The incidence of pulmonary tuberculosis in industrialized countries has declined over the years. Skeletal tuberculosis is less common in the United Kingdom than in the first half of the 20th century. Although it is a rare condition, the exact incidence is not known. Skeletal tuberculosis accounts for approximately 10% of reported cases of extrapulmonary tuberculosis in the United States.1 Some developed countries have now recorded a resurgence in the incidence of tuberculosis due to a rise in the number of people with immunosuppression, the development of drug-resistant strains of Mycobacterium, an aging population, and an increase in the number of health-care workers who are exposed to the disease.2 Bony tuberculosis of the hand is uncommon, and it is even rarer in children, with <10 cases reported in the past 10 years. Since the advent of antituberculous drugs, control of tuberculosis has been achieved in most places and its incidence in the hand has diminished. This article reports a case of tuberculosis affecting the fifth metacarpal in a 6-year-old girl.
A 6-year old girl presented in June 2001 with a 1-month history of swelling affecting the left hand. The hand appeared to have increased in size; however, it was not painful or tender to palpation. There was no history of trauma to the hand, and the patient had a full, painless range of motion (ROM) of all joints. She also had a palpable epitrochlear lymph node that was painless and non-tender to palpation. The patient was well systemically and had no fever or noticeable loss of weight as reported by her father.
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Figure 1: Radiograph showing expansile lesion of the fifth metacarpal. Figure 2: Postoperative radiograph showing the defect filled with Biobon substitute.
Laboratory evaluation revealed an erythrocyte sedimentation rate (ESR) of 14 mm/hr, a C-reactive protein of <1, and hemoglobin of 10.5 g/dL. A plain radiograph of the hand showed a lesion in the fifth metacarpal that was consistent with an enchondroma (Figure 1).
The patient underwent curettage and bone grafting of the fifth metacarpal in August 2001 (Figure 2). Intraoperatively, gelatinous material was curetted out and it was noted that the dorsal cortex was destroyed. The bony defect was filled with Biobon (Biomet Merck, Darmstadt, Germany) bone substitute. On histopathological examination, the gelatinous material showed chronic granulomatous inflammation with an occasional focus of central caseous necrosis consistent with tuberculosis. No acid-fast bacilli were identified. No material was sent for culture as tuberculosis was not suspected at that stage.
At 2-week follow-up, a chest radiograph showed right paratracheal lymphadenopathy consistent with tuberculosis. Heaf testing was strongly positive. The child had not had a BCG vaccination as a baby.
The patient was prescribed 4 antituberculous drugs (rifampicin, pyrazinamide, isoniazid, and ethambutol) for 2 months as initial intensive treatment, and was continued on isoniazid and rifampicin in the maintenance phase for 4 months. Radiographs at 12 months showed complete resolution of the bony lesion of the affected metacarpal (Figure 3).
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Figure 3: One year after treatment, AP (A) and oblique (B) radiographs show complete resolution of the disease.
In children and adults, skeletal tuberculosis more frequently involves the axial than the appendicular skeleton.3 Tuberculosis of the skeleton comprises 10%-15% of all extrapulmonary tuberculosis.4,5 The spine accounts for 50% of cases,6-8 and the digits for 4%.4,5 Goldblatt and Cremin3 reviewed a series of 271 patients with skeletal tuberculosis aged <10 years and found 6 patients (2.2%) in whom the long bones were affected without joint space involvement.
Tuberculous dactylitis is rare, and several conditions may cause a slowly growing expansile metacarpal tumor with radiological bone destruction. Enchondroma, osteomyelitis, Pagetâ€™s disease, sarcoma, and sarcoidosis should be considered.
Primary bone involvement usually is discovered late because symptoms are subtle. Several authors have reported a delay in the diagnosis of bone tuberculosis.6-8 Although bone tuberculosis is reported as almost always secondary to a primary focus in the chest, no history of tuberculosis infection or exposure may be present. Rasool,9 in a study of 42 children with tuberculous osteomyelitis, found an incidence of 20% with associated chest involvement. A normal ESR and negative skin tests do not exclude a diagnosis of tuberculosis. The importance of accurate diagnosis by bacteriologic and histological investigation has been emphasized in large reports.7-11 The diagnosis can be based on the pathology report of specific granulomatous inflammation with caseous necrosis and a positive tuberculin skin test in a patient who has not previously been given a BCG vaccination.12
According to Watts and Lifeso2 no features are pathognomonic of tuberculosis radiologically. In a series of 17 pediatric patients with tuberculosis of the appendicular skeleton reported by Versfeld and Solomon,13 the radiographic appearance in 14 patients was a poorly defined cystic lesion with minimal marginal sclerosis.
Currettage alone has been reported to yield favorable results,3,8,14,15 although bone grafting of defects has been reported to lead to good resolution and remodeling of the involved bone.11
Antituberculous chemotherapy is the cornerstone of the management of skeletal tuberculosis. Joint Tuberculosis Committee of The British Thoracic Society has recommended a 6-month regimen for bone and joint tuberculosis.16 Ambulatory chemotherapy for 6 months has been highly effective in the treatment of spinal tuberculosis.17 Surgery is a valuable adjunct in establishing the diagnosis and in the treatment of selected complications, such as evacuation of an abscess or debridement of necrotic bone.
- Rieder HL, Snider DE Jr, Cauthen GM. Extrapulmonary tuberculosis in the United States. Am Rev Respir Dis. 1990; 141:347-351.
- Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am. 1996; 78:288-298.
- Goldblatt M, Cremin BJ. Osteoarticular tuberculosis: its presentation in coloured races. Clin Radiol. 1978; 29:669-677.
- Snider DE Jr. Extrapulmonary tuberculosis in Okhlahoma, 1965 to 1973. Am Rev Respir Dis. 1975; 111:641-646.
- Halsey JP, Reeback JS, Barnes CG. A decade of skeletal tuberculosis. Ann Rheum Dis. 1982; 41:7-10.
- Martini M, ed. Tuberculosis of the Bones and Joints. New York, NY: Springer-Verlag; 1988.
- Vohra R, Kang HS, Dogra S, Saggar RR, Sharma R. Tuberculous osteomyelitis. J Bone Joint Surg Br. 1997; 79:562-566.
- Wang MN, Chen WM, Lee KS, Chin LS, Lo WH. Tuberculous osteomyelitis in young children. J Pediatr Orthop. 1999; 19:151-155.
- Rasool MN. Osseous manifestations of tuberculosis in children. J Pediatr Orthop. 2001; 21:749-755.
- Davidson PT, Horwitz I. Skeletal tuberculosis. A review with patient presentations and discussion. Am J Med. 1970; 48:77-84.
- Mittal R, Gupta V, Rastogi S. Tuberculosis of the foot. J Bone Joint Surg Br. 1999; 81:997-1000.
- Jensen CM, Jensen CH, Paerregaard A. A diagnostic problem in tuberculous dactylitis. J Hand Surg [Br]. 1991; 16:202-203.
- Versfeld GA, Solomon A. A diagnostic approach to tuberculosis of bones and joints. J Bone Joint Surg Br. 1982; 64:446-449.
- Komins C. Multiple cystic tuberculosis; a review and a revised nomenclature. Br J Radiol. 1952; 25:1-8.
- Nicholson OR. Tuberculosis of the pubis; a report of eleven cases. J Bone Joint Surg Br. 1958; 40:6-15.
- Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Joint Tuberculosis Committee of the British Thoracic Society. Thorax. 1998; 53:536-548.
- Controlled trial of short course regimens of chemotherapy in the ambulatory treatment of spinal tuberculosis. Results at three years of a study in Korea. Twelfth report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg Br. 1993; 75:240-248.
Dr Verma is from the Department of Orthopedics, and Drs Varma and Leahy are from the Department of Respiratory Medicine, Trafford General Hospital, Manchester, United Kingdom.
Reprint requests: Rajat R. Verma, FRCS, 202 Walton Rd, Sale Cheshire M33 4FG, United Kingdom.