Rare site for tubercular osteomyelitis with HIV infection

Abstract

Tuberculosis of the scapula is a rare clinical entity. Few cases have been reported in the literature so far. We report a case of tuberculosis of the scapula in a HIV positive patient, which was managed successfully with antitubercular drugs. This case illustrates the difficulties in diagnosing tubercular osteomyelitis of the scapula as it has an insidious onset, paucity of constitutional symptoms and frequent absence of associated pulmonary involvement. Pitfall in diagnosis is the delay in considering the diagnosis of bony tuberculosis, especially in patients who have normal chest radiographs.

Keywords: Amtiretroviral therapy, antitubercular treatment, osteomyelitis, scapula, tuberculosis

How to cite this article:
Bohra V, Naithani N, Sharma P. Rare site for tubercular osteomyelitis with HIV infection. Ann Trop Med Public Health 2012;5:525-7

 

How to cite this URL:
Bohra V, Naithani N, Sharma P. Rare site for tubercular osteomyelitis with HIV infection. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Nov 26];5:525-7. Available from: https://www.atmph.org/text.asp?2012/5/5/525/105153

 

Introduction

Musculoskeletal tuberculosis constitutes 2% of the total burden of TB, half of which involves the spine. The indolent nature of tuberculous bone and joint disease often leads to a delayed diagnosis. Osteomyelitis of the flat bones with scapula in particular is a very rare clinical entity. Very few cases have been reported in literature that too in isolation and most of them as incidental detection while searching for other causes of the case scenario. The problem in diagnosis is compounded by the fact that there are no pathognomonic imaging findings and since the lesions are paucibacillary the microbiological yield is also poor.

A high index of suspicion is necessary for an early diagnosis, especially in the context of pain and swelling near or over the bone in a high-risk individual. We report here a case of HIV infection with tuberculous osteomyelitis of the scapula with coexistent spinal tuberculosis.

Case Report

A 30-year-old married lady known case of HIV infection detected in 2003 during her antenatal checkup who was on antiretroviral therapy (ART) with nucleoside reverse transcriptase (NRTI) drugs Zidovudine and Lamivudine and non-nucleoside reverse transcriptase (NNRTI) Nevirapine since February 2010 (indication of initiation of ART being low CD4 count) reported to our centre in July 2010. At the start of ART, i.e., in February 2010 no opportunistic infection or coinfection were identified. In July 2010, she presented with complaints of inability to lift left arm above the shoulder for six weeks and an ill-localized pain in the left arm from the onset. Pain was usually present during movements of the involved limb; gradually it progressed to severe incapacitating pain. The pain was nonradiating and associated with thinning of left upper limb. There was no history of fever or night sweats. She complained of anorexia but no other constitutional symptoms. There was no history of tuberculosis in the past.

On examination, she was an averagely built and nourished female with a BMI: 22.1 kg/m 2 , with stable hemodynamics at presentation but had high grade, continuous fever. She had mild pallor but no icterus or peripheral lymphadenopathy. Local examination of left upper limb revealed a bogey swelling that was present in the axillary region with marked tenderness. There was no abscess, scar, or sinus. The skin in the axillary region did not show any other signs of inflammation.

Movements at the left shoulder joint showed restriction in abduction, internal and external rotation. Movements at the elbow and radioulnar joints were normal. Wasting was apparent in the affected muscle groups. No sensory loss was present. The peripheral pulses were palpable. Pulmonary and systemic examination was unremarkable. The investigations at the time of presentation are shown in [Table 1].

Table 1: Investigations at the time of presentation
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USG left axilla and left shoulder: Heterogenous hypoechoic collection measuring approximately 15 mm × 20 mm with a thickness of approximately 10 mm noted in the left subscapular region.

MRI shoulder joint was done as shown in [Figure 1]. Altered marrow signal in scapula with cortical break in the spino-glenoid notch is seen to communicate with the collection beneath supraspinatus. Small cortical break is also seen in anterior part of glenoid communicating with the collection beneath subscapularis. Findings were suggestive of osteomyelitis of scapula.

Figure 1: Altered marrow signal in scapula with cortical break in the spino-glenoid notch which is seen to communicate with the collection beneath supraspinatus. Small cortical break is also seen in anterior part of glenoid communicating with the collection beneath subscapularis

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Bone scan was done to confirm the presence of scapular osteomyelitis and it revealed hot spots in the left scapula and LV5 shown in [Figure 2].

Figure 2: Bone scan was done to confirm the presence of scapular osteomyelitis and it revealed hot spots in the left scapula and LV5

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In view of the presence of increased radioisotope uptake in the lumbar spine, the patient underwent MRI lumbosacral spine though she did not complain of any symptoms to suggest any myeloradiculopathy [Figure 3]. Hyperintensity noted in the body of L5 with preserved cortical contour and endplates suggestive of early evidence of tuberculosis.

Figure 3: Hyperintensity noted in the body of L5 with preserved cortical contour and endplates suggestive of early evidence of tuberculosis

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A USG guided FNAC was performed from the lesion which was negative for AFB, while the MTB PCR was positive for Mycobacterium tuberculosis.

The patient was diagnosed and managed as a case of Tubercular osteomyelitis and stage 01 Pott’s spine. She was started on antitubercular therapy with 04 first line drugs and antiretroviral therapy was continued. Patient tolerated ATT well and fever defervescence started in a week time with improvement of anorexia. During follow up at 01, 02, and 06 months she has shown clinical improvement in the form of resolution of constitutional symptoms, abatement of pain, tenderness, and swelling during movements of the left shoulder joint. There was no new focal neurological deficit. She has been presently on continuation phase and plan is to continue the ATT for a total duration of 12 months.

Discussion

Tuberculous osteomyelitis involving flat membranous bones is extremely rare. Tuberculosis of the scapula is even a rare clinical entity. Very few cases of tubercular osteomyelitis of scapula have been reported till date and all of these were associated with other forms of tubercular osteomyelitis. [1],[2],[3] though the incidence of reactivation TB is more in immunocompromised individuals as compared to the immunocompetent population, scapular osteomyelitis still remains a rare subset of bony tubercular lesion. [4] The diagnosis of tuberculous scapular osteomyelitis requires a high degree of suspicion for accurate and timely diagnosis. [5]

Bone involvement is usually by hematogenous spread but can occur by lymphatic or local extension secondary to contiguous tubercular synovitis, or, conversely, osteomyelitis may lead to a septic joint. [6]

Challenges in the diagnostic work up include lack of familiarity with the spectrum of tuberculous osteomyelitis bone lesions and not considering it in the differential diagnosis early on. The reasons behind the delay in early diagnosis in such cases are no pulmonary involvement, insidious onset of symptoms with minimal signs of local inflammation, and no early characteristic radiographic finding. Clinical symptoms are very nonspecific and can include insidious onset of pain, swelling, decreased range of motion, and difficulty in ambulating. Patients may also have weight loss, night sweats, generalized malaise, and decreased appetite. Tuberculosis of the bone can go unnoticed for a long time until there is extension of the disease to skin and adjacent structures including the joints. A significant challenge in the diagnosis of tuberculous osteomyelitis is that the smears for acid-fast bacilli are often negative, leading to a delay in diagnosis while waiting for the organisms to grow in culture media. Polymerase chain reaction or nucleic amplification assays may be helpful in obtaining an earlier diagnosis; however, a negative result does not rule out tuberculosis.

Most authors feel that the sequestra of tuberculous osteomyelitis are absorbed under adequate antituberculosis therapy and surgical removal is not needed in most of the cases. [7] Surgical removal is required in patients with giant sequestra or where the response to conservative treatment of 4-6 weeks is not satisfactory. [8] In the present case, as we achieved symptomatic improvement with antitubercular drugs, we had decided to continue the same.

This case highlights the importance of a high index of suspicion for early diagnosis of extra pulmonary tuberculosis, especially in the context of an immunosuppressed state. Tuberculosis can be diagnosed easily based on characteristic histopathology supported by microbiological evidence and cure is achievable with appropriate treatment.

References

 

1. Kam WL, Leung YF, Chung OM, Wai YL. Tuberculous osteomyelitis of the scapula. Int Orthop 2000;24:301-2.
2. Martini M, Adjrad A, Boudjemaa A. Tuberculous osteomyelitis. A review of 125 cases. Int Orthop 1986;10:201-7.
3. Vohra R, Kang HS, Dogra S, Saggar RR, Sharma R. Tuberculous osteomyelitis. J Bone Joint Surg Br 1997;79:562-6.
4. Goodman PC. Tuberculosis and AIDS. Radiol Clin North Am 1995;33:707-17.
5. Tsay MH, Chen MC, Jaung GY, Pang KK, Chen BF. Atypical skeletal tuberculosis mimicking tumor metastasis: Report of a case. J Formos Med Assoc 1995;94:428-31.
6. Waldrogel FA, Medoff G. Osteomyelitis. Clinical features, therapeutic considerations and unusual aspects. Springfield IL: Charles C Thomas, Publisher; 1991. p. 78-91.
7. Tuli SM. Tuberculosis of the Skeletal System (bones, joints, spine and bursal sheaths). 1 st ed. New Delhi (India): Jaypee Brothers Medical Publishers (P) Ltd; 1993. p. 121.
8. Khan SA, Zahid M, Sharma B, Hasan AS. Tuberculosis of frontal bone: A case report. Indian J Tuberc 2001;48:95-6.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.105153

Figures

[Figure 1], [Figure 2], [Figure 3]

Tables

[Table 1]

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