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 Table of Contents  
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 343-345

An exceptional location of tuberculous arthritis: The metatarsal phalangeal joint

1 Department of Orthopedic Surgery and Trauma, MT Maamouri Hospital, Nabeul, Tunisia
2 Department of Pharmacology, MT Maamouri Hospital, Nabeul, Tunisia
3 Department of Plastic Surgery, La Rabta Hospital, Tunis, Tunisia

Date of Web Publication13-Feb-2017

Correspondence Address:
Mohamed Ali Sbai
MT Maamouri Hospital, La Mrezga, 8000 Nabeul
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Source of Support: None, Conflict of Interest: None

DOI: 10.1016/j.ijmyco.2016.05.002

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Osteoarticular tuberculosis is a rare type of tuberculosis. The spine is the most frequent location, while peripheral locations in the limbs are rare. We report a case of tuberculous osteoarthritis of the metatarsophalangeal joint of the first ray of the foot in a 48-year-old woman.
The patient presented with painful swelling of the dorsum of the big toe, insidiously evolving for 6 months. Diagnosis was obtained with histological study after surgical biopsy. Antitubercular chemotherapy for 12 months promoted healing.
Through this clinical case the authors describe the epidemiological, diagnostic features, and treatment of osteoarticular tuberculosis and discuss the causes of delayed diagnosis often encountered in these exceptional locations and differential diagnoses, gout in particular, for this particular case.

Keywords: Antituberculous chemotherapy, Foot, Metatarsophalangeal joint, Osteoarthritis, Tuberculosis

How to cite this article:
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

How to cite this URL:
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 [serial online] 2016 [cited 2022 Jan 27];5:343-5. Available from: https://www.ijmyco.org/text.asp?2016/5/3/343/200077

  Case report Top

We report a case of a 48-year-old woman without any pathological history or prior notion of tuberculous contagion. She presented with swelling of the big toe of the left foot, evolving for more than 6 months. The toe was slightly painful, without local inflammatory signs. She had no complaints regarding any other joints. There was no history of fever, weight loss, loss of appetite, trauma, or septic inoculation, and the patient was not immunodeficient. She was taking analgesics for months without improvement.

A clinical study revealed swelling of the big toe and the metatarsophalangeal joint of the big toe was painful to palpation and to mobilization ([Figure 1]). The pleuropulmonary and musculoskeletal study was without any abnormalities. Radiography of the foot revealed a near-total destruction of the metatarsophalangeal joint of the big toe ([Figure 2]). A blood test showed an elevated erythrocyte sedimentation rate (48 mm/h) with a normal white blood cell count.
Figure 1: Clinical appearance before treatment.

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Figure 2: Radiological appearance before treatment.

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A surgical biopsy was performed. The histological study revealed granulomatous inflammation with caseous necrosis confirming the diagnosis of tubercular osteoarthritis. Chemotherapy was prescribed for 12 months, consisting of four antitubercular drugs (isoniazid, rifampicin, pyrazinamide, and streptomycin) over 2 months followed by bitherapy (isoniazid and rifampicin) for 10 months.

Clinical control revealed an improvement with pain relief and a reduction in the volume of the swelling. Radiological control showed a progressive regression of the bone destruction with osseous reconstruction ([Figure 3],[Figure 4],[Figure 5]).
Figure 3: After 6 months of medical treatment.

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Figure 4: After 10 months of medical treatment.

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Figure 5: After 15 months of medical treatment.

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  Discussion Top

Despite the relatively limited attention to tuberculosis, it remains one of the major infections that causes death around the world [1]. Osteoarticular tuberculosis (OAT) represents 2–5% of all tuberculosis localizations and 11–15% of extrapulmonary tuberculosis [2]. In at least 50% of cases the main location is the spine [3],[4]. Localization in the foot and ankle is rare and involvement of the metacarpal phalangeal joint is exceptional. To our knowledge, this is the first case ever reported of OAT of the metacarpal phalangeal joint of the big toe.

The location of tuberculosis at the metatarsophalangeal joint of the big toe is misleading and poses a differential diagnosis of gout, explaining the diagnosis delay and the importance of bone and joint destruction.

While many authors attach trauma as a trigger in the development of OAT by reactivating dormant Koch's bacillus, others think that trauma could simply be the reason for consultation [5].

The nonspecific clinical features explain the delayed diagnosis. The main clinical manifestations are pain and swelling. Systemic manifestations such as fever, night sweats, and weight loss are rare. At an advanced stage, a fistulization to the skin could be observed [6]. The intradermal tuberculin reaction test is positive in 90% of cases of immunocompetent patients, but its negativity does not exclude the diagnosis of tuberculosis [7].

Plain radiographs show soft tissue swelling at first, then decalcification, and at least progressive bone destruction. Martini [8] proposed four stages of radiological classification from discrete epiphyseal osteoporosis to complete joint destruction with deformity [9].

Magnetic resonance imaging remains the investigation of choice because it is sensitive from the beginning of the infection and can distinguish infected bone areas from healthy zones and shows precisely the extension to the soft tissues, the surrounding joints, and studies synovial hypertrophy and cartilage destruction; however, it remains an expensive tool.

Clinical features and laboratory tests are usually helpful to guide the diagnosis. The bacteriological and histological analysis after surgical biopsy remains essential for confirmation [10]. OAT is a paucibacillary form in which the Mycobacterium tuberculosis is a quiescent, slow multiplication type. Sometimes the diagnosis of OAT is difficult given its paucibacillary nature. Diagnosis is confirmed using the polymerase chain reaction method. This technique is based on the detection of the mycobacterial DNA with a specificity of 92–98% [11],[12].

The treatment of OAT mainly consists of long-term antitubercular chemotherapy: isoniazid, rifampicin, pyrazinamide, and streptomycin for 2 months, and then isoniazid and rifampicin for 10–14 months, along with immobilization which leads to a progressive eradication of the Mycobacterium tuberculosis, whereas the radiological lesions improve slowly until complete osseous reconstruction leaving painful sequelae and deformities [13].

Surgical treatment is indicated in cases of medical treatment failure, when synovitis persists, or in cases of fistulization or abscess. Finally, surgery can correct deformities and painful sequelae [14],[15]. Arthrodesis in the foot and ankle are the gestures usually indicated at this stage.

  Conclusion Top

Tuberculous involvement of the foot is still an exceptional localization of tuberculosis evolving, in an insidious way, with poor clinical presentation and usually a delay in diagnosis.

In cases of long standing pain and swelling of the big toe mimicking gout, tuberculosis should be suspected, especially in an endemic country. Efficiency of antitubercular treatment remains undisputed with a progressive regression of bone destruction and osseous reconstruction with good functional outcome.

  Conflicts of interest Top

The authors have nothing to disclose.

  References Top

M.S. Dhillon, O.N. Nagi, Tuberculosis of the foot and ankle, Clin. Orthop. Relat. Res. 398 (2002) 107–113.  Back to cited text no. 1
P.C. Jutte, J.H. van Loenhout-Rooyackers, M.W. Borgdorff, et al, Increase of bone and joint tuberculosis in The Netherlands, J. Bone Joint Surg. Br. 86 (2004) 901–904.  Back to cited text no. 2
E. Pertuiset, J. Beaudreuil, A. Horusitzky, et al, Epidemiological aspects of osteoarticular tuberculosis inadults. Retrospective study of 206 cases diagnosed in the Paris area from 1980 to 1994, Presse Med. 26 (1997) 311–315.  Back to cited text no. 3
K. Benbouazza, A. El Maghraoui, N. Lazrak, et al, Les aspectsdiagnostiques de la tuberculose ostéoarticulaire. Analysed'une sé rie de 120 cas identifiés dans un service derhumatologie, Sem. Hop. Paris 75 (1999) 1057–1064.  Back to cited text no. 4
M.A. Berrady, I. Hmouri, A. Benabdesslam, et al, A rarelocation of tuberculosis arthritis of the metatarsalphalangeal, Pan Afr. Med. J. 17 (2014) 323.  Back to cited text no. 5
T.T. Zacharia, J.R. Shah, D. Patkar, et al, MRI in ankletuberculosis: review of 14 cases, Aust. Radiol. 47 (2003) 11–16.  Back to cited text no. 6
F.F. Nielsen, O. Helmig, A. Carvalho, Case report 533: tuberculosis of calcaneus and talus with negative tuberculinskin test, Skeletal Radiol. 18 (1989) 153–155.  Back to cited text no. 7
M. Martini, La tuberculose osté o-articulaire, Springer Verlag, Berlin, 1988.  Back to cited text no. 8
N. Ridley, M.I. Shaikh, D. Remedios, et al, Radiology of skeletaltuberculosis, Orthopedics 21 (1998) 1213–1220.  Back to cited text no. 9
S. Masood, Diagnosis of tuberculosis of bone and soft tissueby fine-needle aspiration biopsy, Diagn. Cytopathol. 8 (1992) 451–455.  Back to cited text no. 10
R. Ghorbel, C. Campaore, V. Farrenq, et al, Localisationinhabituelle d'une tuberculose ostéoarticulaire, Rev. Rhum. 74 (2007) 1114.  Back to cited text no. 11
E. Pertuiset, Tuberculose ostéoarticulaire extravertébrale, Rev. Rhum. 73 (2006) 387–393.  Back to cited text no. 12
M.A. Sbai, S. Benzarti, H. Sahli, et al, Osteoarticulartuberculosis dactylitis: four cases, Int. J. Mycobacteriol. 4(2015) 250–254.  Back to cited text no. 13
S.M. Tuli, General principles of osteoarthicular tuberculosis, Clin. Orthop. Relat. Res. 398 (2002) 11–19.  Back to cited text no. 14
S. Inoue, S. Matsumoto, Y. Iwamatsu, et al, Ankletuberculosis: a report of four cases in a Japanese hospital, J. Orthop. Sci. 9 (2004) 392–398.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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