Fulminant tuberculosis: Simultaneous shoulder and pulmonary involvement


Olusola A.M Adesiyun, Adekunle Y Abdulkadir, Halimat J Akande

Department of Radiology, University of Ilorin Teaching Hospital, Ilorin, Nigeria

Correspondence Address:
Adekunle Y Abdulkadir
Department of Radiology, University of Ilorin Teaching Hospital, Ilorin, P.M.B 1459, Ilorin, Kwara state
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DOI: 10.4103/0973-6042.38652

Fulminating tuberculosis (TB) of the shoulder joint and lung occurring concurrently is rare. A case diagnosed by plain radiograph in a 60-year-old peasant who had left shoulder swelling, pain and limitation of movement of this joint for six months is presented. This is for radiologist and clinicians to be wary of TB in cases of non-resolving osteoarticular infection especially in TB endemic regions. Despite growing advances in radiological methods, plain radiograph should remain a valuable investigation. The patient had satisfactory response to 12-month anti-tuberculous regimen.

Keywords: Osteomyelitis, pyogenic arthritis, shoulder joint, tuberculosis

How to cite this article:
Adesiyun OA, Abdulkadir AY, Akande HJ. Fulminant tuberculosis: Simultaneous shoulder and pulmonary involvement. Int J Shoulder Surg 2007;1:114-6

How to cite this URL:
Adesiyun OA, Abdulkadir AY, Akande HJ. Fulminant tuberculosis: Simultaneous shoulder and pulmonary involvement. Int J Shoulder Surg [serial online] 2007 [cited 2013 Apr 19];1:114-6. Available from: http://www.internationalshoulderjournal.org/text.asp?2007/1/4/114/38652


Introduction Top

Skeletal tuberculosis (TB) is common in endemic areas and in migrants from such areas especially southern Sahara and the Asians countries, where the majority of the population live below poverty line and health care facilities are inadequate. [1],[2] However, fulminating simultaneous TB of the shoulder joint and lung is rare. [3],[4],[5]

Osteoarticular TB although treatable is often misdiagnosed. [3] A case of fulminating simultaneous left shoulder and pulmonary TB earlier misdiagnosed as pyogenic osteoarthritis is presented to emphasize the need to exclude TB in all cases of non-resolving osteoarticular infection. Patient responded satisfactorily to anti-tuberculous drugs with good restoration of functions.

Case Report Top

A 60-year-old farmer from a remote Nigerian village had progressive left arm and shoulder swelling of six-month duration. He presented at the general outpatient department of our hospital from a rural clinic because of deteriorating symptoms. Swelling was characterized by moderate pain but severe enough to disturb patient’s sleep. There was no previous history of trauma nor was there symptom referable to hematological disorder. He had poor appetite, weight loss and occasional dry cough. Three weeks prior to presentation, the swelling became associated with purulent discharge from a point at its posterolateral aspect. He had been to many traditional healers as well as private hospitals where he had multiple herbal, antibiotic and analgesic therapies without resolution.

On examination, he was slightly pale, afebrile, anicteric and moderately wasted. The left upper arm swelling was warm, tender and with a discharging sinus at its posterolateral aspect. There was marked limitation of movement (movement of elevation and retraction) across the joint. Neither of these could go beyond 30 degree from rest position due to pain and swelling.

Plain radiograph showed increased cortical thickening and poor corticomedullary differentiation of the upper third of the humerus. The humeral head was superiorly migrated from the glenoid fossa whose rim was eroded and the scapula was displaced superolaterally. The inferolateral margin of the scapula showed cortical thickening and irregularities. Overlying soft tissue swelling around the shoulder joint was also demonstrated. These features suggest osteoarticular infection of the left shoulder joint with some effusion [Figure – 1]. The chest radiograph [Figure – 2] showed widespread fibrocystic opacities with background nodularities in both lung fields and hilar lymphadenopathies. The aorta was unfolded. The diagnosis of simultaneous tuberculosis of the left shoulder joint and lung was made based on radiographic findings.

Laboratory work-up, revealed raised erythrocyte sedimentation rate (ESR) of 34 mm/hr and sputum was positive for acid fast bacilli (AFB). The purulent discharge culture showed no microbial growth. Both random and fasting blood sugars were normal. He tested negative for human immunodeficiency virus (HIV) screening. Tissue biopsy showed granulomatous changes.

Patient had good response to 12-months anti-tuberculous regime with no appreciable residual loss of function at 15 months of follow-up.

Discussion Top

There is rising incidence of TB worldwide attributable to the scourge of HIV-AIDS pandemic, increasing resistance of TB to drugs in endemic areas and because of increasing trans-border travels made worse by wars and famine. [1],[2],[3],[5] Hence, increasing incidences of skeletal TB are expected. Osteoarticular involvement occurs in 1 to 3% of patients with extra pulmonary TB, about 1/3 are diagnosed with concomitant active pulmonary disease. [3] About 50% of extra pulmonary TB occurs in the spine. [3]

Skeletal TB is often misdiagnosed as osteoarthritis or pyogenic osteomyelitis because of its rarity and unspecific differentiating clinical features. [3] These two entities can be differentiated, radiologically, based on recognized bony appearances; osteopenia is characteristic of TB while sclerosis is commoner in pyogenic infections. Likewise, sequestrum formation is rare in TB compared to pyogenic infections. Extra-pulmonary osteoarticular affection may be associated with complaints of swelling, stiffness and pain (“night cries” classical of musculoskeletal TB), [2],[6],[7] while symptoms such as cough, low-grade fever, night sweat, weight loss, anorexia and malaise are features of pulmonary TB. [1],[2],[6]

The occasional dry cough noted in this patient is not typical of TB, and localized warmth over the discharging swelling around the left shoulder and restriction of movements across this joint suggested osteoarticular infection (septic arthritis). Thus, musculoskeletal TB was unsuspected for six months in this patient probably because of subtle symptoms and lack of laboratory or radiological work-up occasioned by non-availability.

Joint involvement of TB can also be mistaken for a number of other joint diseases, e.g. chronic villous synovitis, pigmented nodular synovitis, synovioma, etc. [8] In all these conditions treatment failure with antibiotic are expected. Again, swelling in them are unlikely to be associated with purulent discharge as observed in our patient, which supported pyogenic infection. However, this was a sterile discharge.

The late radiographic findings of scapulo-humeral osteomyelitis and pulmonary features of TB on plain radiographs [Figure – 1],[Figure – 2] prompted the diagnosis of osteoarticular TB. Features that supported osteoarticular TB in this patient include; raised ESR (although non-specific), satisfactory response to anti-tuberculous drugs after six months of treatment failure with antibiotics and positive sputum for AFB.

According to Spiegel et al ., [6] tuberculous osteomyelitis that does not involve a joint is uncommon and isolated bone involvement without spread to a joint often fails to attract attention because of the subtle nature of the symptoms. [6] This is supported by the long duration of symptoms in our patient; the diagnosis was not made until the process was advanced, and migration of the humeral head from the glenoid cavity, probably due to joint effusion and erosion of the glenoid rim, had occurred.

Mangwani et al ., [2] reported the first case of fulminating variety of tuberculosis of the shoulder joint; the authors believe this entity is rarer than the classical dry type (caries sicca) in adults.

Fulminating joint TB may mimic malignant disease both clinically and radiologically. [7] The winging (superolateral displacement) of the scapula, erosion of the glenoid rim and the overlying soft tissue swelling suggest tumor in this case. However, the bony changes of osteomyelitis in the humeral shaft and scapula, and widespread fibronodular pulmonary opacities and the bilateral hilar glandular enlargement on the chest radiograph are suggestive of pulmonary TB with TB osteomyelitis.

Conventional radiography remains the mainstay in the radiological diagnosis of tuberculous arthritis and osteomyelitis. [2],[3] However, magnetic resonance imaging can be helpful in differentiating pyogenic from tuberculous osteomyelitis in addition to detecting associated bone marrow and soft tissue abnormalities. [6] On the other hand, computed tomography is superior in the demonstration of calcifications, sometimes found in chronic tuberculous abscesses. [6] The latter two investigative modalities are not readily available and are relatively expensive in our environment as it is in many developing countries.

In such instances, laboratory confirmation of diagnosis is sufficient. According to Kothari et al ., [5] AFB is seldom detected in the aspirated pus, rather frequently, secondary infecting organisms are cultured. This can mislead the unsuspecting clinician to diagnose pyogenic infection rather than TB and then treat accordingly. Biopsy is essential to differentiate them. [5]

The laboratory diagnosis of TB continues to be difficult as prompt isolation of Mycobacterium tuberculosis (the causative agent of TB) is hampered by the slow growth rate of tubercle bacilli in standard culture media, requiring about three to six weeks. [9] Hence, radiometric methods of mycobacterial identification with BACTEC system and polymerase chain reaction (PCR) are important advances in the diagnostic technology. [9] The BACTEC system quantifies the released 14CO2 from mycobacteria metabolized radiolabeled palmitic acid to identify the presence and growth of the bacteria. It allows for the detection of M. tuberculosis growth with a mean detection time of 7-13 days for smear-positive and 14-22 days for smear-negative sputum specimens. [9] On the other hand, PCR, which uses nucleic acid amplification techniques, allows direct detection of M. tuberculosis in clinical specimens without the need for prior culture. Its acceptance into the clinical setting has been hampered by reports of both false-negative and false-positive reactions caused by the presence of inhibitors and contaminants in samples, respectively. [9] Radiometrics was not employed in this patient due to non-availability.

A 12 month-regime of anti-tuberculous drugs gave satisfactory response in our patient with restoration of function and marked improvement in the chest radiographic features of pulmonary TB at 15 months of follow-up.

Acknowledgment Top

We acknowledge the contribution of the head of GOPD, University of Ilorin Teaching Hospital.

References Top

1. World Health Organization. Global tuberculosis control: Surveillance, planning, financing. World Health Organization: Geneva, Switzerland;2005. Back to cited text no. 1
2. Mangwani J, Gupta AK, Yadav CS, Rao KS. Unusual presentation of shoulder joint tuberculosis: A case report. J Orthop Surg (Hong Kong) 2001;9:57-60. Back to cited text no. 2 [PUBMED] [FULLTEXT]
3. Evanchick CC, Davis DE, Harrington TM. Tuberculosis of peripheral joints: An often missed diagnosis. J Rheumatol 1986;13:187-91. Back to cited text no. 3 [PUBMED]
4. Richter R, Nubling W, Schulz HJ, Kohler G. Tuberculosis of the shoulder joint. Z Orthop Ihre Grenzgeb 1986;124:36-45. Back to cited text no. 4
5. Kothari PR, Kumar T, Jiwane A, Kulkarni B, Kalgutkar A. Tuberculous osteomyelitis: A bizarre presentation. Indian J Surg 2003;65:515-6. Back to cited text no. 5
6. Spiegel DA, Singh GK, Banskota AK. Tuberculosis of the musculoskeletal system. Tech Orthop 2005;20:167-78. Back to cited text no. 6
7. Vohra R, Kang HS, Dogra S, Saggar RR, Sharma R. Tuberculous osteomyelitis. J Bone Joint Surg Br 1997;79:562-6. Back to cited text no. 7 [PUBMED] [FULLTEXT]
8. Muradali D, Gold WL, Vellend H, Becker E. Multifocal osteoarticular tuberculosis: Report of four cases and review of management. Clin Infect Dis 1993;17:204-9. Back to cited text no. 8 [PUBMED]
9. Herold CD, Fitzgerald RL, Herold DA. Current techniques in mycobacterial detection and speciation. Crit Rev Clin Lab Sci 1996;33:83-138. Back to cited text no. 9 [PUBMED]


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