Imaging of extraspinal musculoskeletal tuberculosis

doi:10.1016/j.ejrad.2005.07.005

European Journal of Radiology

Volume 57, Issue 1, January 2006, Pages 119-130

https://doi.org/10.1016/j.ejrad.2005.07.005 Get rights and content

Abstract

Tuberculosis (TB) is still a major cause of significant morbidity and mortality despite universal availability of effective chemotherapy. The emergence of multidrug-resistant mycobacteria along with a worldwide increase in HIV infection has led to a recent surge in the number of patients with TB. TB involves both pulmonary and extrapulmonary sites. Tuberculous spondylitis is the most common form of musculoskeletal TB and accounts for approximately 50% of cases. Extraspinal musculoskeletal TB is among the least common manifestations of TB. It shows a predilection for joints and para-articular areas while isolated soft tissue TB occurs extremely rare. A non-specific, often indolent clinical presentation in conjunction with its low prevalence constitutes obstacles for diagnosis. The differential diagnosis of extraspinal musculoskeletal TB consists of degenerative processes, inflammatory and infectious conditions, primary neoplasms, and metastatic lesions. Early diagnosis and treatment is of utmost importance to prevent serious joint and bone destruction. Radiological assessment of patients with musculoskeletal TB is often the key to adequate diagnosis and early treatment. The purpose of this manuscript is to review the imaging features of extraspinal musculoskeletal TB and to focus on the magnetic resonance imaging (MRI) characteristics of this pathology.

Introduction

Tuberculosis (TB) remains a common illness among immigrants to the industrialized countries from underdeveloped regions. The prevalence of TB is also high among patients with AIDS, and often represents the first manifestation of HIV infection [1], [2]. Extrapulmonary manifestations are estimated to occur in approximately 20% of patients with TB, most often presenting as lymphadenopathy and genitourinary disease [3]. Extraspinal musculoskeletal TB is among the least common manifestations of TB with a relative frequency of about 1–2% [4]. The reported frequency of peripheral arthritis is 60%, of osteomyelitis 48%, and of tenosynovitis and bursitis 2% [5], [6], [7], [8]. Previous or current pulmonary TB is detected in only about one half of these patients.

A non-specific, often indolent clinical presentation together with a low prevalence and low index of suspicion may result in delayed diagnosis of extraspinal musculoskeletal TB. However, prompt diagnosis and treatment of this curable disease remain critical to minimize pain, maintain joint function, and prevent joint deformity and serious bone destruction [9]. Diagnosis of extraspinal musculoskeletal TB is not possible solely based on clinical or imaging findings. However, in the appropriate clinical setting, radiological assessment may guide diagnostic work-up and may result in earlier and adequate treatment. Histopathological examinations and culture identification are among the most accurate methods for definite diagnosis.

Section snippets

Pathogenesis

Mycobacterium tuberculosis is the main causative organism of extraspinal musculoskeletal TB and only a few cases are attributable to Mycobacterium bovis. Atypical mycobacteria, such as Mycobacterium kansasii, Mycobacterium marinum, Mycobacterium scrofulaceum, and Mycobacterium avium complex account for approximately 1–4% of cases of tuberculosis [10].

A musculoskeletal TB lesion mainly results from hematogenous dissemination or lymphogenous spread from a primarily or reactivated infected focus

Tuberculous arthritis

As in most infectious joint diseases, TB arthritis is usually monoarticular. In approximately 10% of patients, however, multiple joints may be involved [18]. In musculoskeletal TB, involvement of the synovial joints is the second most frequent location following spinal TB [17]. Most commonly involved joints are the hip and knee, followed by, in order of frequency, the sacroiliac joint, shoulder, elbow, and ankle in order of frequency (Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5). However, according

Extra-axial tuberculous osteomyelitis

TB osteomyelitis is less common than TB arthritis. Previously, TB osteomyelitis was more often multifocal and disseminated as a result of hematogenous spread from a primary focus mostly in the lungs, or lymphatic system [26]. However, recent reports indicate that solitary lesions are now more commonly seen [17]. Although a pulmonary focus is often presumed, intercurrent active pulmonary TB is seen in a minority of the patients. TB osteomyelitis occurs most commonly in bones of the extremities,

Tuberculous tenosynovitis and bursitis

Primary TB tenosynovitis is considered an extremely rare condition, most commonly involving the flexor tendon sheaths of the dominant hand [6]. TB tenosynovitis may result from hematogenous spread or may be a secondary finding resulting from periarticular extension of TB arthritis (Fig. 5, Fig. 7). Either tendon, synovium, or both may be infiltrated and thickened. Tubercle formation may result in caseation necrosis and secondary effusion within the tendon sheath. Disease progression may lead to

Conclusion

A wide range of imaging findings in extraspinal musculoskeletal TB may be seen, according to whether the infection is confined to joints, skeleton, muscles, tendon sheaths or synovial bursae and whether there is secondary extension to the neighboring tissues. Extraspinal musculoskeletal TB, however, produces no pathognomonic imaging signs, and in advanced stages mimics other disease processes. Although the diagnosis depends largely on the clinical context, ultrasound, CT, and especially, MRI

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Imaging of extraspinal musculoskeletal tuberculosis

Abstract

Introduction

Section snippets

Pathogenesis

Tuberculous arthritis

Extra-axial tuberculous osteomyelitis

Tuberculous tenosynovitis and bursitis

Conclusion

Tubercle

Radiol Clin North Am

Radiol Clin North Am

J Infect

J Hand Surg

Tuberculous abscesses in patients with AIDS

Clin Infect Dis

Tuberculous pancreatic abscess as an initial AIDS-defining disorder in a patient infected with the human immunodeficiency virus: case report and review

Clin Infect Dis

Tuberculosis levelling off worldwide

BMJ

Imaging of tuberculosis. V. Peripheral osteoarticular and soft-tissue tuberculosis

Acta Radiol

Tuberculous tenosynovitis of the flexor tendons of the wrist: MR imaging with pathologic correlation

Skeletal Radiol

Tuberculous tenosynovitis and bursitis: imaging findings in 21 cases

Radiology

MR imaging of tuberculous arthritis: clinical and experimental studies

J Magn Reson Imaging

Tuberculous osteomyelitis. A review of 125 cases

Int Orthop

Osteoarticular tuberculosis: current diagnosis and treatment

Am J Ther

Chemotherapy for osteoarticular tuberculosis

Clin Orthop

General principles of osteoarticular tuberculosis

Clin Orthop

Tuberculous gluteal abscess without bone involvement

Skeletal Radiol

Osteoarticular tuberculosis of the foot and ankle

Foot Ankle Int