A 53-year-old man with remote history of Tuberculosis (Tb) exposure was admitted with a pneumothorax. He had mild chronic dry cough but no other Tb risk factors or constitutional symptoms. Chest imaging revealed bilateral upper lobe nodules and calcified intrathoracic lymph nodes. Transbronchial biopsy and bronchoalveolar lavage were performed but no acid-fast bacilli (AFB) were noted on smear and neither specimen grew any organisms. The histopathology revealed a non-necrotizing granuloma but no AFB. Tuberculin skin test and interferon gamma releasing assay were negative, as was an HIV test. No Tb therapy was initiated.
Two months later he visited the Emergency Room with left elbow pain, swelling and limited range of movement. Joint fluid analysis revealed a leukocyte count of 14 000, no crystals and AFB smear negative. Magnetic resonance imaging (MRI) favored a benign proliferative condition of the synovium. However, after 5 weeks, the joint fluid culture grew Mycobacterium Tb. He was then readmitted and revaluated with a second MRI which also reported proliferative arthropathy, but now revealed multifocal erosive changes involving the olecranon fossa. Empiric rifampin, isoniazid, pyrazinamide and ethambutol were started and after 6 weeks of therapy and confirmation of susceptibility to this regimen, his pain and limitation of motion improved (Fig. 1).
Figure 1.
(A) Picture of the patients’ left elbow showing swelling. (B) Sagittal T2 weighted image from the second MRI. It shows synovial hypertrophy and lobulated synovial effusions with foci of low signal intensity within the collections, which may represent hemorrhagic products (green arrow). More characteristically, there is loss of joint space, cortical irregularity and erosive changes involving the olecranon fossa (blue arrow).
The recognition of osteoarticular Tb is often delayed for multiple reasons. It is uncommon, with involvement of the elbow being rare [1]. The onset is insidious, the classic systemic symptoms of Tb may be absent [2] and early imaging may not demonstrate pathognomonic findings [3].
Specific to this case, it is important to note that the absence of evidence for active pulmonary Tb does not exclude extrapulmonary Tb [4]. This fact, added to the lack of clinical improvement, mandated expeditious, extensive workup for osteoarticular Tb. Function can be preserved by early diagnosis [1].
CONFLICT OF INTEREST
None declared.
FUNDING
The authors received no financial support for the research, authorship or publication of this article.
ETHICAL APPROVAL
This case is exempt from IRB approval at our institution.
INFORMED CONSENT
Written informed consent was obtained from the patient and is available for review upon request.
GUARANTOR
Kamir N. Boodoo.
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