Electronic supplementary material
It is well known that bacteria, in addition to MTB, are capable of forming and surviving within the biofilm found on the surface of prosthetic materials and thus are protected from immunological and antibiotic response. It was not clear in our patient whether her hip prosthesis had been colonized by MTB protected within the biofilm. PJI should still be suspected, even when routine cultures from infected joints are negative.
Follow-up evaluations after treatment should be based on clinical conditions, ESR, CRP, and radionuclide study.
Recurrent infection poses difficulties in surgical removal of the implant. The distal part of the prosthesis tends to be stabilized on the femur diaphysis, rendering surgical removal very dangerous and traumatic.
There are several open questions in medical and surgical treatment of the total hip replacement infected with MTB (in regard to choice of medical therapy, duration, complications, and so on). The length of treatment for periprosthetic tuberculosis infection is debatable and not standardized. The medical drug treatment in our patient included four drugs for two months, followed by 16 months of therapy with only two drugs, which provided good results. The anti-mycobacterial agents used have a high diffusion capacity, which probably allowed eradication of the infection.