seen in up to 19%
consider TB reactivation as a possible cause chemotherapy, symptoms had progressively of cases.2 It is more common in children than
of joint symptoms. deteriorated although the patient was concor- in adults, probably owing to the greater
dant with therapy. She was walking with the aid amount of bone marrow present in immature
of one walking stick and knee flexion was 20°- bone. In adults, TB shows a preponderence to
Case Report 50°. Radiographs showed progressive erosive the spine (40%), then the hip (25%), and
joint destruction. Currently the patient is under finally the knee (8%).6,7 While extrapulmonary
A slim 75-year-old woman of Vietnamese ori- consideration for total knee arthroplasty. manifestations of TB are common, account-

[page 64] [Orthopedic Reviews 2009; 1:e24]

Case Report

improve symptoms and quality of life in

patients affected by joint infection. Treatment
for TB in the first instance revolves around
four reserved drugs: isoniazid, rifampicin,
pyrazinimide, and ethambutol. Second-line
treatments also are available to combat the
increasingly common variant of multi-drug
resistant TB (MDR-TB). Unlike for pulmonary
TB, the treatment for bone and joint disease
is a lengthier process, often requiring twelve
to eighteen months of chemotherapy. 15
Surgical management options include
Figure 2. Lateral radiograph of the right debridement, synovectomy, arthrodesis, and
knee with tricompartmental degenerative amputation, and success has been shown
joint destruction. with primary joint arthoplasty.16
This case highlights the uncommon but
increasingly recognized presentation of
tuberculous arthritis of a joint. What may ini-
tially present as an uncomplicated arthritis,
at a time when TB is increasing in prevalence
must be considered as potential evidence of
tuberculous arthritis, more in patients with a
gradually worsening monoarticular arthritis
and where risk factors for TB are present.
Respiratory symptoms may be evident in only
half of patients with skeletal involvement, and
Figure 1. Anteroposterior radiograph of a multidisciplinary approach is required to
the right knee with tricompartmental offer patients an optimal outcome. It remains
degenerative joint destruction. a controversial topic whether one can ever
truly describe a case of primary tuberculosis
of a joint; however, there remain isolated
cases, such as that presented here, which
ing for around 15-20% of cases in immuno- Figure 3. Coronal T2-weighted magnetic seem to manifest only as extrapulmonary TB.
competent patients,8 the first presentation of resonance image of the right knee showing These patients most likely represent a subset
the disease as a joint infection is rare. articular surface destruction (arrow) of the in whom TB is reactivated in some way many
Primary bone infection with TB is less likely lateral tibial plateau and associated bone years after the primary infection and in whom
edema. the extrapulmonary symptoms predominate.
than hematogenous spread from a primary
focus elsewhere. However, our patient It is these patients who often prove to be the
showed no systemic symptoms of TB and a most challenging to diagnose and treat.
chest radiograph at the time of diagnosis was mon presenting symptoms in their series as
unremarkable. Pulmonary TB has been found gradual onset, pain, stiffness, limp, swelling,
to be present in only around half of those and local heat. Radiographs demonstrate
found to have bone and joint disease.9 The ris- changes only after three to four weeks of
ing rate of TB is explained partly by the infection, and initially soft tissue swelling
increase in HIV-infected patients. Other vul- may be the predominant feature. Later, a clas- 1. Health Protection Agency: Infectious
nerable persons include those living in group sic triad of radiological findings, known as Diseases. (access-
residences (nursing homes, schools, pris- the Phemister triad11 are seen, which include ed 04/07/09).
ons), the malnourished, intravenous drug juxta-articular osteopenia, joint space nar- 2. Carrol ED, Clarke JE, Cant AJ. Non-pul-
abusers, alcoholics, and immunosuppressed rowing, and erosions. Laboratory investiga- monary tuberculosis. Paediatr Respir Rev
people. tions may yield the classical, although non- 2001;2:113-9.
Diagnosis of tubercular infection of bone specific findings of raised ESR, a leukocyto- 3. Watts HG, Lifeso RM. Tuberculosis of
and joints depends largely on suspicion of the sis, and high C-reactive protein.12 Histological bones and joints. J Bone Joint Surg (Am)
diagnosis, and in an age where prevalence of patterns in tissue specimens will show a cen- 1996;78:288-98.
the disease is rising, all clinicians should be tral necrotic area surrounded by histiocytes 4. World Health Organisation: TB factsheet.
aware of the potential of the infection. Joint and occasional giant cells with nuclei posi- (accessed 04/07/09).
TB may be suspected in a chronic case of joint tioned at the margin of the cell.13 Although it 5. Todar’s Online Textbook of Bacteriology.
pain, usually monoarticular. Although pul- is suggested that the organism is difficult to
monary TB may be absent, patients may culture, a 1984 study by Mondal showed an (accessed 09/07/09).
demonstrate systemic symptoms of fatigue, 89% sensitivity of aspirate cultures for identi- 6. Mittal R, Trikha V, Rastogi S. Tuberculosis
lethargy, and weight loss. Pyrexia of unknown fying the organism in known infections.14 of patella. The Knee. 2006;13:54-6.
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1937 Hederson and Frinton10 of the Mayo confirmed must involve antituberculous che- ment for New World disease. Clin
Clinic reported on a large series of patients motherapy, but surgery may be indicated to Imaging 2009;33:136.
treated for knee TB. They described the com- 8. Sharma SK, Mohan A. Extrapulmonary

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Case Report

tuberculosis. Indian J Med Res 2004;120: culous arthritides and its bearing on bral tuberculosis with fine needle. J Bone
316-53. treatment. Ann Surg 1924;4:481-500. Joint Surgery (Am) 1994;76:181-4.
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h t t p : / / w w w. w h e e l e s s o n l i n e . c o m / culosis of the knee joint. SA J Radiology tuberculosis: A forgotten entity? West
(accessed 20/07/09). 2006;10:28. Indian Med J 2005;54:202-6.
10. Henderson MS, Fortin HJ. Tuberculosis of 13. Adler CP. Bone diseases: macroscopic, 16. Leclere LE, Sechriest VF, Holley KG, et al.
the knee joint in the adult. J Bone Joint histological and radiological diagnosis of Tuberculous arthritis of the knee treated
Surgery (Am) 1927;9:700-13. structural changes in the skeleton. with two-stage total knee arthroplasty. A
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