Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 98-99  

Tubercular monoarthritis of wrist


1 Department of Medicine, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India
2 Central Research Laboratory, Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India

Date of Web Publication9-Jan-2017

Correspondence Address:
Dr. Abhishek Agarwal
Department of Medicine, Sri Aurobindo Medical College and PG Institute, Indore Ujjain Highway, Indore - 453 111, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.197891

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  Abstract 

Tuberculosis (TB) has been a major health concern since decades, and millions continue to be afflicted with this disease. Extrapulmonary sites of TB must not be neglected as there is paucity of systemic manifestations and absence of distinct clinical features which delay its diagnosis and can lead to functional disability and severe infirmities. Osteoarticular TB is an infrequent form of the disease and monoarthritis of the wrist accounts for 1% of all cases of skeletal involvement. Hereby, we report a 45-year-old female patient with history of progressive pain and swelling of right wrist joint which is refractory to analgesics and anti-inflammatory drugs. She was diagnosed to have tubercular monoarthritis after synovial fluid analysis and radiographic findings. Standard antitubercular treatment for 6 months was given. The joint was salvaged after 9 months from the start of the treatment. Pain and swelling of joint were subsided and joint was rehabilitated with full range of motion and weight bearing.

Keywords: Antitubercular treatment, monoarthritis, osteoarticular tuberculosis, tuberculosis, wrist joint


How to cite this article:
Joshi P, Manoria P, Agarwal A, Vyas S, Kumar R. Tubercular monoarthritis of wrist. Med J DY Patil Univ 2017;10:98-9

How to cite this URL:
Joshi P, Manoria P, Agarwal A, Vyas S, Kumar R. Tubercular monoarthritis of wrist. Med J DY Patil Univ [serial online] 2017 [cited 2022 Aug 11];10:98-9. Available from: https://www.mjdrdypu.org/text.asp?2017/10/1/98/197891


  Introduction Top


Tuberculosis (TB) remains one of the most common infections worldwide, but skeletal involvement is seen in only 1–3% of cases.[1],[2] Osteoarticular TB (OAT) accounts for 1–5% of total TB cases and 10–18% of extrapulmonary TB cases. Tubercular bacteria can infect any bone, joint, tendon, or bursa and usually presents as chronic monoarticular arthritis in weight-bearing joints (i.e., vertebrae, hip, and knee). We would like to append this case report in the literature because OAT poses a diagnostic challenge. Unawareness of the existence of this disorder and the absence of distinct clinical manifestation often lead to considerable delay in diagnosis and treatment.[3]


  Case Report Top


A 45-year-old female attended the medicine department with a 6 months history of spontaneous onset right wrist pain and progressive swelling on the dorsoradial aspect of right wrist joint for which patient consulted several physicians who advised analgesics and anti-inflammatory drugs only; however, she did not get relieved. The patient had no recent history of trauma, fever, anorexia, and weight loss. There was no early morning stiffness, reddening of eyes, psoriasis, chronic diarrhea, or any other joint involvement. The patient also has restricted range of motion in all directions and significant pain on mobilizing her affected wrist joint. The rest of the musculoskeletal examination was unremarkable. Routine laboratory investigations including biochemical and hematological tests were all normal except raised erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). X-ray chest was normal. She had positive tuberculin skin test with 18 mm induration. X-ray right wrist (anteroposterior [AP] view) showed extensive bony erosions involving carpal bones and epiphysis of the radius and ulna with loss of joint space suggestive of chronic inflammation [Figure 1]a. The patient was initially continued on analgesics and anti-inflammatory drugs. Synovial fluid culture was sent which revealed mycobacterium TB infection. The diagnosis of wrist TB was made and the patient underwent DOTS Category I antitubercular treatment for 6 months. After completion of Anti Tuberculosis Treatment (ATT), her pain and swelling subsided and she had full range of motion in all directions with full weight-bearing capacity.
Figure 1: X-ray wrist (anteroposterior view) showing extensive bony erosion involving carpal bone and epiphysis of radius and ulna with loss of joint space (a). X-ray wrist after 9 months showing recovered salvage joint (b)

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Follow-up X-ray of right wrist (AP view) after 6 months shows only mild diffuse sclerosis of carpal and epiphysis of radius and ulna with no erosions [Figure 1]b.


  Discussion Top


OAT occurs either through hematogenous spread or direct spread of tubercular bacilli from an adjacent infectious focus.[3] Despite these underlying etiologies, most cases do not have history of pulmonary TB. Involvement of the wrist is exceptional, accounts for 2–4% of OAT cases.[4] Most commonly radial aspect of the hand is afflicted mainly distal radius and bone of the hand (i.e., Scaphoid, trapezium, capitate, and base of 2nd and 3rd metacarpals); our case also showed erosive bone changes in scaphoid and trapezium bone.[5] Diagnosis is usually established on the basis of following parameters, that is, rise in acute phase reactants (ESR and CRP), a positive synovial fluid culture for Mycobacterium tuberculosis, and characteristic radiographic findings.[4] As in our case, acute phase reactants are raised, culture of synovial fluid showed M. tuberculosis, and X-ray of wrist showed the classical Phemister's triad (i.e., juxta-articular osteoporosis, peripheral bone erosions, and gradual narrowing of the joint space), we diagnosed our case to be tubercular arthritis of wrist joint. Treatment of this type of localized TB mainly consists of anti-tubercular regime of 6–12 months.[4],[6] Surgery is usually reserved for biopsies, fistulectomies, and drainage of abscesses.[6]

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Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zychowicz ME. Osteoarticular manifestations of Mycobacterium tuberculosis infection. Orthop Nurs 2010;29:400-6.  Back to cited text no. 1
    
2.
Tuli SM. General principles of osteoarticular tuberculosis. Clin Orthop Relat Res 2002;398:11-9.  Back to cited text no. 2
    
3.
Hadadi A, Rasoulinejad M, Khashayar P, Mosavi M, Maghighi Morad M. Osteoarticular tuberculosis in Tehran, Iran: A 2-year study. Clin Microbiol Infect 2010;16:1270-3.  Back to cited text no. 3
    
4.
Torres Lozano P, Gallach Sanchis D, Pardo Coello MM. Osteoarticular tuberculosis with destructive wrist arthritis secondary to extrapulmonary tuberculosis. Rev Esp Cir Ortop Traumatol 2012;56:378-80.  Back to cited text no. 4
    
5.
Mishra D, Gupta A. Tuberculosis of wrist presenting as scaphoid fracture: A case report. Malays Orthop J 2011;5:47-9.  Back to cited text no. 5
    
6.
Monchal T, Levadoux M, Pellet N, Nguyen MK, Ottomani S, Gaillard C, et al. White tumor of the wrist: A rare site of tuberculosis involvement. Med Trop (Mars) 2007;67:134.  Back to cited text no. 6
    


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