Discussion:
Approximately 10% of extrapulmonary cases of tuberculosis (TB) are musculoskeletal in origin; the most prevalent form of skeletal TB is vertebral involvement, often known as Pott’s disease or tuberculous spondylitis (1). A less prevalent kind of skeletal TB is that which affects the foot and ankle (2). Diagnostic and therapeutic delays are brought on by the rare site, ignorance of the condition, and the condition’s clinical and radiographic mimicry of other conditions; medical treatment results in great healing and no residual problems when the disease is in its early stages and is restricted to the bone (2).
To correctly diagnose musculoskeletal TB, one must have a strong index of suspicion; TB should be taken into consideration in the differential diagnosis of the aetiology of skeletal discomfort because pain is the most frequent complaint that prompts a patient to seek medical attention(1). It’s interesting to note that sometimes local discomfort, edema, and restricted movement occur up to 8 weeks before radiographic findings (3). Patients with suspected musculoskeletal TB and other skeletal disorders can benefit from being evaluated using imaging modalities such as conventional radiography, computed tomography (CT), and magnetic resonance imaging (MRI)(4). The diagnostic process has been transformed, leading to more precise diagnosis, thanks to the use of more recent procedures including CT, MRI, and CT-guided fine needle aspiration biopsy (4, 5). Since there are no pathognomonic radiographic signs, tissue biopsy and/or culture data are typically used to make the diagnosis (6). To prevent function and mobility loss, it’s crucial to get a proper diagnosis and start treatment as soon as possible, if the diagnosis is established early enough, full restoration of function without deformity can be safely expected even if only mild radiologic abnormalities have taken place(1). The biggest benefit of surgery in the current management of musculoskeletal TB may in fact be early diagnosis(3). Extra-pulmonary forms of the illness are also managed according to the same fundamental principles as pulmonary TB(7, 8). Studies on the treatment of bone and joint TB have indicated that 6- to 9-month regimens incorporating rifampin are at least as successful as 18-month regimens that do not contain rifampin for the treatment of drug-susceptible illness (9–11).
M S Dhillon et al. conducted a case series involving 13 patients in 1993, in which they have evaluated the foot and ankle TB from diagnosis and management aspect and concluded that early detection and thorough treatment will result in full recovery without the uncomfortable side effects of a damaged joint; Bone and joint tuberculosis frequently misleads the treating physician with its vast range of clinical and radiological manifestations, which can mimic a variety of foot pathologies; few instances had the typical constitutional signs(2). Only situations where medical management has failed or painful, damaged joints where arthrodesis is a great alternative warrant surgical surgery is indicated (2).
In 2014, Korim M et al. conducted a case series involving 2 patients to highlight the diagnostic pit falls leading to delay in the initiation of treatment; they have stated that foot ankle TB is an uncommon diagnosis that needs a high index of suspicion to enable prompt medical intervention (12). Before beginning protracted multimodal medical therapy, prompt cross-sectional imaging and tissue diagnosis are essential; an incomplete diagnosis could result in worse outcomes; rarely is surgical intervention necessary, and it is only done to make a diagnosis (12).
Not very much different to this case, Kumar P et al. reported a case of a 19-year-old man came with lateral right ankle pain and edema for two months; the skin was attacked to the underlying bone and had an undermined discharge sinus with surrounding induration; diagnosed as lateral malleolar and calcaneal TB; after receiving treatment with antitubercular medications, the patient’s condition completely resolved after three years of follow-up (13).
The educational objective for this case is that skeletal TB is rare and foot and ankle TB is rarest. The diagnosis of foot and ankle TB is challenging because the un-usual presentation and Bone and joint tuberculosis can mimic a variety of foot pathologies with its varied spectrum of clinical and radiological presentations, which frequently misleads the treating clinician. So high index of suspicion is needed in order to establish an early diagnosis and to early start of anti-tuberculous therapy so that to minimize the complications if not prevented.
Conclusion: despite being uncommon, skeletal TB needs to be suspected when multiple bony lesion were present and appropriately treated in the developing countries and in patients with or without history of pulmonary TB.
This case has been reported in line with the SCARE criteria (xx).