Report of a Case of Tuberculosis of Mandibular Condyle in a Patient on Haemodialysis

Introduction

Tuberculosis is an infectious disease of granulomatous nature affecting multiple organs commonly caused by the acid-fast bacilli Mycobacterium tuberculosis and rarely Mycobacterium bovis [1]. Worldwide, tuberculosis is one of the top ten causes of death and the leading cause from a single infectious agent (above HIV/AIDS). India has the highest tuberculosis burden in the world accounting for 27% of all the cases in the world [2].

Head and neck tuberculosis comprises nearly 10% of all cases of extrapulmonary tuberculosis (EPTB) [3]. Primary TB of the temporomandibular joint (TMJ) is a rare occurrence, and only 14 such cases have been reported in the literature so far. The presentation of tuberculous infection of the TMJ can resemble arthritis, osteomyelitis or any other kind of chronic joint disease.

Many risk factors are associated with tuberculosis, such as human immunodeficiency virus (HIV) infections, transplant recipients, substance abuse, renal insufficiency, malignancy and low socio-economic status [4]. Because of cellular immunity defects, patients with end-stage renal disease (ESRD) are at increased risk of developing TB [5]. Primary tuberculosis of the condyle occurring in patient of chronic kidney disease undergoing haemodialysis is being reported here for the first time in English literature.

Case Report

A 61-year-old female patient presented to the OPD with a history of preauricular swelling present since a month. She was treated by otolaryngologists for a presumptive diagnosis of acute parotitis with antibiotics which brought no relief. The patient was being haemodialysed biweekly for chronic renal failure.

Examination revealed a diffuse, tender swelling measuring approximately 3 cm × 4 cm in the right preauricular region (Fig. 1). No abnormality was noted in the overlying skin or intra-orally. Mouth opening at that time was 15 mm. A panoramic radiograph revealed an osteolytic lesion of the right condyle, and CT scan confirmed the provisional diagnosis of osteomyelitis (Fig. 2). She was seronegative for human immunodeficiency virus. Given the medical status of the patient, condylectomy with debridement was planned. As the capsule of the TMJ was incised, a copious amount of pus exuded (approx. 20 ml) which was collected for culture and sensitivity tests as well as for acid-fast bacilli. Sequestrae with respect to mandibular condyle and a portion of superior aspect of ramus were teased out, debrided and sent along with the condylar specimen for histopathologic testing (Fig. 3).

Fig. 1.

Preauricular swelling of right side measuring approximately 3 cm * 4 cm. Published with the patient’s consent

Fig. 2.

3D-CT scan showing osteolysis of right condylar head and neck

Fig. 3.

Sequestra found in the head of condyle and debris from superior aspect of ramus

The histopathology studies reported caseating, granulomatous lesion of the right mandibular condyle (Fig. 4). This indicated a tuberculous infection of the TMJ. Pulmonary involvement was ruled out following a chest X ray. Following the diagnosis, the patient was started on anti-tubercular regime of rifampicin, isoniazid, pyrazinamide and ethambutol for two months followed by 4 months of isoniazid and rifampin. The postoperative panoramic radiograph revealed a healing condylar head. The patient was followed up for 4 months during which her mouth opening improved significantly from 15 to 35 mm (Fig. 5).

Fig. 4.

Caseating granuloma with epithelioid and giant cells (haematoxylin and eosin stain, × 20 magnification)

Fig. 5.

Improvement in mouth opening post-operatively (35 mm achieved)

Discussion

India along with seven other countries accounts for two-thirds of all tuberculosis cases in the world. EPTB can be seen in more than 50% of patients with concurrent seropositivity [6]. Jaw involvement occurs in fewer than 2% of EPTB. The condyles are more prone to tubercular involvement because of their cancellous portion [7]. Additionally, the incidence of tuberculosis in dialysis patients is 6–16 times higher than that in the general population and is usually extrapulmonary [4].

The gold standard for the diagnosis of osseous tuberculosis is culture of M. tuberculosis from bone tissue [6] aided by radiographs and Mantoux test. In 2014, based on very low quality evidence, the WHO recommended conditionally the use of GeneXpert over conventional microscopy and culture to detect M. tuberculosis and rifampin resistance in lymph node and certain other non-respiratory tissue samples [8].

So far, 14 cases of primary tuberculosis of condyle have been reported in the literature; however, this is the first case of tuberculosis of condyle in a patient on hemodialysis. The presenting signs and symptoms are usually, as in our case, of preauricular swelling, pain and trismus. Complete resolution can be achieved if given the proper regime of anti-tubercular drugs, which is a 6–9-month multidrug regimen recommended as initial therapy for all forms of EPTB unless the organisms are suspected to be resistant to first-line drugs. In patients with chronic renal failure, the anti-tubercular drug dosages have to be adjusted [9].

Failure to detect the cause of the symptoms of swelling and osteomyelitis will lead to unwarranted misuse of antibiotics, multiple visits to a doctor in vain, excessive joint destruction, loss of TMJ function and a possible spread to contiguous areas. Patients in high-risk countries with concomitant compromised immune status such as that in chronic renal failure presenting with non-specific features of osteomyelitis of condyle should be tested to rule out TB as that can be the causative agent of the osteomyelitis. Prompt treatment with anti-tubercular drugs can assure a 90–95% return to normal structure and function.

Compliance with Ethical Standards

Conflict of interest

The author declares that they have no conflict of interest.