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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 333-335

The epidemiology of tuberculous dactylitis: A case report and review of literature


1 Rheumatological Medical Department, Faculty of Medicine, University of Tunis El Manar, Tunis; Department of Internal Medicine, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia
2 Rheumatological Medical Department, Faculty of Medicine, University of Tunis El Manar; Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
3 Rheumatological Medical Department, Faculty of Medicine, University of Tunis El Manar, Tunis; Department of Orthopaedics and Trauma, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia
4 Rheumatological Medical Department, Faculty of Medicine, University of Tunis El Manar, Tunis; Department of Clinical Laboratory, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia

Date of Web Publication17-Nov-2017

Correspondence Address:
Asma Bachali
Mrazka, 8000 Nabeul
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_122_17

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  Abstract 


The literature on tuberculous dactylitis is poor, and most literature consists of isolated case reports. The aim of this case series is to study the particularities and the epidemiological aspects of tuberculous dactylitis in Tunisian patients. Google and Medline search was done using key words “tuberculous dactylitis” and “spina ventosa.” Only Tunisian reports in adult patients were included. Eleven cases including this mentioned case were included in this review. There was a female predominance, high frequency of trauma before disease installation, rarity of predisposing factors, and less inflammation in blood tests when comparing with other cases in literature.

Keywords: Dactylitis, epidemiology, tuberculosis


How to cite this article:
Sahli H, Roueched L, Sbai MA, Bachali A, Tekaya R. The epidemiology of tuberculous dactylitis: A case report and review of literature. Int J Mycobacteriol 2017;6:333-5

How to cite this URL:
Sahli H, Roueched L, Sbai MA, Bachali A, Tekaya R. The epidemiology of tuberculous dactylitis: A case report and review of literature. Int J Mycobacteriol [serial online] 2017 [cited 2017 Dec 16];6:333-5. Available from: http://www.ijmyco.org/text.asp?2017/6/4/333/218621




  Introduction Top


Skeletal tuberculosis accounts for only 1%–5% of all tuberculous infections.[1] Tuberculous dactylitis (TD) is a very rare form of extrapulmonary tuberculosis involving the small bones of the hand or the foot in adult patients.[2] In the literature, there are only scattered reports with no statistics.[3] Although we live in an endemic country of tuberculosis, TD always poses a diagnostic challenge for orthopedic surgeons. Here, we present one case of TD revealed by a trauma that we treated in our center and provide a review of the published literature of this rare form of osteoarticular tuberculosis in our country.


  Case Report Top


A 54-year-old woman, working as a seamstress, presented with pain and swelling of the major finger of the right hand lasting for 1 year. It was a mechanical pain. The examination revealed that she had a minimal trauma of the major finger 1 year ago. She had no fever, decreased appetite, or weight loss. There was no history of tuberculous contagion. The examination showed a swelling around the third phalanx without an inflammatory aspect of the skin. The finger motion was painful and limited. Right hand radiograph showed an osteolytic lesion with blurred limits of the second phalanx of the major finger associated with narrowing of the interphalangeal joint [Figure 1]. Chest X-ray was normal. Magnetic resonance imaging showed inflammatory aspect of the second and third phalanx with medullar edema and osteoarthritis [Figure 2]. The laboratory examinations showed a normal erythrocyte sedimentation rate (ESR) and total leukocyte count at 6500/mm 3. The intradermal tuberculin reaction test was negative. The bone biopsy of the third finger revealed granulomatous inflammation without caseous necrosis. The special coloring of Ziehl–Neelsen did not highlight the Mycobacterium tuberculosis. This histological aspect made it possible to carry the diagnosis of a TD after eliminating all the other diagnoses. The investigations did not show other tubercular sites. Chemotherapy associating four antitubercular drugs was prescribed (isoniazid, rifampicin, pyrazinamide, and ethambutol) over 2 months followed by bi-therapy (isoniazid, rifampicin) over 10 months. Chemotherapy was associated with immobilization of the third finger by a splint for 21 days. There was a remarkable response to therapy with the disappearance of the swelling. Radiographs after 1-year treatment showed bone condensation and decrease in the osteolytic lesion size [Figure 3].
Figure 1: Right hand radiograph showing osteolytic lesion with blurred limits of the second phalanx of the major finger associated with narrowing of the interphalangeal joint

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Figure 2: Magnetic resonance imaging showing inflammatory aspect of the second and third phalanx with medullar edema and osteoarthritis

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Figure 3: Radiographs after 1-year treatment showing bone condensation and decrease in the osteolytic lesion size

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Literature search

Medline and Google search using key words: “tuberculous dactylitis” and “spina ventosa” was done. Published case reports that are from our country were included for review. Case reports that mentioned age, patient sex, and the site of TD were included for review. Ten reports of TD in our country from 5 published papers report fulfilled inclusion criteria. Thus, 11 cases including this mentioned case were included in this review. There was only one report in infant which was excluded. Data extracted were age, patient sex, TD site, presenting symptom, duration of symptoms before consultation, presence of constitutional symptoms of tuberculosis, predisposing factors, any history of local trauma, history of contact or positive family history, radiological findings, associated tubercular lesion, ESR, hemogram abnormalities, intradermal tuberculin reaction test result (positive or negative), and the bacteriological findings.

Literature review

Included case reports were published between 2003 and 2016.[4],[5],[6],[7],[8] Age of the patients ranged from 38 to 64 years (average = 51.36 years). A majority were female (10 women and one man). Chief presenting complaint was mentioned in all cases and all patients presented with swelling which was painful in most cases (n = 10). Discharging was noted in two cases. Inflammatory aspect of the skin was reported in 3 cases. The symptoms' duration was mentioned in 9 cases. Patients presented for the first time between 3 weeks and 12 months from the onset of symptoms (mean duration = 4.75 months). Tuberculosis predisposing factors were present in 2 cases: diabetes and corticotherapy. One or more constitutional symptoms of tuberculosis were present in only one case. ESR was elevated above normal range in 6 cases from 10 available data. Leukopenia was reported in two cases. Intradermal skin sensitivity test was positive in 3 of the 10 cases with available data. Five patients had history of local trauma before the development of TD symptoms. One patient had family history of tuberculosis.[6] Ten cases had hand involvement with multifocal localization in one case.[5] One patient had foot involvement.[8] Different radiological findings of the hand and feet are enumerated in [Table 1]. One patient had associated tubercular lesion at another site.[5] It was a mediastinal tuberculous lymphadenitis. Bacteriological examinations were negative in all cases.
Table 1: Radiographic findings in patients with tuberculous dactylitis

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  Discussion Top


TD, also known as spina ventosa, is a rare form of tuberculous osteomyelitis involving phalanges, metacarpals, and metatarsals.[9] Literature on this entity is poor and there are not many TD reports.[3] In a literature review including cases published and not published between 1971 and 2013, 41% of TD cases were younger than 10 years of age.[3] Our literature review concerned only adult patients. However, there was only one Tunisian case in infant. TD in our report was more frequent in female patients which is different from other reports. Indeed, TD is reported to be 3 times more common in males than females.[10] In another review,[3] authors found only a slight preponderance of males with a male to female ratio of 1.26. The presenting complaint is painless swelling in most cases which is similar to other cases.[3] TD often becomes symptomatic few months after the initial infection.[11] In our review, there was an acute presentation with 3 weeks' duration. There is often a long delay in the diagnosis of osteoarticular tuberculosis with a mean delay of 5–12 months.[12] This was about 4.75 years in our country. Multiple reasons can explain the delay in diagnosis such as the lesion paucibacillary nature,[13] insidious onset, slow progression, symptoms paucity with nonspecific clinical manifestations, and nonspecific nature of radiographic findings.[3] In this review case series, 2 patients had some underlying predisposing factors for tuberculosis. This rarity could be related to the epidemic of tuberculosis in our country. Low socioeconomic status and immunodeficiency were the most common predisposing factors followed by malnutrition in a review published in 2014.[3] About half of the patients in this review had history of trauma before the development of symptoms. This is more frequent than seen in the literature.[3] In our review series, one patient had history of contact with tuberculosis. This was about 23% in other reviews.[3] Bones of the hand are more commonly involved than of the foot as in literature as noted in our review. Radiological findings in TD are of nonspecific nature. In the review of Nadeem et al.,[3] ESR was elevated above normal range in 80% and intradermal skin sensitivity test was positive in 75% cases, which seems to be more elevated than in our review. This result could be explained by vaccination problems in endemic countries.


  Conclusion Top


TD presents nonspecific clinical and paraclinical presentation. It is characterized by a diagnosis delay. In our country, TD is characterized by a female predominance, frequency of trauma before symptoms development, rarity of predisposing factors, and less inflammation in blood tests.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Subasi M, Bukte Y, Kapukaya A, Gurkan F. Tuberculosis of the metacarpals and phalanges of the hand. Ann Plast Surg 2004;53:469-72.  Back to cited text no. 1
[PUBMED]    
2.
Bhaskar TK, Bareh J. Tuberculous dactylitis (spina ventosa) with concomitant ipsilateral axillary scrofuloderma in an immunocompetent child: A rare presentation of skeletal tuberculosis. Adv Biomed Res 2013;2:29.  Back to cited text no. 2
    
3.
Nadeem A, Abedullah B, Akeela F, Khalid M, Irfan Ahmad L, Rajinder S. Tuberculous dactylitis: A case series and review of literature. J Pioneer Med Sci 2014;4:184-90.  Back to cited text no. 3
    
4.
Ben Brahim E, Abdelmoula S, Ben Salah B, Kilani F, Chatti Dey S. Digital tuberculous revealed by trauma. Rev Chir Orthop Reparatrice Appar Mot 2003;89:71-4.  Back to cited text no. 4
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5.
Hassen-Zrour S, Younes M, Haj Salah-Othman M, Korbäa W, Touzi M, Béjia I, et al. Multifocal tuberculous dactylitis: A case report. Chir Main 2008;27:122-5.  Back to cited text no. 5
    
6.
Loussaief C, Ammari F, Toumi A, Ben Brahim H, Ben Rhomdane F, Chakroun M. Tuberculosis of finger bones: Three cases. Rev Med Interne 2012;33:e22-4.  Back to cited text no. 6
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7.
Sbai MA, Benzarti S, Sahli H, Sbei F, Maalla R. Osteoarticular tuberculosis dactylitis: Four cases. Int J Mycobacteriol 2015;4:250-4.  Back to cited text no. 7
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8.
Sbai MA, Benzarti S, Gharbi W, Khoffi W, Maalla R, Khorbi A. An exceptional location of tuberculous arthritis: The metatarsal phalangeal joint. Int J Mycobacteriol 2016;5:343-5.  Back to cited text no. 8
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9.
Bandyopadhyay R, Mukherjee A, Mondal RK. Case report: “spina ventosa” tuberculous dactylitis in a 2 year old boy-A very rare disease. Open Orthop J 2012;6:118-20.  Back to cited text no. 9
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10.
Sunderamoorthy D, Gupta V, Bleetman A. TB or not TB: An unusual sore finger. Emerg Med J 2001;18:490-1.  Back to cited text no. 10
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11.
Hassan FO. Tuberculous dactylitis pseudotumor of an adult thumb: A case report. Strategies Trauma Limb Reconstr 2010;5:53-6.  Back to cited text no. 11
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12.
Ali R, Jalil A, Qureshi A. Extra spinal osteoarticular tuberculosis: A case series of 66 patients from a tertiary care hospital in Karachi. J Pak Med Assoc 2012;62:1344-8.  Back to cited text no. 12
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13.
Panchonia A, Kulkarni CV, Mehar R, Mandwariya S. Isolated tuberculous dactylitis (spina ventosa) in a 9 year old boy-A rare entity. Int J Basic Appl Med Sci2012;2:52-5.  Back to cited text no. 13
    


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