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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 338-340

Tuberculosis with multiarticular involvement diagnosed by positive acid-fast staining in synovial fluid: An unusual case report


1 Department of Clinical Medicine, Health Science Center; Postgraduate Program Gerontology, Universidade Federal de Santa Maria, Santa Maria, Brazil
2 Department of Clinical Medicine, Health Science Center, Universidade Federal de Santa Maria, Santa Maria, Brazil

Date of Submission01-Aug-2021
Date of Acceptance30-Aug-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Diego Chemello
Av. Presidente Vargas,2084. Sala1101. CEP: 97015-512 Centro Profissional Pedro Martinez - Centro, Santa Maria - RS
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_144_21

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  Abstract 


Osteoarticular tuberculosis (TB) is an uncommon form of extrapulmonary TB, comprising approximately 5% of all TB and 10%–15% of extrapulmonary TB cases. Multifocal skeletal TB is rare and accounts for 10% of all osteoarticular TB cases. Sometimes, the diagnosis is difficult. The potential delay in the clinical diagnosis may be critical for patients since it can cause the spread of the infection from the bone to the adjacent joints and surrounding tissues. We present a rare case of military TB with multiarticular involvement in a patient with chronic tophaceous gout. The initial diagnosis was confirmed throughout the positive analysis for Ziehl–Nielsen acid-fast staining in synovial fluid of two different joints, which is unusual. The patient was treated with antituberculosis drugs and presented good recovery signs.

Keywords: Gout, Mycobacterium tuberculosis, tuberculosis osteoarticular


How to cite this article:
Chemello D, Londero Chemello RM, Jahnke GT. Tuberculosis with multiarticular involvement diagnosed by positive acid-fast staining in synovial fluid: An unusual case report. Int J Mycobacteriol 2021;10:338-40

How to cite this URL:
Chemello D, Londero Chemello RM, Jahnke GT. Tuberculosis with multiarticular involvement diagnosed by positive acid-fast staining in synovial fluid: An unusual case report. Int J Mycobacteriol [serial online] 2021 [cited 2021 Dec 8];10:338-40. Available from: https://www.ijmyco.org/text.asp?2021/10/3/338/325502




  Introduction Top


Osteoarticular tuberculosis (OAT) tuberculosis (TB) is an uncommon form of extrapulmonary TB, comprising approximately 5% of all TB and 10%–15% of extrapulmonary TB cases.[1] Multifocal osteoarticular TB accounts for only 10% of all osteoarticular TB.[2] Concurrent gout and Mycobacterium tuberculosis arthritis (specially polyarticular) are rare, with few case reports described so far.[3] Most rare is the direct detection of the bacillus on synovial fluid.[4]

The potential delay in the clinical diagnosis may be critical for patients since it can cause the spread of the infection from the bone to the adjacent joints and surrounding tissues. Functional disabilities and death and the most threatened consequences. The early use of anti-tuberculous drugs is effective.


  Case Report Top


A 63-year-old male patient with chronic gout presented to the hospital with a 3-month history of pain, volume increase, and swelling on previous tophaceous lesions, particularly in knees, ankles, wrists, and elbows. Over the past week, some lesions became erythematous and tender, especially in the left ankle, where a purulent discharge was present. His medical history was characterized by chronic and severe tophaceous gout, gouty arthritis, and renal impairment function (creatinine clearance of 30 ml/min). He also had a history of smoking and alcohol abuse. On physical examination, he presented with mild fever episodes (max. 37, 6° C), normal blood pressure, and oxygen saturation levels (142/86 mmHg and 98% in room air, respectively). Several tophaceous lesions were observed in wrists, elbows, knees, and ankles with articular deformities [Figure 1]. There were signs of edema and increase in temperature around the left elbow and left ankle. Laboratory examination revealed mild normocytic and normochromic anemia (hemoglobin of 9.0 mg/dL), increased white cells in peripheral blood (leukocytes of 21,010 with 5% immature forms). There was renal impairment function (creatinine 5.65 mg/dL) and metabolic acidosis (lactate levels of 1.9 mg/dl and serum bicarbonate of 6.5 mg/dL). Liver function tests were normal. Serology tests for HIV and hepatitis B and C were negative. Blood cultures were also negative.
Figure 1: (a) – Right swollen knee with signs of joint effusion. (b) – Tuberculous bacilli (acid-fast bacilli, black arrow) presented within the infiltrate of the synovial fluid. (c) – Tophaceous gout presented in the right feet. (d) – Right hand radiology showing signs of gouty arthritis

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After a presumptive diagnosis of septic arthritis, the patient was started on ceftriaxone and clindamycin. Synovial fluid analysis of the right knee was negative for bacteria but showed the presence of urate crystals. In addition, the polymerase-chain reaction (PCR) for M. tuberculosis and the Ziehl-Nielsen acid-fast staining (AFS) were both positive [Figure 1]. A chest computed tomography (CT) was performed, revealing nodules of 1–3 mm, sharply and poorly defined, diffusely spread in random distribution in both lungs. There were also multiple enlarged lymph nodes in mediastinum [Figure 2]. A fibrobronchoscopy examination with broncoalveolar lavage revealed a positive PCR for M. tuberculosis.
Figure 2: Chest computed tomography in sagittal (a) and axial (b) views revealing nodules of 1–3 mm, sharply and poorly defined, diffusely spread in random distribution in both lungs, characteristic of miliary tuberculosis

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Anti-tuberculous treatment was initiated with renal dose adjustment of rifampin, isoniazid, pyrazinamide, and ethambutol (RHZE regimen) with clinical improvement of inflammatory signs on articular lesions.


  Discussion Top


We present a rare case of miliary TB with diffuse osteoarticular involvement in a patient with chronic tophaceous gout. Miliary TB results from hematogenous dissemination of the TB bacilli, leading to the development of innumerable small granulomas in lungs and other organs. OAT is an uncommon form of extrapulmonary TB. It represents 2%–5% of all TB localizations and 10%–15% of extrapulmonary TB.[1] In at least 50% of cases the main location is the spine, following by the hips and knees.[5] Localization in the foot and ankle is rare. Multifocal skeletal TB is rarer and accounts for 10% of all osteoarticular TB cases.[2]

Few examples of coexistent gout and mycobacterial arthritis in immunocompromised patients have been reported.[6],[7] Rare cases have been reported in nonimmunocompromised.[3],[8] Rupture of the tophi with secondary wound infection is the most likely route for bacterial infections. Ongoing destruction of joint and periarticular tissues with alterations of the hemodynamic circulation and inflammatory milieu may provide a hematogeneous nidus for mycobacterial infections. In the present case, the isolation of M. tuberculosis in multiple sites, including the synovial fluid of two different joints, favors the hematogenous spread of OAT.

The differential diagnosis with septic arthritis should always been considered. This diagnosis, although simple, can become challenging when crystal-induced arthritis presents simultaneously. Both patients with septic and those who develop crystal-induced arthritis can manifest pain, rubor and joint swelling; therefore, it is essential to perform an arthrocentesis with microbiological analysis of synovial fluid to establish a precise diagnosis. Regardless of whether the leukocyte count in synovial fluid is remarkably high, or whether Gram staining shows microorganisms, it is imperative to take cultures, including mycobacterial cultures in cases with a more subacute course.[9] On synovial fluid analysis, the positive rates in detecting M. tuberculosis throughout polymerase chain reaction are approximately 82%. However, since osteoarticular TB is usually paucibacillary, Ziehl-Nielsen AFS positivity was reported in only 6.12%. In the present case, the presence of AFS bacilli in several synovial fluid analyses reinforces the hematogenous route for dissemination of disease.

One should consider the potential problems in treating TB in this case, since drug-induced hyperuricemia is a well-known adverse effect of several anti-TB drugs.[10] For example, the incidence of PZA-induced hyperuricemia has been reported to affect 43%–86.3% of patients treated with PZA alone or in combination therapy.[10] The main mechanism of hyperuricemia with this drug is through the anti-uricosuric effect, causing a more than 80% reduction in renal clearance of uric acid when administered at a 300 mg therapeutic daily dose.[10] Despite the limitations, the patient received the classic RHZE regimen with renal dose adjustment. Fortunately, there was no further gout exacerbation. This reinforces the presence of diffuse tuberculous arthritis as the main cause of arthritis exacerbation in the present case.


  Conclusion Top


Multiarticular TB, particularly with concomitant gouty arthritis is such a rare disease that a high index of suspicious is required for a diagnosis. The diagnosis is usually supported by histopathological examination and since osteoarticular TB is usually paucibacillary, Ziehl–Nielsen AFS positivity was reported in only 6.12%. Early initiation of anti-TB treatment is essential. Sometimes, surgical debridement and complete excision of the infected synovium may be required to prevent the complications and deterioration of joint functions.

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.
Jutte PC, van Loenhout-Rooyackers JH, Borgdorff MW, van Horn JR. Increase of bone and joint tuberculosis in the Netherlands. J Bone Joint Surg Br 2004;86:901-4.  Back to cited text no. 1
    
2.
Hu S, Guo J, Ji T, Shen G, Kuang A. Multifocal osteoarticular tuberculosis of the extremities in an immunocompetent young man without pulmonary disease: A case report. Exp Ther Med 2015;9:2299-302.  Back to cited text no. 2
    
3.
Haider N, Aziz M, Khan AQ, Zulfiqar M. Tubercular dactylitis and multifocal osteoarticular tuberculosis--Two rare cases of extrapulmonary tuberculosis. BMJ Case Rep 2011;2011:bcr0920114800.  Back to cited text no. 3
    
4.
Sun YS, Lou SQ, Wen JM, Lv WX, Jiao CG, Yang SM, et al. Clinical value of polymerase chain reaction in the diagnosis of joint tuberculosis by detecting the DNA of Mycobacterium tuberculosis. Orthop Surg 2011;3:64-71.  Back to cited text no. 4
    
5.
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. 5
  [Full text]  
6.
Czachor JS, Gopalakrishnan R. Coexistent gout and Mycobacterium avium-intracellulare arthritis in a renal transplant recipient. Kidney Blood Press Res 1997;20:62-3.  Back to cited text no. 6
    
7.
Santos-Ocampo AS, Tupasi TE, Villanueva F, Roxas FK, Ramos CP. Mycobacterium tuberculosis infection of a tophaceous pseudogout nodule. J Rheumatol 2002;29:1093-6.  Back to cited text no. 7
    
8.
AbdullGaffar B, Abdul Hameed B, Fodeh S, Sreeram R. Concomitant gouty and tuberculous granulomatous arthritis. Int J Surg Pathol 2020;28:288-9.  Back to cited text no. 8
    
9.
Prior-Español Á, García-Mira Y, Mínguez S, Martínez-Morillo M, Gifre L, Mateo L. Coexistence of septic and crystal-induced arthritis: A diagnostic challenge. A report of 25 cases. Reumatol Clin (Engl Ed) 2019;15:e81-5.  Back to cited text no. 9
    
10.
Pham AQ, Doan A, Andersen M. Pyrazinamide-induced hyperuricemia. P T 2014;39:695-715.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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