TB and MSK infections in children

Dr Joanna Kasznia-Brown

Consultant Radiologist

Bristol, UK

55th ESPR meeting

May 2019, Helsinki

TB epidemiology

➢ TB is a global health problem !!!➢ 8.6 million cases worldwide

➢ the most common cause of death from a single infectious agent➢ 1.3 million died in 2017

➢ TB prevalence: ➢ Asia – 58%

➢ Africa regions – 27%

➢ Eastern Mediterranean – 8%

➢ Europe – 4%

WHO Global Tuberculosis Report 2018

TB in children

➢ epidemiology➢ 530,000 cases

➢ 64,000 deaths per year

➢ difficult to diagnose➢ non-specific symptoms

➢ culture not usually performed

➢ skin test – false positive and negative results

➢ medical imaging plays a crucial role in diagnosis and follow-up

TB vaccination

Skeletal TB in children

➢ accounts for 10– 35% of pediatric extra-pulmonary TB

➢ systemic symptoms found in only 33% of patients

➢ less than 50% of children have concurrent pulmonary TB

➢ lesions can develop more than 10 years after the initial infection

➢ typical presentation – solitary bone lesion with local signs of inflammation

➢ early diagnosis is crucial to prevent serious bone and joint destruction

Common skeletal manifestations

➢ spondylitis – 50%

➢ arthritis – 35%

➢ osteomyelitis – 11%

➢ multifocal – 5 -10%

TB corner, World Federation of Paediatric Imaging

Tuberculosis spondylitis

➢ most common manifestations of skeletal tuberculosis

➢ found in younger children, even < 5 years

➢ clinical symptoms➢ intermittent

➢ relatively long bouts of fever

➢ insidious progression

➢ common site – lower thoracic and upper lumbar spine

➢ venous spread in the paravertebral Batson’s venous plexus

Tuberculosis spondylitis

➢ typically involves anterior vertebral body

➢ spread along anterior longitudinal ligament

➢ involvement of multiple vertebra

➢ homogenous enhancement with contrast

➢ well-defined enhancing paravertebral soft tissue

Tuberculosis spondylitis

➢ relative presentation of disks

➢ bone destruction

➢ thoraco-lumbar junction

TB spondylitis

➢ well-defined enhancing paravertebral soft tissue

➢ para-spinal abscess – thin and smooth walls

➢ vertebral intra-osseous abscess

Pyogenic spondylitis

➢ less than 2 vertebra involved

➢ usually starts from intervertebral disk

➢ moderate to complete disk destruction at early phases

➢ disc abscess

➢ infrequent bone destruction

➢ ill-defined enhancing para-spinal soft tissue –less common

➢ abscess – thick and irregular walls

Tuberculous vs. Pyogenic spondylitis

Tuberculosis Pyogenic

Well defined paraspinal

abnormal mass

Ill-defined paraspinal

abnormal mass

Thin and smooth abscess

wall

Thick and irregular abscess

wall

Presence of paraspinal or

intraosseous abscess

Absence of paraspinal or

intraosseous abscess

Multiple body involvement Involvement ≤ 2 vertebral

bodies

Early TB spondylitis

➢ spread along anterior longitudinal ligament

➢ relative preservation of disks

Early TB spondylitis

Early TB spondylitis

TB arthritis

➢ 2nd most common involvement of skeletal system

➢ typically mono-arthritis

➢ hip and knee most commonly affected, followed by SIJs, shoulder and elbow

➢ can mimic rheumatoid arthritis when hands and feet are effected

➢ spread➢ origin in metaphysis with trans-physeal spread

➢ direct spread to joint space and synovium

TB arthritis

➢ juxta-articular osteopenia

➢ joint effusion

➢ synovial involvement

➢ peripheral osseous erosions

➢ gradual tapering of joint space

➢ cartilage loss – late in disease, as no proteolytic enzymes in exudates

➢ para-articular soft tissue masses and cold abscesses

➢ fistulas and sinus tracts

TB arthritis

TB arthritis

TB osteomyelitis

➢ multifocal and/or disseminated from hematogenous spread – previously

➢ solitary bone involvement – more recent

➢bone destruction at metaphysis or epiphysis

➢ growth plate can be effected

➢ trans-physeal spread in children > 1.5 years

TB osteomyelitis

➢ permeative destructive pattern

➢ lack of sclerosis

➢ less sequestra

➢ less periosteal reaction in comparison to pyogenic infection

➢ types➢ cystic

➢ infiltrative

➢ focal erosions

➢ spina ventosa

TB osteomyelitis

➢ non – specific clinical symptoms

➢ lack of sclerosis

➢ less sequestra

➢ less periosteal reaction in comparison to pyogenic infection

Patient 1

TB osteomyelitis

Patient 2

TB osteomyelitis

Patient 3

TB osteomyelitis

TB skeletal infections

➢ recent increase in European countries and US

➢ non-specific clinical symptoms

➢ difficult to diagnose

➢ early imaging and diagnosis is crucial !!!

THANK YOU