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CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 2  |  Page : 155-156  

Skeletal tuberculosis leading to pathological fracture


1 MGM Medical College and Hospital, Aurangabad, Maharashtra, India
2 Department of Pediatrics, B. J. Wadia Hospital for Children, Mumbai, Maharashtra, India

Date of Submission20-Mar-2018
Date of Acceptance15-Jul-2018
Date of Web Publication25-Mar-2019

Correspondence Address:
Ira Shah
1/B Saguna, 271/B St Francis Road, Vile Parle, Mumbai - 400 049, Maharashtra
India
Lavina Vijay Desai
41, Juhu Ajanta, Gulmohar Road No. 1, JVPD Scheme, Mumbai - 400 049, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_47_18

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  Abstract 


Skeletal tuberculosis (TB) is usually present in 1%–3% of active TB patients. Those with altered immunity have an increased of Skeletal TB. The most commonly involved sites are hip (20%), knee (10%), ankle and foot (5%), and shoulder (1%), and the most common forms of presentation are arthritis, spondylitis, and osteomyelitis. Tuberculous pathological fracture is a rare presentation, and only three cases have been reported in literature. We present a case of a 4½-month-old boy with a nontraumatic fracture of the humerus secondary to TB. Our patient was started on a four-drug regimen consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide and advised immunodeficiency workup.

Keywords: Pathological fracture, skeletal tuberculosis, skeletal tuberculosis in children, tuberculosis pathological fracture, tuberculosis


How to cite this article:
Desai LV, Shah I. Skeletal tuberculosis leading to pathological fracture. Med J DY Patil Vidyapeeth 2019;12:155-6

How to cite this URL:
Desai LV, Shah I. Skeletal tuberculosis leading to pathological fracture. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Apr 18];12:155-6. Available from: http://www.mjdrdypv.org/text.asp?2019/12/2/155/254772




  Introduction Top


At present, there are nearly 30 million people suffering from active tuberculosis (TB) worldwide, of these 1%–3% have involvement of the skeletal system.[1] Skeletal TB is usually secondary to primary involvement of the chest or genitourinary system,[2] and the overall occurrence in children younger than 5 years is unknown, but lies somewhere between 5% and 10% with half of them involving the spine.[3] Other sites involved are hip (20%), knee (10%), ankle and foot (5%), hand and wrist (3%), and shoulder (1%).[1] Previously, only three cases of tuberculous pathological fracture have been reported in literature.[4],[5],[6] We report a 4½-month-old boy with a nontraumatic fracture of the humerus secondary to TB.


  Case Report Top


A 4½-month-old boy presented in March 2016 with a fever for 10 days and a history of a nontraumatic fracture of the left humerus at 2½ months of age. In February 2016, he had decreased movement of the left arm and X-ray of the arm had shown fracture in the proximal 1/3rd of the humerus. Magnetic resonance imaging of the left arm showed a pathological fracture with metastatic lesion in proximal 1/3rd of humerus. Computed tomography chest and abdomen was suggestive of extra-adrenal mass encasing the aorta with pulmonary metastasis. He was suspected to have neuroblastoma. However, a bone marrow examination was normal and hemogram showed hemoglobin of 10.3 gm/dl, white cell count of 4300 cells/cumm (80% polymorphs and 8% lymphocytes), and platelets of 179,000 cells/cumm. Biopsy of the left humerus showed a caseating granuloma without the presence of acid-fast bacilli (AFB) on the smear. Serum immunoglobulin G was 1.41 g/dl (normal - 2.32–14.11 g/dl) whereas IgA and IgM were normal. Investigations for suspected neuroblastoma were not done as the biopsy of the humerus showed granuloma. There was no contact with a patient suffering from TB. He was then referred to us for further management. On presentation in March 2016, he still had swelling over the left arm and the range of motion of his left shoulder was restricted. No reaction was observed at or around the fracture site. There were multiple subcentrimetric cervical lymph nodes along with hepatosplenomegaly. Other systems were normal. He was suspected to have disseminated TB and an underlying immunodeficiency as he had lymphopenia and low serum IgG levels. In view of his multiple pulmonary lesions, his primary focus was suspected to be in his lungs. He was started on four-drug antituberculous therapy consisting of isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z). He was also advised immunodeficiency workup in the form of lymphocyte subset analysis, HIV ELISA, and workup for mendalian susceptibility for mycobacterial diseases, but was subsequently lost to follow-up within 15 days of starting therapy. X-ray of humerus and chest are unavailable for review.


  Discussion Top


Skeletal TB refers to involvement of bones and joints. Primary infections with Mycobacterium tuberculosis may cause bacillemia which leads to seeding of organisms in bone and synovial tissue. Small foci of infections are confined by local adaptive immune responses and reactivation of these focus are contained by cellular immune responses with CD4 and CD8 T lymphocytes playing an important role.[7] thereby making immunocompromised patients more likely to progress to tuberculous disease and develop extrapulmonary manifestations.[8] Other systemic factors which affect host immunity and may facilitate development of skeletal TB are diabetes mellitus, autoimmune disorders, AIDS, agranulocytosis, anemia, chemotherapy, corticosteroid therapy, alcohol, tobacco, drug abuse, prior major surgery, herpes simplex virus infection, herpes zoster virus infection, and cytomegalovirus infection.[6]

Forms of skeletal TB include spondylitis (most common), arthritis, and osteomyelitis.[7] Fracture as a presentation of TB is rare.[4],[5],[6] Our patient presented with a tuberculous pathological fracture as a presentation which was initially mistaken as a neoplastic lesion. Pathological fractures in children are generally due to benign or malignant tumors, metabolic diseases, or infections, and radiological imaging along with microscopy and culture is required to establish the diagnosis.[9] In our patient, we also suspected an underlying immunodeficiency due to lymphopenia and hypogammaglobulinemia. Since the extent of involvement of the bone was extensive, it may have led to the fracture. The current recommendation for the treatment of skeletal TB is 2-month initial phase of Isoniazid, Rifampin, Pyazinamide, Ethambutol followed by 6–12 months' regimen of HR. This case highlights the importance of high index of suspicion when evaluating a patient with an unusual destructive bone lesion, especially in a susceptible epidemiological and clinical setting of TB.[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am 1996;78:288-98.  Back to cited text no. 1
    
2.
Autzen B, Elberg JJ. Bone and joint tuberculosis in Denmark. Acta Orthop Scand 1988;59:50-2.  Back to cited text no. 2
    
3.
Dormans JP. Muskuloskeletal infections. Pediatric Orthopedics and Sports Medicine: The Requisites in Pediatrics. Surgery in Africa, 2011;p. 106.  Back to cited text no. 3
    
4.
Jenyo MS, Komolafe F. Tuberculous pathological fracture of the femur in a 15-year-old boy. Pediatr Radiol 1986;16:260-1.  Back to cited text no. 4
    
5.
Harris RI, Coulthard HS. Multiple pathological fractures caused by tuberculosis. Can Med Assoc J 1939;41:434-6.  Back to cited text no. 5
    
6.
Gadgil RM, Bhoosreddy AR, Upadhyay BR. Osteomyelitis of the mandible leading to pathological fracture in a tuberculosis patient: A case report and review of literature. Annals of Tropical Medicine and Public Health 2012;5:383-6.  Back to cited text no. 6
    
7.
McDonald M, Sexton DJ. Skeletal Tuberculosis. Available from: https://www.uptodate.com/contents/skeletal-tuberculosis. [Last accessed on 2018 Feb 15].  Back to cited text no. 7
    
8.
Cruz AT, Starke JR. Clinical manifestations of tuberculosis in children. Paediatr Respir Rev 2007;8:107-17.  Back to cited text no. 8
    
9.
De Mattos CB, Binitie O, Dormans JP. Pathological fractures in children. Bone Joint Res 2012;1:272-80.  Back to cited text no. 9
    




 

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