tuberculosis of bones and joints
DESCRIPTION
radiologyTRANSCRIPT
TUBERCULOSIS OF
BONES AND JOINTS
Historical aspects
Oldest recognized disease of mankind
Percival Pott presented the classic
description of spinal tuberculosis in 1779
Robert Koch discovered Mycobacterium
tuberculosis in 1882
Predisposing factors
• Malnutrition's
• Poor sanitation
• Living in crowded areas
• Close contact with TB patients
• Immunodeficiency states
Lesions of individual bones
• Spine
• Greater trochanter
• Phalanx
• Skull
Joint lesions
infection by mycobacterium tuberculosis of one or
more extradural components of spine namely the
vertebra, intervertebral discs, paraspinal soft tissues
and epidural space
Tuberculosis of spine
Pathophysiology
• Usually by hematogenous route
• Midthoracic spine and the region below it is
more frequently involved
• Usually two continuous vertebrae are involved
but several vertebrae may be effected
• Skip lesions or solitary vertebral involvement
may occur
Clinical features
Constitutional
symptoms
Malaise
Loss of
appetite/weight loss
Night sweats
Specific features
Stiffness
Enlarged lymph
nodes
Neurodeficit
Imaging modalities
• Conventional radiographs
• CT
• MRI
• Ultrasonography
1.Conventional Radiographs
• Reduced disc space
• Blurred paradiscal margins
• Destructions of bodies
• Loss of trabecular pattern
• Increased prevertebral soft tissue shadow
• Subluxation/dislocation
• Decreased lordosis/kyphosis
Central type of lesion:
• Spread through batson’s venous plexus/
branches
of posterior vertebral artery
• Minimal disc space reduction
• At the end concentric collapse
Anterior type lesion
Starts beneath the anterior longitudnalligament & periosteum
Collapse & disc reduction usually minimal & occurs late
Erosion is primarily mechanical
Appendicular type
Rare
Isolated infection of pedicles/lamina/transverse process/spinousprocess
Erosions
Paravertebral shadows
Intact disc space
Lateral shift & scoliosis:
• More destruction of vertebral body on one
side
• Posterior articulation involvement in addition
to usual paradiscal lesions
Skipped lesions:
• More than one TB lesion present in vertebral
column with one or more healthy vertebrae in
b/w the 2 lesions
• 7% on routine x-rays
• More frequently detected on CT/MRI
Healing is indicated by
• decreased soft tissue shadow
• Disappearance of erosions
• Return of normal density(mineralization)
• Bony ankylosis
CT & MRI
• the extent of involvement
• presence of epidural component
• cord compression
• Irregularity of both end plate and anterior
aspect of vertebral bodies
• Bone marrow edema
• Enhancement on MRI
T2 Weighted sagital image of lumbar spine shows altered
Marrow signals involving anterosuperior margin.
Ultrasonography
To diagnose the presence of tubercular
abscesses in dorsolumber vertebral disease
UltrasoundJoint effusion may be the
only finding but is
nonspecific.
Difference
TB spondylitis
a pattern of mainly bone destruction
• relative disc preservation(destruction is late sign)
• focal and heterogeneous contrast enhancement of the vertebral body
• well-defined paraspinal area of abnormal signal intensity
Pyogenic spodylitis
a pattern of mainly discitis
mild to moderate peridiscal
bone destruction
relative diffuse and
homogeneous contrast
enhancement of the vertebral
body
Difference
TB spondylitis
vertebral intraosseous rim
enhancement on sagittal
views.
Calcification when present
indictes TB.
Pyogenic spodylitis
• ill-defined paraspinal area of
abnormal signal intensity
• peridiscal rim enhancement
Tuberculous
dactylitis
spina = short bone
ventosa = expanded with air
• Plain Radiography is the modality of choice
• Tends to affect the bones distal to tarsus and wrist
• upper limb being more commonly involved
• involved bone shows a diaphyseal expansile lesion
• a periosteal reaction is uncommon
• healing is by sclerosis and is usually gradual
Poorly defined lytic change with medullary expansion, cortical erosion
and mild periosteal reaction in the mid and distal aspect of the right
middle finger in a patient with TB dactylitis.
Calvarial tuberculosis
• Rare entity
• May be localized and well defined
• Or may be more diffuse
• Associated with cold abscess
1)Lateral radiograph shows large circumscribed lytic lesion in frontal bone.
2) AP radiograph demonstrates a large frontoparietal lytic lesion suggestive
of diffuse spreading type.
3) Frontal radiograph shows a lytic lesion with a sclerotic margin.
Joint Lesions• One of the common cause of infectious arthritis in
developing countries
Never a primary lesion it is always a sequelae of
pulmonary or lymph node tuberculosis
It can occur at any age.
Radiographic features
Plain film
early stages (stage of synovitis and
arthritis)
• periarticular demineralisation
• joint space widening (due to joint effusion)
• mild subchondral erosion
late stages (stage of erosion and destruction)
• gradual narrowing of joint space (there is involvement of
articular cartilage)
• severe subchondral erosion and destruction
• pathological subluxation and dislocation
• fibrous ankylosis
• atrophic changes in bones may occur and lead to
atrophic arthropathy (seen in shoulder joint as carries
sicca)
CT degree of bone destruction or rarely sequestrum
Extension of infection in surroundings or any sinus tract
formation can also be demonstrated on post contrast
scan.
Caries sicca : there is erosion and destruction of humoral head and
glenoid cavity with soft tissue swelling, along with fibrotic opacites in the
right upper and middle lobe.
Osteolytic lesion in distal shaft of radius with osteopenia
There is a lucent lesion in the medial tibial metaphysis with thinning of
the cortex, subtle periosteal reaction and faint calcification in the
adjacent soft tissue.
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