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).