Tuberculosis of bones and joints


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Tuberculosis of bones and joints

  1. 1. Dr. Vishal Sankpal
  2. 2.  Spine Joints - Tubercular arthritis Long and flat bones - Tubercular osteomyelitis Short bones – Tubercular dactylitis Tendon sheath & bursae
  3. 3.  Most frequent site of osseous involvement by TB about 50 % of cases The disease was first described by Sir Percival Pott in1779, hence the name Potts disease There has been a resurgence of the disease in the developedcountries following the HIV pandemic. Defined - as an infection by Mycobacterium tuberculosis ofone or more of the extradural components of the spinenamely the vertebra, intervertebral disks, paraspinal softtissues and epidural space
  4. 4.  Usually by hematogenous route Perivertebral arterial or venous plexus is still in debate, but arterialroute considered more important. Primary focus in the lung or other extra-osseous foci such as lymphnodes, GIT or any other viscera Lower thoracic and lumbar vertebrae are most often affected followed by middle thoracic and cervical vertebrae The C2-C7 region is reportedly involved in 3 to 5 % of cases and theatlanto-axial articulation in < 1% of cases Usually two continuous vertebrae are involved but several vertebrae maybe affected, skip lesions and solitary vertebral involvement may occur The so-called skip lesions or a second lesion not contiguous with themore obvious lesion is seen in 4 -10 % of cases.
  5. 5.  begins in the cancellous area of the vertebral body commonly in the para-discal location less often in the centrum or anterior surface The vertebral body becomes soft and gets easilycompressed to produce either wedging or total collapse Anterior wedging is commonly seen in the dorsal spine This produces kyphus with a gibbus deformity Spread of infection can occur beneath the anteriorlongitudinal ligament, involving adjacent vertebral bodies.
  6. 6.  spreads to the adjacent disc The inter-vertebral disk resists infection by Mycobacteriumtuberculosis probably due to a lack of proteolytic enzymes inthe Mycobacterium as compared with pyogenic infection disk destruction begins only when two vertebral bodies areso involved that the disk loses its nutritional support Hence, disk space narrowing occurs later and is less markedin tubercular infection as opposed to pyogenic infection the posterior elements may be affected initially orpredominantly in some persons
  7. 7.  A marked exudative lesion due to hypersensitivityreaction to Mycobacterium occurs results in formation of thick pus Pus contains serum, leukocytes, caseousmaterial, tubercle bacilli and bone fragments whichtracks through the pre and paravertebral soft tissuesforming abscesses The exudate penetrates ligaments and follows the pathof least resistance along fascial planes, blood vesselsand nerves to distant sites from the original bonylesion as cold abscess The abscesses may further extend into the spinal canalproducing an epidural abscess and cord compression
  8. 8.  any age group but majority under 30 years of age Rare in the 1st year of life but when it occurs, it tends to be moresevere with greater bone destruction and multiple vertebralinvolvement Some patients may be afebrile and free of systemic symptomsuntil late stage of the disease, others may present withconstitutional symptoms before symptoms related to the spinemanifest The usual presentation is with persistent spinal pain, localtenderness and limitation of spinal mobility The ESR is elevated in more than 80 % of cases and tuberculinskin test is usually positive.
  9. 9.  Paraparesis in about 20 to 30 % of all patients much higher incidence in cervical region (40 % casesquadriparesis) Early onset paraplegia usually due to cord compression by epidural abscess or granulationtissue, pathological subluxation or dislocation, sequestered bone ordisk fragments Non-mechanical causes include inflammatory cord edema due tovascular stasis and toxins or cord granulation tissue due to passage oftuberculous inflammation to the meninges and eventually the cord Rarely paraplegia may be due to cord infarction due to endarteritis Late onset paraplegia due to dural fibrosis, severe kypho-scoliotic deformity, spinal canalstenosis, gliosis of cord or sequestra from vertebral body Late onset paraplegia has a much less favorable prognosis thanearly onset paraplegia.
  10. 10.  Relative lymphocytosis, a low level of hemoglobin and araised ESR are found in active tubercular disease The Mantoux test is non-diagnostic in an endemic regionand may be negative in an immuno-deficient individuals The sensitivity of AFB staining may vary from 25 to 75 % Culture of AFB requires a long incubation period of 4 to 6weeks, although Bactec radiometric culture takes < 2 weeks
  11. 11. Serological tests Non-diagnostic in lesions with a low level of bacilli IgG and IgM titres show significant differences between theinitiation of treatment and at three months later (can beused for follow up) PCR - efficient and rapid method of diagnosis can differentiate between typical and atypical mycobacteriaHowever, a positive result is not a substitute for culture NOT indicative of the activity of the disease does not differentiate live from dead microorganisms
  12. 12. Conventional Radiographs – Initial investigation often negative in early disease More than 30 to 50 % of mineral must be lost before a radiolucentlesion becomes conspicuous on the plain films and this takesabout 2 to 5 months limited evaluation of cranio-vertebral junction, cervico-dorsal junction, posterior neural arches sacrum
  13. 13. Advantages – early detection of bone and soft tissue changes when plainfilms are normal better anatomic localization and characterization of lesions evaluation of areas difficult to evaluate on plain films such ascranio-vertebral junction, cervico-dorsal junction, sacrum providing guidance for biopsy and surgical approach Early signs as inflammatory marrow changes in the vertebralbody are not well depicted Effect of extradural disease on the thecal sac and itscontained spinal cord and neural elements is difficult toevaluate properly
  14. 14.  modality of choice advantages – multiplanar capability the direct demonstration of early bone marrowinvolvement or edema unsurpassable assessment of spinal canal and neuralinvolvement Soft tissue and Intraosseous abscesses are also welldemonstrated on MR imaging Higher sensitivity for early infiltrative diseaseincluding endplate changes and marrow infiltrationthan bone scan and plain films
  15. 15.  MRI Scores over CT in- Detection of early disease (marrow edema) Skip lesions more easily and more often detected.Incidence of multilevel noncontiguous vertebraltuberculosis is generally reported to be between 1.1 and 16% Detection of epidural, meningeal and cord involvement Planning the surgical approach
  16. 16.  Diffusion weighted MR imaging has been applied in anattempt to distinguish between tubercular andneoplastic vertebral disease (mets , myeloma) In one study the authors concluded that DW-MRI andADC values may help in the differentiation of spinaltuberculosis from other lesions of similar appearance .
  17. 17. Disadvantages – Calcification hallmark of tubercular infection and small bonefragments are not readily detectable Gradient echo images (GRE)demonstrates calcificationbetter Small bone fragments in an epidural abscess areimportant to detect when surgical management is beingconsidered so that they can be accurately removed Interventional procedures are difficult to perform withMR imaging
  18. 18. Nuclear Medicine Scintigraphy – Technetium di-phosphonate study is an economical butnonspecific tool for early detection Sensitivity - 87.5 to 95 % Radiotracer uptake is usually increased in osseous tuberculousinfection and may reveal multiple sites in disseminated disease— a nonspecific finding that may mimic metastases False-negative bone scans disseminated tuberculosis cervical spine lesions isolated neural arch lesions Posterior neural arch lesions are more readily detectable whencross-sectional nuclear medicine imaging is performed
  19. 19. The pitfalls of nuclear imaging - limited anatomic resolution Non-specificity false-negative examinations Advantage – may help identify a focus of interest Further imaging of the area in question, along withadditional tissue sampling, can then be performed toaid in diagnosis
  20. 20. PET CT - PET-CT (FDG PET) have high sensitivity for detection of chronicosteomyelitis increased FDG uptake in regions of active granulomatousinflammation Can delineate the sinus tracks without the need for contrast With the incorporation of CECT in the PET/CT protocol, thecomplete extent of bone marrow and soft tissue involvement canbe delineated Metabolically active disease can be distinguished from residualfibrotic tissue
  21. 21.  As in oncological imaging, PET/ CT plays a useful rolein determining multiple occult foci of involvement in asingle scan It can also serve as a valuable baseline for monitoringresponse to treatment and provide information ondisease spread It is also a useful tool to guide the site of biopsy orother interventional procedures.
  22. 22. Limitations of PET - CT - uptake patterns that are indistinguishable from malignantprocesses Though high standardized uptake values (SUVs) greater than 2.5have been attributed to malignant lesions, high values (up to 21)have been seen in tuberculosis as well 2 time points scan - Includes delayed imaging at 90 to 120 minutes At malignant sites, the FDG uptake continues to increase for severalhours In inflammatory lesions, uptake peaks at approximately 60 minutesafter administration and the SUVs either stabilize or declinethereafter Another approach to increase the diagnostic accuracy of PET isthe combined use of 18F-FDG and C-11 acetate as the latteraccumulates in tumors and not in inflammatory lesions.
  23. 23.  The exact role of FDG-PET and PET/CT in TB andother inflammatory diseases is evolving and is NOT asyet clearly defined With the development of newer and more specificradiotracers like positron emitter labeled anti-tuberculous drug molecules such as INH andrifampicin in the future, PET/CT may play asignificant role in establishing an early diagnosis andeffective monitoring of therapeutic response.
  24. 24.  Vertebral, disk space and the soft tissue changes Para-vertebral abscesses are an important early feature ofPotts spine incidence varying from 55 to 96 % - rarely may precede anyvisible vertebral lesion usually antero-laterally and is less often directly posteriorly inthe peri-dural space Associated changes in the spinal cord and rare variants ofdisease such as extra-osseous extradural granuloma may bedetected by modern imaging techniques.
  25. 25.  depends on the initial focus of infection within thevertebra – Paradiscal Central Anterior subperiosteal / subligamentous Appendiceal / Neural arch
  26. 26. Paradiscal – most common type AKA called marginal, intervertebral, subarticular ormetaphyseal lesion most often begins in the anterior part of the vertebralbody either superiorly or inferiorly adjacent to theendplate Two adjacent vertebral bodies are involved in about 50% of cases demineralization and loss of definition endplates Little or no periosteal reaction or reactive sclerosisaffect the remainder of the vertebra
  27. 27.  As infection spreads, the adjacent intervertebral diskbecomes involved with narrowing of the disk space Rarely the disk space may remain intact for a longtime.This makes the diagnosis difficult, since disk spacenarrowing constitutes an important diagnostic feature ofinfection and serves to differentiate tuberculosis fromfracture, malignant disease, solitary myeloma and poroticcollapse. Anterior wedging or collapse Varying degrees of kyphosis Scoliosis - asymmetric or unilateral destruction ofvertebral bodies and disks and is virtually confined to thelower thoracic and lumbar vertebrae
  28. 28. Marginal
  29. 29. Central – Lytic area with absence of normal trabeculae in thecentral portion Gradually enlarges Vertebral body may expand or balloon out like a tumor In later stages concentric collapse occurs, almostresembling a vertebra plana Paravertebral shadows may be absent or minimal The disk space is either not affected or only minimallyaffected
  30. 30. Central
  31. 31. Anterior Subperiosteal – begins at the anterior vertebral margin underneath theperiosteum spreads beneath the ALL subtle anterior erosions of multiple vertebrae clinical symptoms are severe in relation to the minorradiographic abnormalities Disk destruction maybe late and anterior erosions aredifficult to detect on plain radiographs.
  32. 32. Anterior sub-periosteal
  33. 33. Appendiceal or Neural Arch Tuberculosis – Ranges from 2 to 30 % of cases usually in contiguity with vertebral body involvement Isolated involvement of the neural arch is rare (< 2 % in nonendemic and < 5 % in endemic areas) plain films – limited evaluation of the neural arch lesions(CT and MR useful ) NAT most commonly affects the cervical and upper dorsalspine (unlike classical spinal tuberculosis which is mostcommon at the lumbo-dorsal junction )
  34. 34.  tendency towards pedicular and laminar involvementin (pyogenic spondylitis - predilection for the facetjoints) The pedicle - most common site Usually unilateral Radiographic findings in NAT include - Pedicular or laminar destruction Erosion of the adjacent ribs in the thoracic region Erosion of posterior cortex of the vertebral body withrelative sparing of the intervertebral disks large para-spinal mass
  35. 35. Importance of NAT ?? Recognition of co-existing posterior and anteriorinvolvement is essential for pre-surgical planning Because decompression can lead to instability, anterior andposterior stabilization must be performed Cases of isolated NAT respond well to simpledecompression and debridement followed bychemotherapy Paraplegia associated with NAT reportedly has a betterprognosis than that with typical spinal tuberculosis
  36. 36. NAT
  37. 37. Abscess formation – Paravertebral soft tissue opacity Usually out of proportion to the degree of osseousdestruction commonly bilateral and uniform may be globular indicating pus under tension may be minimal in the central variety of tubercular lesion cervical region - widening of the pre-vertebral soft tissues dorsal spine - the posteromedial pleural line is displacedlaterally & the abscess produces as typical fusiform shapecalled the "birds nest" appearance
  38. 38.  The aneurysmal effect – may be found with an anterior paravertebral orsubligamentous abscess between D4 and D10 levels Shallow erosions or gouge defects on the anterior surfaceof vertebral bodies due to transmitted aortic pulsations Intervertebral disks being resistant to pressure atrophyare spared An abscess at the dorsolumbar junction has anindistinct converging lower border and is referred to asa petering abscess‘ In the lumbar region the abscess tends to track alongthe psoas producing bulging of the psoas outline.
  39. 39. Petering abscess
  40. 40.  Calcification in the para-spinal abscesses isconsidered pathognomonic of tuberculosis as non-tubercular abscesses rarely calcify. Tuberculous abscesses of the psoas muscle calcify intwo distinct patterns: faint amorphous deposits tear drop shaped calcification With healing the calcification tends to become moredense and in rare instances may be seen to diminishor disappear on serial radiographs
  41. 41. Four patterns of bone destruction have been describedon CT- fragmentary—47 % osteolytic— 33 % sub-periosteal—10 % well-defined lytic with sclerotic margins—10 %
  42. 42. The fragmentary type- most frequent and characteristic numerous residual small bone fragments embedded in a soft tissuemass Similar appearance in involved areas of vertebral appendagesWhy bone fragments ???tuberculous inflammatory exudates lack proteolytic enzymesrequired to lyse bone Bone fragments may migrate into the surrounding structuresincluding the spinal canal, paravertebral soft tissues and psoasmuscles easily detected by CT This is in contrast to pyogenic spondylitis that shows multiplesmall erosions like a pepper pot and no calcification
  43. 43.  Disk space narrowing, multilevel involvement kyphosis (particularly well seen on multiplanarreconstructions) Obliteration of the fat planes around the vertebral bodyearly in the evolution of abscess formation Soft tissue abscesses –characterized by their CT attenuation values - high attenuation lesions being defined as granulation tissue low density lesions defined as abscesses or caseous material CT is ideally suited to demonstrate small amounts ofcalcification which are not visible on plain radiographs.
  44. 44.  Pre-contrast scan - thick nodular rim of increased tissueattenuation of an abscess may be seen (represents the hyper-vascular, hypercellular fibrotic wall of the inflammatory cavity) IV contrast – usually strong rim enhancement around low attenuationmultiloculated collection This is also called the ‘rind sign’ Granulation tissue shows a more homogenous enhancement Epidural extension of these soft tissue masses with cordcompression Small bone fragments some distance away from the actual siteof vertebral destruction
  45. 45.  Combination of - Multi-locular and calcified para-spinal abscess Thick & well-enhancing irregular rim Presence of vertebral body bony fragmentation is astrong indication of tuberculous(rather than pyogenic infection or neoplasm) CT guided biopsy procedures as well providingmaterial for histo/cytopathology, AFB staining andculture in equivocal cases.
  46. 46. Osteolytic type
  47. 47. Subperiosteal type
  48. 48.  Calcification – more specific for TB
  49. 49.  T1 - usually decreased marrow signal & loss of corticaldefinition T2 - a relative increase in signal intensity within involvedvertebral bodies and disks Disk involvement has been reported in 46 to 72 % of casesand occurs relatively late compared to pyogenic spondylitis ‘Floating disk sign’ - Occasionally the disk space ispreserved despite extensive bone destruction In children the hydrated disks do not seem to form a goodbarrier to infection and are involved in most patients
  50. 50. Involvement of posterior elements - detected well by MR more common in tuberculosis than pyogenicinfections Contrast study – may show inhomogeneousenhancement in the region of marrow infiltration
  51. 51. T1 pc – posterior element involvement
  52. 52. Paraspinal soft tissue masses / abscesses - about 71 % of cases on MRI On T1W loss of the uniform psoas muscle signal intensity enlargement of the affected muscle On T2W - hyperintensities Postcontrast – Thick rim enhancement around intra-osseous and paraspinalsoft tissue abscesses More uniform enhancement is seen with granulation tissueor phlegmon
  53. 53. Epidural extension - about 61 % cases on MRI displace the thecal sac spinal cord is distorted Post-contrast fat sat T1W sequences – best to demonstrate meningeal and epidural inflammatorysoft tissues, with improved definition of cord and nerve root compromise Heavily T2W FSE sequences can also be used to provide amyelographic effect showing thecal sac compression.
  54. 54.  The MR imaging features, with high sensitivity andspecificity for diagnosis of spinal tuberculosis are – disruption of the endplate (100 and 81.4 % respectively) paravertebral soft tissue (96.8%, 85.3%) high signal intensity of the intervertebral disk ontheT2-W image (80,6%, 82.4%) The overall sensitivity and specificity for diagnosis are100 and 88.2 %, respectively
  55. 55.  Conventional radiographs provide no information Even CT cannot adequately assess the cord status MR imaging provides invaluable information about the status ofthe cord Cord involvement often results in neurological deficit orparaplegia The spinal cord has physiologic reserve to with standpressure, particularly when pressure develops slowly 40 to 50 % reduction in cord diameter is often compatible withgood cord function !!!
  56. 56. Spinal cord changes –1. Edema of the cord - hyperintense signal on T2-weightedimages but no signal alteration on T12. Myelomalacia - T1 hypointense signal (higher than that ofCSF) may be associated with thinning of the cord3. Atrophy of the cord4. Syringomyelia - signal characteristics of CSF. Edema is compatible with good neurological recovery followingtreatment Thinning of the cord with syrinx or myelomalacia leads to poorcord function Rarely, a small tuberculoma of the cord may be responsible forneurological deficits presenting as ‘spinal tumor syndrome’
  57. 57. Cord edema
  58. 58. Thinning &stretching ofthe cord
  59. 59. Importance of MRI in management ??? MR shows a relatively preserved cord with evidenceof myelitis or edema and a predominantly fluidcollection in the extradural space, respond well toconservative treatment Early surgical decompression is indicated whenMRI shows that the extradural compression is due togranulation tissue or caseous tissue, with little fluidcomponent compressing the spinal cord
  60. 60.  Definition- compressive myelopathy with no visible or palpablespinal deformity and without the radiological appearance of atypical vertebral lesion relatively uncommon difficult to diagnose and treat in the early stages more chance of neurological complications Atypical lesions may present as an intra-spinal tubercular granuloma involvement of the neural arch compressive myelopathy in single vertebral disease sclerotic vertebra Tubercular granuloma should be considered in the differentialdiagnosis of spinal tumor syndrome in zones endemic fortuberculosis.
  61. 61. Extraosseous extradural granuloma - rare variant Hematogenous route more common in men than women dorsal epidural space and in the thoracic segment Clinically compressive radiculomyelopathy Pathology - a granulomatous membrane is found ensheathingand compressing the spinal cord or cauda equina. may be easily diagnosed by MR imaging isointense to cord on T1W images and have mixed signalintensity on T2W images Enhancement after gadolinium will be uniform if theinflammatory process is phlegmonous in nature or peripherallyenhancing if abscess formation or caseation has occurred
  62. 62. Extraosseous extradural granuloma
  63. 63. Conventional Radiographs – healing is appreciated late on routine radiographs lags behind by about 3 months Bony changes may even progress till 14 months after startingtreatment and should not necessarily be considered anadverse feature Soft tissue paravertebral masses may also progress while ontreatment reaching a maximum size within 1.5months, although they may take up to 15 months to resolve
  64. 64. Radiographic signs of healing – static lesion regression of a lesion well-defined outlines of the lesion evidence of sclerosis fusion of adjacent vertebral bodies forming a large block ofosseous mass Fusion of contiguous vertebrae has been regarded as thesurest sign of healing of spinal tuberculosis In the absence of reliable serological and immunologicalmarkers of healing, the healed status is achieved if thereis clinical and radiological evidence of healing with norecurrence after two years
  65. 65.  Features of resolution – increase in vertebral bone density reduction in the size of paraspinal soft tissue masses The inflammatory reaction in the bonemarrow, however, is not well depicted
  66. 66. Signs of healing – The earliest sign - reduction in the amount ofinflammatory soft tissue. However, increasing soft tissuemass, bony destruction or an alteration in signal intensitydo not indicate failed treatment High-signal intensity rim on the T1W sequences at the edgeof the osseous lesion represents healing Reduction / loss of contrast enhancement However, persistent or increasing enhancement are notnecessarily indicative of either deterioration or treatmentfailure
  67. 67.  T1 hyperintense rim –sign of healing
  68. 68. Reactivation of old tubercular spondylitis – The change of signal from low signal in healedtuberculosis to high signal on T2W Reactivation may present with an isolated psoasabscess without evidence of bony lesions
  69. 69.  pyogenic fungal degenerative disk disease Brucellosis neoplasms
  70. 70. Degenerative spondylosis – Clinical findings (afebrile) disk space usually not markedly narrowed On MR, disk dessication is manifested as low signalintensity on T2W images After IV contrast infected disks enhance strongly whereasdegenerated disks only occasionally enhance to a smalldegree
  71. 71. Tuberculous v/s pyogenic spondylitis – Chronicity and slow progression lack of sclerotic and reactive changes On MR imaging relative preservation of disk with involvement of multiple contiguous more frequent involvement of posterior elements a well-defined para-spinal lesion disproportionally large para-spinal masses, especially withcalcification or a thick rim of enhancement subligamentous spread to three or more vertebral levels andpresence of skip lesions favor a tubercular etiology However, differentiation from pyogenic infection can attimes be difficult.
  72. 72. Brucellosis – Like tuberculosis the course is indolent Characteristic features of brucellar spondylitis include gas within the disk, only minimal associated paraspinal soft tissue mass, absence of gibbus deformity predilection for the lower lumbar spine. On MR images, vertebral body morphology and corticalmargins are intact despite evidence of osteomyelitis.
  73. 73. When a solitary vertebra is involved - metastatic disease in adults eosinophilic granuloma, in childrenSpinal lesions - lymphoma neoplasms such as multiple myeloma and chordomathat involve contiguous vertebrae and disks can add tothe diagnostic difficulty.
  74. 74.  Spine Joints - Tubercular arthritis Long and flat bones - Tubercular osteomyelitis Short bones – Tubercular dactylitis Tendon sheath & bursae
  75. 75.  begins in the synovium or in the metaphyseal spongiosa contiguous spread or hematogenous spread The metaphyseal lesion may involve the joint throughsubperiosteal space, through capsule or through destruction of theepiphyseal plate Sequestration & peri-osteitis are NOT very common (c/w pyogenicinfections) Ischemic necrosis and end arteritis may result in a very smallsequestrum which is usually not visible radiologically (unlesscalcified) Granulation tissue spreads onto the free surface of cartilageeroding it in patches, later causing loosening and separation of thecartilaginous tissue as it proceeds causing necrosis of cartilagewith erosion of exposed bone.
  76. 76. Osteolytic lesion with a small sequestrum
  77. 77.  Marginal erosions are common in TB of weight bearingjoints (hip, knee, ankle) Wedge shaped necrotic foci may become evident on eitherside of joint leading to the appearance of ‘kissing sequestra’ Necrosed cartilage and fibrinous material form ‘rice bodies’in synovial joints, tendon sheaths and bursae. Abscesses that form may track along the fascia planes andform sinuses Plaques of irregular bone, if present in walls of chronicabscess or sinus suggests long standing TB infection.
  78. 78.  Periarticular ostopenia Marginal erosion Gradual reduction in joint space
  79. 79.  BCG osteitis can occur following BCG vaccination follows benign course It resembles chronic osteomyelitis radiologically butresponds to ATT. Synovial sheath infections common with non typical mycobacteria (other than M.tuberculosis and M. bovis), history of trauma (puncturewounds), surgery, immunocompromised status andexposure to contaminated marine life
  80. 80.  Infection of prosthetic joints late complication usually 6 to 12 months after surgery attributed to extensive surgery, use of implants andfavourable conditions for mycobacteria likeDM, steroids and immunocompromised status
  81. 81.  Can be divided into 4 Radio-pathological stages –1. Inflammatory edema & exudates (pre-destructivestage)2. Necrosis & cavitation3. Destruction & deformation4. Healing & repair Infection in bones is said to develop 2 to 3 years afterprimary focus (lung, lymph nodes), so diagnosis isusually delayed (c/w pyogenic infections which areseen 2 to 3 weeks after clinical presentation)
  82. 82.  Insidious onset (c/w pyogenic infections) Low grade fever Weight loss Night sweat Movement restriction, muscle wasting, regional lymphnode involvement and neurologic symptoms Weight bearing joints like hip, knee and ankle arecommonly involved, though any part of the skeleton canget involved
  83. 83.  Radiography USG CT MRI Nuclear imaging
  84. 84.  AP and lateral views of the involved region radiograph of the chestRadiological stages –1. Stage of synovitis2. Stage of arthritis3. Stage of advanced arthritisRadiography
  85. 85. 1. Stage of synovitis: Soft tissue swelling and joint widening due to effusionand synovial hypertrophy The first radiological sign may be juxta-articularosteoporosis. If there is secondary superaddedinfection, subperiosteal reaction may result. As a result of localized hyperemia growth plate mayshow overgrowth, especially in childhood.
  86. 86. 2. Stage of arthritis: Articular margin and bony cortices become hazy (blurringand fuzzy) giving rise to "washed out appearance“ Narrowing of joint space (involvement of articular cartilage) Phemister Triad” juxta-articular osteopenia, peripherally located osseous lesions and gradual narrowing of joint spaceare considered pathognomonic of tubercular osteoarthritisEarly loss of articular joint space is more typically seen inrheumatoid arthritis and thus helps in differentiating fromtuberculosis.
  87. 87. 3. Stage of advanced arthritis: Collapse subluxation or dislocation migration of bone deformity of joint
  88. 88. 4. Healing – Re-mineralization Cortical and articular margins become distinct Fibrous ankylosis may occur during healing phase(pyogenic arthritis – bony ankylosis) In contrast to pyogenic arthritis, the development ofbone ankylosis is uncommon in tubercular arthritis
  89. 89.  Helpful in the evaluation of large joints Demonstrates joint effusion, synovitis and capsular thickening Synovial thickening - hypoechoic intra-articular soft tissue.Synovial sheath along tendons is thick and heterogeneous withminimal fluid suggestive of chronic tenosynovitis Soft tissue abscess like psoas abscess Cortical disruption & irregularity of articular margins Smaller joints like wrist, hand, foot and ankle Guided joint fluid aspiration or synovial biopsy is possible
  90. 90.  Lytic areas and marginal erosions seen much before plainradiographs Swelling in soft tissues, granulation, exudations, abscessand early calcification can also be demonstrated muchearlier Joint space better evaluated by CT Limitation - The plain radiographs and CT scan are notlikely to detect the stage of inflammatory edema andexudates. Computed tomography guided aspirations and needlebiopsy for difficult areas like sacroiliac joints
  91. 91.  Synovial hypertrophy is commonly seen1. Hypointense areas on T2-weighted images suggestinghemosiderin deposition2. Rim of synovial lesions on pregadolinium Tl-weightedimages3. Fluid loculations with enhancing synovial rims anderosions on postgadolinium images All the above features may be helpful in characterizing thelesion as tubercular when the radiographs are normal
  92. 92.  STIR – Fat saturation technique, results in markedly decreased signalintensity from fat and strikingly increased signal from fluid andedema. extremely sensitive tool for detecting tissue & marrow pathology T2-weighted sequence –hyperintense joint effusion Synovial proliferation due to tubercular arthritis maybehypointense on T2-weighted images and thickened synoviumenhances vividly after gadolinium. Active pannus proliferating into the subarticular bone enhanceson the postcontrast scans while chronic fibrosis does notenhance.
  93. 93.  Caseating granulomas with solid centers give acharacteristic hypointense signal to the synovium onT2-weighted images Chondral lesions and subchondral bone erosions maybe visible at a stage when the joint space is still wellpreserved. Penumbra sign - A thin intermediate signal intensityrim along the periphery of a bone or soft tissue abscesson unenhanced T1 -weighted images, due to layer ofgranulation tissue along its wall. It is useful inidentifying soft tissue abscesses.
  94. 94.  MRI helpful in detecting bone marrow inflammation, intra-osseous abscess, sequestrum, cortical destruction, cloaca and sinus tract formation Tenosynovitis may be seen Bursitis may be seen as distended bursa or multiple smallabscesses. Repeat imaging can be helpful in follow-up and if there isdeterioration, then a representative biopsy is mandatoryfrom the area.
  95. 95.  Fluid loculations Enhancing synovium erosions
  96. 96.  The pre-destructive stage can be visualized by MRI and alsoprobably by bone scans. Isotope bone scan or MRI may reveal subclinical active lesion in40 % of patients in addition to the presenting lesion. Out of technetium-99m, gallium-67 and indium-111 isotopes usedin skeletal scintigraphy, technetium-99m is the mostsensitive, though not specific. Positive scan helps in localizing and for follow-up. 18Fluorine fluorodeoxyglucose-positron emission tomography(18F-FDG- PET) has also been found useful in localizingtubercular disease and in differentiating soft tissue infection fromosseous infection
  97. 97. HipKneeAnkle & footShoulderElbowWrist & carpusSacro-iliac joints
  98. 98.  Involvement in about 15 % cases of osteo-articular TB Lesions can arise in acetabulum, synovium, femoralepiphysis or metaphysis or spread to the hip from fociin the greater trochanter or ischium. If upper end of femur involved(being entirelyintracapsular), the joint is involved early in disease Erosion or lytic lesions may also occur in the greatertrochanter or the overlying bursa, without involvementof the hip joint for a long period of time
  99. 99. Radiography – Plain radiograph usually normal Displacement of fat planes (effusion) Soft tissue swelling and deossification Radiologically significant osteoporosis appears 12 to 18weeks after onset of symptoms (c/w pyogenic arthritis) Clinical - Irritable hip, Positive obturator sign occur dueto flexion deformity (Reduced obturator foramina size)
  100. 100. Ultrasound, CT and MRI more sensitive in this stage to detect increased joint spaceand accumulation of fluid. Investi-gations may be repeated, at three to six weeksinterval, to help in establishing the diagnosis. Differential diagnosis – traumatic or nonspecific transient synovitis Perthes slipped capital femoral epiphysis low grade pyogenic infections.
  101. 101.  Peri-articular erosions Reduction of joint space (destruction of articularcartilage) Lesions can usually be picked up on CT before theyare apparent on plain radiographs
  102. 102.  Destruction of articular cartilage, acetabulum, femoralhead, capsule and ligaments Capsule may get thickened and contracted Upper end of femur may displace upwards and dorsallybreaking the Shenton’s line Lower part of acetabulum empty (Wandering acetabulum) If femoral head, neck are grossly destroyed and collapsed inon enlarged acetabulum, this appearance is called "mortarand pestle" appearance
  103. 103. Stage of advanced arthritis -Complete destruction, deformity & subluxationWandering acetabulum
  104. 104. Mortar & pestle appearance• Gross destruction of head• Enlarged acetabulum
  105. 105.  Largest intra-articular space Involved in about 10 % of osteo-articular tuberculosis Any age group Symptoms - pain, swelling, palpable synovialthickening and restriction of mobility. Tenderness inthe medial or lateral joint line and patello-femoralsegment of the joint The initial focus may be in synovium or subchondralbone of distal femora, proximal tibia or patella.
  106. 106.  Osteoporosis, soft tissue swelling, joint / bursaeffusion. Distension of supra-patellar bursa on lateralradiograph of knee Infection in childhood can lead to accelerated growthand maturation resulting in big bulbous squaredepiphysis Widening of the inter-condylar notch (synovitis)
  107. 107.  Periarticularosteopenia Erosions Symmetric reductionof joint space
  108. 108.  Loss of definition of articular surfaces Marginal erosions Decreased joint space Osteoporosis Osteolytic cavities with or without sequestra formation Marked reduction of joint space Destruction and deformity of joints In advanced cases, there is triple deformity of the knee, that islateral, posterior and superior displacement of tibia on femur
  109. 109. • Peripherallyenhancing jointcollection• Marginal erosionT1 PC non fat sat
  110. 110. • Marrow edema• SynovialthickeningT2
  111. 111. Differential diagnosis – Juvenile rheumatoid arthritis Villonodular synovitis Osteochondritis dissecans Hemophilia Biopsy of the synovial membrane and aspiration of thejoint fluid followed by smear & culture can confirm thediagnosis
  112. 112. ANKLE - Swelling - in front of the joint, around the malleoli andtendoachilles insertion Marked osteoporosis with or without erosion unsharpness of articular surfaces along with reduction joint space In long standing cases, gross destruction of bones and sinusformation can result. pathological anterior dislocation can occur periosteal reaction (rare)
  113. 113. • Erosions• Osteopenia• Joint effusion (widenedjoint space)
  114. 114. FOOT – common involvement of calcaneum, subtalar andmidtarsal joints Anterior 2/3rds of calcaneum being commonly affected Radiograph can reveal presence of osteolytic lesion with orwithout coke-like sequestrum. rapidly spreads across the inter-communicating synovialchannels, so multiple bones are commonly involved DD - Osteochondritis desicans of talus can simulate atuberculous lesion of the ankle
  115. 115.  The foot bones can have isolated tubercular lesions as in the oscalcis or as diaphyseal foci in metatarsal bones (tuberculardactylitis) A subchondral lesion in the calcaneum leading to talo-calcanealarthritis Talo-navicular and naviculo- cuneiform lesions and calcaneo-cuboid joint involvement can also occur, particularly in diabetesmellitus The tarso-metatarsal & metatarso-phalangeal joint can beinvolved. Lesions may look very similar to Madurella infection. Differential diagnosis – neuropathic change in the foot, secondary to diabetes or leprosy.
  116. 116. T1W
  117. 117.  rare more frequent in adults incidence of concomitant pulmonary tuberculosis ishigh The classical sites could be - head of humerus, glenoid, spine of the scapula, acromio--clavicular joint, coracoid process and rarely synovial lesion.
  118. 118.  Iatrogenic due to steroid injection given for a stiffshoulder with the mistaken diagnosis of frozenshoulder, particularly in diabetics. Initial tubercular destruction is typically widespread(because of the small surface contact area of articularcartilage) Symptoms – severe painful movement restriction particularlyabduction and external rotation gross wasting of shoulder muscles
  119. 119.  Radiologically, osteoporosis erosion of articular margins (fuzzy) osteolytic lesion involving head of humerus, glenoid orboth The lesion may mimic giant cell tumor. The joint space involvement and capsular contractureare seen early in the disease. Sinus formation Inferior subluxation of the humeral head Fibrous ankylosis
  120. 120.  Deformity Erosions Osteopenia Peri-articular calcifications
  121. 121. • Erosion• Synovial proliferation• Subdeltoid collection
  122. 122. Caries sicca - atrophic type of tuberculosis of the shoulder benign course without pus formation small pitted erosions on the humeral headClassical dry type is more common in adultsfulminating variety with cold abscess or sinusformation is more common in children
  123. 123.  Differential diagnosis - peri-arthritis of the shoulder, rheumatoid arthritis post-traumatic shoulder stiffness Aspiration of the shoulder and FNAC might benecessary to establish the diagnosis. The patients usually respond well to anti-tuberculardrugs.
  124. 124.  2-5 % percent cases The most frequent sites of involvement medial and lateral condyles of the humerus articular surface of olecranon usually intra-articular but occasionallyextra- articular head of radius. Rarely synovial in origin Radiographic features Articular type - involve-ment of humerus andulna, osteoporosis, blurring of articular cortex and early diminutionof joint space Extra articular type - ulna is involved most commonly withdestructive lesions seen in olecranon or coronoid process. Periostitismay also be seen
  125. 125.  In infants and children, sequestra may be present Peri-osteitis is a common feature and most commonlyaffects the ulna Pathological dislocation of elbow is very rare Differential diagnosis – osteochondritis desicans of the humeral condyle osteoid osteoma of the lateral condyle of the humerus whichbeing intra articular in location can be mistaken fortuberculosis of the elbow joint. The diagnosis can be confirmed by aspiration or biopsy ofsynovium from the lateral side.
  126. 126. Erosions in radius and ulnaPeripheral enhancement of the synoviumenhancement of the adjacent bone marrowT2W MRI - in another patient shows jointeffusion and a relatively hypointense signal ofthe thickened synovial tissue
  127. 127.  rare site usually affecting adults The anatomical sites of the lesions Radius (distal end) proximal row of carpal bones —scaphoid, lunate Capitate Concomitant involvement of the sheaths of volar ordorsal tendons might also occur
  128. 128.  Radiographic features - include intense osteoporosis, softtissue swelling, erosions of articular margins and cartilagedestructions, periosteal reaction and early appearance ofossification centers. All carpal bones tend to get involved in adults More localized lesions in children (due to thicker articularcartilage in children) Intense demineralization is present in carpus, distal radiusand ulna, metacarpals being usually spared. This serves as adifferentiating feature from rheumatoid arthritis. Biopsy of the wrist can be easily done from the dorsalroute, when in doubt.
  129. 129. • lytic area of bonedestruction• transphyseal spread ofinfection across thegrowth plate
  130. 130. T2 fat sat
  131. 131.  more often in young adults than children involvement is usually unilateral usually associated with tuberculosis of spine Clinical - Tenderness over the sacroiliac joint andcompression and distraction tests are painful
  132. 132. Radiographic features – irregularity and fuzziness of articular surfaces starting at theinferior surface Sub-articular erosions may be present causing widening ofjoint space. Both the sclerosis and erosions predominate on the iliac sidewhile punched out lesions may be seen in ilium or sacrum
  133. 133.  Tuberculosis at this uncommon site is frequently missed. The cold abscess can be either intra-pelvic or under thegluteus maximus muscle.Magnetic resonance imaging Ideal means of evaluating SI joints Coronal imaging of the SI joints, parallel to the plane of thesacrum allows direct comparison of one SI joint to the other Diagnosis is established by aspiration or FNAC Antituberculosis therapy and protective bracing are thetreatment of choice.
  134. 134.  Erosions Destruction Abscess Associated disseminated tuberculous osteomyelitisT1 fat sat
  135. 135.  vaccine of an attenuated bovine tubercular bacillus generalized BCG infection and bone and joint infection can occurvaccination not usually associated with immunologic disorder and has a favorableprognosis BCG osteomyelitis affects children between 6 months and 6 years ofage usually affects epiphysis and metaphysis of tubular bone especiallyaround the knee, ribs, the sternum, the small bones of hand and feet more common on same side of the body as the vaccine was injected !!!! Solitary lesions predominate as well defined lytic fociBCG osteomyelitis / arthritis
  136. 136.  Diagnosis of osteitis after BCG vaccination isestablished according to criteria proposed by Foucardand Hjelmsted:1. BCG vaccination in the neonatal period2. A period of less than 4 years between vaccination andsymptom onset3. No contact between the child and any adults with TB4. A consistent clinical profile5. Histopathology suggestive of TB
  137. 137. BCG osteomyelitis
  138. 138.  Spine Joints - Tubercular arthritis Long and flat bones - Tubercular osteomyelitis Short bones – Tubercular dactylitis Tendon sheath & bursae
  139. 139. Long bonesFlat bones• Ribs• Scapula• Sternum• Skull pelvis• SC and AC joint
  140. 140.  TB osteomyelitis about 3 % of MSK tuberculosis In 7 % of them, multiple skeletal site of lesions The most frequent sites manubrium sterni sternum and isolated spinous processes spine of the scapula ischium and fibula The lesions tend to be simultaneous in onset and progression andgenerally affect persons with low Immune resistance Symmetric well round, oval cystic lesions, with little or noperiosteal reaction initially may be present In untreated cases, laminated periosteal reaction may be seen.
  141. 141.  Sequestra formation uncommon in adults, large sequestra may be seen in children (intra0osseousvasculature is more prone to thrombosis) Joint involvement is rare as the lesions are diaphysealor metaphysealClosed cystic tuberculosis – Disseminated lesions as bone cysts NO sclerosis, abscess or sinus formation
  142. 142.  Differential diagnosis – polyostotic fibrous dysplasia eosinophilic granuloma of the bone enchondromatosisA firm diagnosis can only be established by biopsy ofthe lesion Rx - Antituberculosis regimens with curettage
  143. 143.  Hematogenous spread from a primary focus Granulomatous lesion develops within the bone at thesite of deposition of the mycobacterium, usuallymetaphysis which is the site of infection Earliest lesion appears as eccentric osteolytic lesion inthe shaft near the epiphysis or metaphysis Epiphyseal growth plate offers little resistance resultingin transphyseal spread of infections
  144. 144. Two types of lesions have been described(pathologically) – Caseous exudative type - destruction of bonytrabeculae, softening and caseation necrosis followedby formation of tuberculous pus or cold abscess Granular type caries sicca where predominantlygranulation tissue is formed with minimal caseation
  145. 145. Can be Radiologically classified as –1. Metaphyseal type oval or round focus in metaphysis ultimately crosses into the epiphysis & joint femur and tibia most commonly affected2. Cystic (diaphyseal type) – affects children and young adults Diaphysis involved well defined round or oval lytic areas Expansile Large sequestra may be seen Tibia is the most common bone involved. Joint involvement is infrequent
  146. 146.  Solitary involvement is predominant Disseminated skeletal TB is rare Multifocal tuberculous osteomyelitis also known as‘osteitis cystica tuberculosa multiplex’ Multiple sites of involvement are seen inchildren, while in adults, involvement is more oftenconfined to a single bone. Little or no surrounding reactive bone and localosteopenia are salient features.
  147. 147. The radiographic appearance -In young patients favor metaphyseal region usually osteolytic and well defined without sclerosis may show variable sizeIn adults the lesions are smaller located in the long axis of bone may show well-defined sclerotic margins
  148. 148.  Diaphyseal TB
  149. 149. MRI – early focus of altered marrow signal with irregularmargins and cortical invasion ill defined soft tissue Eccentric lesion with cortical breach Small communicating abscesses are better appreciatedon postcontrast T1W images as enhancing rings ofjuxta-cortical inflammatory tissue and are a strongpredictor of tuberculosis
  150. 150. Diaphyseal TB – Lytic lesion Marked periostealreaction Adjacent soft tissueedema MRS – lactate peak
  151. 151. Ribs – about 2 % cases of bone tuberculosis Commonly adults being generally affected one- third of patients will have pulmonary tuberculosis Clinical - pain, tenderness and fluctuant chest wallswelling.Radiology – posterior half of ribs most commonly affected bony rib expansion punched out lesions destruction which may be poorly marginated
  152. 152.  Anterior end involved Expansile lytic lesion
  153. 153. Scapula - Rare acromion, spine, superior or inferior angle of scapula. Patient presents with pain and swelling. CT and MRI are helpful in early detection of lesions.Sternum - Rare An irregular destructive lesion retrosternal and pre-sternal soft tissues paucity of sclerosis or peri-osteitis
  154. 154. Skull - Frontal bone most common site Ill-defined lytic lesion may be the only radiologicalfeature seen with overlying cold abscess (Potts Puffytumor) Button sequestrum sometimes seen Facial bones and mandibular involvement is extremelyrare
  155. 155.  Pott’s puffy tumour – TB osteomyelitis of skull withoverlying abscess
  156. 156. Button sequestrum
  157. 157. Pelvis - Isolated tubercular lesion may occur in iliac bone, ischialtuberosity and ischio-pubic ramus Ischial tuberosity involvement was earlier recognized as"weavers bottom" in which the overlying bursa wasinflamed with secondary involvement of bone. Concomitant involvement of sacroiliac joints is common Radiologically, lytic lesions without surrounding sclerosisor periosteal reaction may be seen
  158. 158. Tuberculous involvement of pubic symphysis
  159. 159.  Spine Joints - Tubercular arthritis Long and flat bones - Tubercular osteomyelitis Short bones – Tubercular dactylitis Tendon sheath & bursae
  160. 160.  Tubercular dactylitis primarily a disease of childhood affects short tubular bones distal to tarsus and wrist bones of the hands are more frequently affected than bones ofthe feet proximal phalanx of the index and middle fingers andmetacarpals of the middle and ring fingers being the mostfrequent locations Frequently present as marked swelling on the dorsum of thehand and soft tissue abscess is normally a common feature
  161. 161.  Monostotic involvement is common Often follows a benign course without pyrexia and acuteinflammatory signs, as opposed to acute osteomyelitis. Plain radiography is the modality of choice for evaluationand follow-up.The radiographic features – Cystic expansion of the short tubular bones have led to thename of "spina ventosa" being given to tubercular dactylitisof the short bones of the hand. spina - short bone and ventosa - expanded with air
  162. 162.  Bone destruction and fusiform expansion of the bone It is most marked in diaphysis of metacarpals and metatarsalsin children Periosteal reaction and sequestra are uncommon. Healing is gradual by sclerosis.Differential diagnosis – Syphilitic dactylitis – bilateral and symmetricinvolvement, more periostitis, less soft tissue swelling. Chronic pyogenic osteomyelitis and mycotic lesions in the footDebridement and antitubercular regimen result in completesubsidence of the lesion
  163. 163.  Spina ventosa
  164. 164. Tuberculous dactylitis
  165. 165.  Spine Joints - Tubercular arthritis Long and flat bones - Tubercular osteomyelitis Short bones – Tubercular dactylitis Tendon sheath & bursae
  166. 166.  The most common sites flexor tendon sheaths of hand subacromial bursa olecranon bursa bursae under the medial head of gastrocnemius Clinical - In the volar aspect of the wrist, the classicalpresentation is a dumb-bell shaped swelling givingcross fluctuation and crepitus. The spread to these sites is normally from theneighboring bone or joint but it could be due tohematogenous spread.
  167. 167.  Primary investigation is ultrasonography In chronic tenosynovitis, tendon and synovialthickening predominate, with relatively little synovialsheath effusion In acute suppurative tenosynovitis, synovial sheatheffusion is the predominant featureMagnetic resonance imaging helps in delineating theprecise extent of soft tissue involvement and anyassociated osseous or joint involvement.
  168. 168.  Among bursal infections , the most commonly affectedlocations are the trochanteric, subacromial, subgluteal radioulnar wrist bursa Plain radiography – local osteopenia (due to hyperemia ) Calcifications within wall of the distended bursaAntituberculosis regimes coupled with excision of thesynovial sheath and bursae are the treatment of choice
  169. 169. Atypical Mycobacterial Infection May be seen in immunocompromised patients , those withrenal transplants or those receiving cortico-steroids Infection can lead to osteomyelitis, septicarthritis, tenosynovitis and bursitis.Radiologically - multiple lesions may be seen metaphysis and diaphysis of long bones usually affected osteoporosis is NOT marked Abscesses and sinus tract seen
  170. 170.  may develop due to reactivation of tubercular arthritisfor which the operation had been performed Arthrocentesis and specimens are required forestablishing the diagnosis
  171. 171.  Mainly diagnostic USG guided – fluid aspiration , pigtail placement(psoas abscess) CT guided – Aspiration / Biopsies (SI joints)
  172. 172.  Tuberculosis of bones and joints can have varied radiologicalappearances Conventional radiographs are the usual initial imaging modality Radiography along with biopsy / FNAC generally suffices fordiagnosing infections of joints & bones (except spine) USG has a limited role, mainly in detection of fluid / collections & inguided interventions Spinal tuberculosis is the most severe among infective spondylitides MRI is the imaging modality of choice for spinal tuberculosis CT can be an alternative tool when MR is not available and for guidedinterventions