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A Case of Tuberculous Sacro-iliitis
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A Case of Tuberculous Sacro-iliitis

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  • 1. AN INTERESTING CASE OF BACKPAIN Prof.K.H.Noorul Ameen’s Unit Dr.E.Thirulogachandar
  • 2.
    • A 17 year old female came with
    • c/o backpain-2 months
    • c/o fever-1 month
  • 3.
    • Backpain- 2 month duration in lower back over buttock region associated with difficulty in walking
    • Persists even after rest or in morning
    • It is relieved by activity,occurs nocturnally and wakes the patient
    • Fever-1 month ,intermittent low grade, not associated with chills rigor
    • No h/o pain over other joints or swelling
    • H/o significant weight loss
    • H/o loss of appetite
    • No h/o skin lesions,oral ulcers,abdominal pain or passing blood mixed with stools
    • No h/o cough with expectoration or haemoptysis
    History of presenting illness
  • 4. Past history
    • No h/o burning micturition,dysentery
    • No h/o previous similar illness or migratory polyarthritis
    • No h/o tuberculosis
  • 5.
    • Personal &Family history:
    • nil significant and no h/o contact with tuberculosis
  • 6.
    • On examination
    • Pt is conscious,
    • oriented,
    • febrile,
    • nourishment poor- BMI-17
    • Anaemia
    • Not jaundiced,
    • No clubbing,
    • Lymphadenopathy in cervical and axillary region of size 1-2 cm ,multiple,mobile,firm,not matted
  • 7.
    • CVS-S1,S2 heard,no added sounds and no murmurs
    • RS-NVBS present bilaterally.no added sounds
    • Abdomen-soft,no organomegaly
    • CNS-No focal neurological deficit
  • 8.
    • Local examination:
    • Tenderness over the sacral region at the sacroiliac junction and posterior superior superior iliac spine.
    • Movements of spine-normal
    • Movements of chest-normal and expansion 4cm
    • Straight leg raising test -negative
  • 9. TESTS FOR SACROILITIS
  • 10.
    • Pelvic diastation test -positive
    • Patrick or FABER Test-positive
    • Stork test
    • Gaenslen's test -positive
  • 11.
    • Gaenslen's test Gaenslen's test is performed with the patient supine (on the back). The hip joint is maximally flexed on one side and the opposite hip joint is extended. This maneuver stresses both sacroiliac joints simultaneously.
  • 12.  
  • 13.
    • Provisional diagnosis-
    • Back pain due to sacroilitis
  • 14. Investigations
    • Hb -8.5gm/dl
    • Tc-5600
    • Dc-P65L32E3
    • ESR-58/72
    • Platelets-1.7 lacs
    • Mantoux-negative
    • Urine:
    • Alb-nil
    • Sugar-nil
    • Dep-2-3pc/hpf
    • ECG-WNL
    • X-Ray chest PAview- Normal
  • 15. X-RAY AP VIEW OF BOTH SACROILIAC JOINTS
  • 16.  
  • 17. Immunological profile
    • CRP-12mg/dl
    • ASO-negative
    • RF-negative
    • ANA-negative
    • HLAB27-negative
    • HIV-negative
    • Ig M Brucellosis- negative
    • Ser.Alkaline phosphatase-180 iu/l
  • 18.  
  • 19.  
  • 20. Seronegative spondyloarthropathies
    • A nkylosing spondylitis (the prototype)
    • P soriatic arthritis
    • R eactive arthritis
      • Formerly called Reiter’s syndrome)
    • E nteropathic arthritis
    • U ndifferentiated spondyloarthropathy
    • Mnemonic is PURE-A
  • 21.
    • Familial tendency
    • Negative for RF and other antibodies
    • No subcutaneous nodules
    • Associated with HLA B27
  • 22. Ankylosing spondylitis
    • Inflammatory back pain requires 4 of these 5 criteria (serves as a screening tool for AS)
      • Y oung onset (  40 years)
      • M orning stiffness (  30 minutes)
      • C hronic (  3 months)
      • A ctivity improves the pain (rest does not)
      • I nsidious (not acute)
      • (mnemonic is YMCA-I)
    • Diffuse lumbar or gluteal
    • Inflammatory back pain
  • 23. Ankylosing spondylitis
    • Low back pain  3 months improved by exercise and not relieved by rest
    • Limitation of lumbar spine in sagittal and frontal planes
    • Chest expansion reduction relative to normal values corrected for age and sex (costovertebral ankylosis, 25%)
    • Radiographic criteria of sacroiliitis
      • Bilateral grade 2-4 OR
      • Unilateral grade 3-4
    • Ankylosing spondylitis is defined by the presence of either radiographic criterion PLUS any clinical criterion
    • Modified New York Diagnostic Criteria
  • 24. Ankylosing spondylitis
    • Radiographic evaluation
    Sacroiliac joints Grade 0 Normal Grade 1 Suspicious changes Grade 2 Minimal abnormality – small localized areas with erosion or sclerosis without alterations in joint width Grade 3 Unequivocal abnormality – moderate or advanced sacroiliitis with  1 of the following: erosions, sclerosis, widening, narrowing, or partial ankylosis Grade 4 Severe abnormality – total ankylosis
  • 25. Reiter’s syndrome and Reactive arthritis (ReA)
    • Prevalence: 16 per 100,000
    • Primarily young adults, aged 20-40 years
    • M:F ratio 1:1 for enterogenic reactive arthritis
    • M>F ratio for urogenital reactive arthritis
    • Rare in children and uncommon in Blacks
    • Arthritis
    • - Mono-or oligo-arthritis (< 5 joints)
    • - Sacroilitis
    • - Spondylitis
    • - Enthesitis
    • 80% resolve within 12 months
  • 26. Reactive arthritis
    • Clinical syndrome triggered by specific etiologic agents in a genetically susceptible host
    • Follows 1-4 weeks after a
      • Urogenital infection (affects principally men)
        • Usually C. trachomatis
      • Enteric infection (affects both genders equally)
        • Salmonella
        • Shigella
        • Campylobacter
        • Yersinia
    • Pathogenesis
  • 27. Reactive arthritis
    • Non gonococcal urethritis
    • Keratoderma blenorrhagica
      • A papulosquamous skin rash
      • Comprises vesicles that become hyperkeratotic, forming crusts before disappearing
        • Palms/soles
        • Penis (causing circinate balanitis)
    • Oral ulcers (ususally shallow and painless)
    • Inflammatory back pain (50% of patients)
    • Enthesitis (40%)
    • Dactylitis (40%)
    • Anterior uveitis (20% of patients)
    • Clinical (continued)
  • 28. Enteropathic Arthritis
    • Affects 10-20% of patients with inflammatory bowel disease (IBD)
    • Peripheral arthritis affects 10-20% of IBD patients
      • Generally affects knees, ankles, and feet
      • Always indicates active IBD
    • Radiographic axial arthritis affects 10% of IBD patients
      • Frequently asymptomatic
      • Independent of bowel inflammation
  • 29.  
  • 30. CONTRAST OF SPONDYLOARTHROPATHY Feature Ankylosing Spondylitis Enteropathic Arthritis Psoriatic Arthritis Reactive Arthritis Male-female ratio 3:1 1:1 1:1 10:1 HLA association B27 B27(axial) B27(axial) B27 Joint pattern Axial Axial and peripheral Axial and asymmetrical peripheral Axial and asymmetrical peripheral Sacroiliac Symmetrical Symmetrical Asymmetrical Asymmetrical Syndesmophyte Smooth, marginal Smooth, marginal Coarse, nonmarginal Coarse, nonmarginal Eye Iritis +/- 0 Iritis and conjunctivitis Skin 0 0 Psoriasis Keratoderma Rheumatoid factor 0 0 0 0
  • 31.
    • FNAC Of Cervical Lymph node-Reactive lymphadenitis
    • Biopsy of lymphnode-caseating granuloma with Acid Fast Bacilli –suggestive of Tb lymphadenitis
  • 32.
    • Ortho opinion –sacroilitis consider Tb aetiology and start ATT
    • Rhematologist opinion-sacroilitis –advised CT sacroiliacjoint ,ANA and review
  • 33.
    • Tuberculosis affect musculoskeletal system in about 1-5% of case.
    • Among skeletal system
    • spine involvement in 50%,
    • oligoarticular joint in 20%
    • Sacroliliac joint involvement in 3-9.7% among skletal Tb
  • 34.
    • Sacroiliac joint tuberculosis is frequently missed because of the vague symptoms .
    • The sacroiliac joint may be secondarily involved following a psoas abscess affecting
    • the lower lumbar spine .
    • A false positive straight leg raising test may be present, due to capsular distention irritating the lumbosacral plexus .
    • Rectal examination may elicit tenderness over the affected sacroiliac joint
  • 35.
    • X-rays reveal haziness initially, but this is replaced by joint widening, sclerosis of the margins and possible sequestrae in the joint in the more advanced stages
    • CT scan demonstrate the joint space widening, sequestrae and calcification more clearly than X-ray
  • 36.
    • Evidence of calcification, sequestrae and joint destruction on X-ray or CT scan is suggestive of tuberculous infection.
    • In the early stages of the infection aspiration using a closed needle biopsy is recommended.
    • An open biopsy is essential when the aspirate yields no growth and in patients who present late with severe joint destruction .
    • International Orthopaedics (SICOT)
    • R. J. S. Ramlakan . S. Govender
    • Sacroiliac joint tuberculosis 4 May 2006
    • Springer-Verlag 2006 31: (2007) 121–124
  • 37. Freire M , Graña J , Míguez E , Pombo F , Atanes A , de Toro J , García Porrua C , Galdo B . An Med Interna. 1995 May;12(5):255-6 Sacroilitis as initial manifestation of miliary tuberculosis
  • 38. Enferm Infecc Microbiol Clin. 1999 Feb;17(2):99-101. [Disseminated tuberculosis manifesting as a clinical picture of sacroiliitis] [Article in Spanish] Maestre JR , Quesada R , Fernández A .
  • 39.
    • CT Sacroiliac joint-Wedge shaped erosion,with kissing sequestrum and cyst like erosion of joint suggestive of Tuberculous etiology
  • 40.
    • FINAL DIAGNOSIS-TUBERCULOUS SACROILITIS
    • Pt was started on Cat I ATT and asked to review after 4 weeks.She became afebrile and improved of constitutional symptoms and pain has become decreased.
  • 41.
    • Thank you