Tuberculous arthritis is a bone–joint form of tuberculosis caused by mycobacteria Koch and having a chronic destructive course. With tuberculous arthritis, patients are concerned about the symptoms of general intoxication, weakness in the extremities, arthralgia, joint defiguration, formation of purulent fistulas. Diagnosis is based on taking into account the features of clinical, radiological and laboratory data, the results of tuberculin tests. The basis of treatment is specific anti-tuberculosis therapy with subsequent rehabilitation and rehabilitation measures; additionally, intra-articular punctures and surgical interventions are performed.
Tuberculous arthritis (tuberculosis of the joints) is an infectious arthritis accompanied by destruction of bone-cartilaginous and periarticular tissues. Tuberculous arthritis is one of the most frequent localizations of extrapulmonary tuberculosis. Among other forms of extrapulmonary infection, tuberculosis arthritis accounts for more than 20%. Osteoarticular tuberculosis develops more often in children aged 7-14 years; in the adult population, men older than 50-60 years are usually ill. In most cases, the infection affects the spine (40%), hip and knee joints (20% each), less often – ankle joints, bones of the foot and upper extremities, flat bones. Tuberculosis arthritis is studied in the framework of phthisiology and rheumatology.
Damage to bones and joints occurs as a result of the spread of tuberculosis infection from the primary focus (more often lymph nodes or lungs) by lymphogenic and hematogenic pathways. The development and progression of tuberculosis arthritis is promoted by:
- unfavorable sanitary and hygienic living conditions,
- low immune reactivity,
- close contact with tuberculosis patients,
- mechanical injuries and joint diseases (chondrocalcinosis, gout),
- chronic diseases (diabetes mellitus),
- alcoholism and drug addiction.
Depending on the pathogenesis, there are primary bone (tuberculous osteoarthritis) and primary synovial (fungous tuberculous arthritis) forms.
In the vast majority of cases (80-90%), Mycobacterium tuberculosis settles in the bone marrow (in the spongy substance of the vertebral bodies, epiphyses and metaphyses of tubular bones), where tuberculous tubercles (granulomas) are formed. Further growth of granulation tissue leads to circulatory disorders and necrosis of bone trabeculae, decay of cellular elements (curd necrosis), development of tuberculous ostitis. With the progression of the tuberculosis process, the structure of the cortical layer of the bone is disrupted, the infection captures the articular bag and periarticular tissues with the formation of abscesses, fistulas, sequesters, subluxations.
In the primary synovial form, tuberculous arthritis manifests with the phenomena of synovitis, followed by a subchondral transition of tuberculous inflammation to the bone. Inflammation of the synovial membrane is accompanied by the formation of serous fibrinous exudate. As the intra-articular effusion is organized, the capsule of the joint is infiltrated, germinates with tuberculous granulations. The joint cavity is filled with mushroom–like granulation growths – a fungus (white tumor) is formed. In the future, the process extends to cartilage and bone with the gradual destruction of the latter.
Most often, the disease occurs in the form of tuberculosis of the spine (spondylitis), arthritis of the knee joint (gonarthritis) or arthritis of the hip joint (coxitis). Taking into account the mechanism of joint damage, metastatic (primary bone and primary synovial), as well as intoxication-allergic (reactive) form of tuberculous arthritis (Ponce polyarthritis) are distinguished.
There are 3 phases in the evolution of tuberculous arthritis: prearthritic, arthritic and postarthritic. The first phase corresponds to the development of tuberculous ostitis, the second – specific arthritis, the third – the subsidence of the tuberculous process with the preservation of residual anatomical and functional disorders (deforming arthrosis). The activity of the tuberculosis process in each phase can be different, and therefore there is an active, torpid-current, lost activity and cured form of arthritis.
Tuberculosis of the joints
The clinical picture of tuberculosis arthritis consists of the phenomena of general tuberculosis intoxication and local signs of joint damage. Articular syndrome usually occurs in the form of monoarthritis of the hip or knee joints.
The prearthritic phase of tuberculous arthritis is characterized mainly by general infectious symptoms: subfebrility, lethargy, decreased performance, weight loss, decreased appetite. Early signs of joint damage are manifested by rapid fatigue when walking, gait disorders, weakness in the limb, arthralgias, weakly expressed muscle contractures.
In the arthritic phase of tuberculous arthritis, the signs of tuberculosis intoxication and joint syndrome become more pronounced. Local manifestations include edema of periarticular tissues, spherical or fusiform defiguration of the affected joint, thickening of the skin fold in the joint area (Alexandrov’s symptom). Functional disorders are represented by restriction of movements in the joint (up to blockade), weakening of muscle tone, a vicious installation of the limb, displacement of the articular ends of the bones. Purulent melting of joint tissues is accompanied by the formation of purulent congestion and fistulas.
In the postarthritic phase of tuberculous arthritis, despite the normalization of general well-being, morphofunctional changes persist and intensify: joint deformation, vicious installation and shortening of the limb, soft tissue atrophy, joint subluxations. The outcome of tuberculous arthritis in most cases is the development of secondary deforming osteoarthritis, ankylosing of the joint.
Tuberculous spondylitis occurs with a feeling of heaviness in the spine, non-localized back pain, decreased mobility of the spine, gait changes and posture disorders, signs of sacroiliitis. In children, the thoracic spine is more often affected; in adults, the lower thoracic and upper lumbar sections. In the outcome of spinal tuberculosis, scoliosis, kyphosis, muscle atrophy, secondary chest deformity, deforming spondylosis and spondyloarthrosis develop. The course of tuberculous arthritis and spondylitis is most often complicated by leaky abscesses, fistulas, amyloidosis of internal organs. Recurrences of the tuberculosis process often occur.
Tuberculosis polyarthritis of Ponce
With tuberculous polyarthritis of Ponce, small joints are usually affected. Pain and swelling of the joints are characteristic. The course is persistent, resembling rheumatoid arthritis. The activity of reactive joint inflammation correlates with the severity of a specific process in the primary focus. This form of tuberculous arthritis has a favorable course, as a rule, is not accompanied by irreversible changes in the joints.
The basis for the alleged diagnosis can be anamnesis data, information about BCG vaccination, the results of X-ray and laboratory studies, tuberculin diagnostics. Patients with suspected tuberculosis arthritis should be referred to a phthisiatrician. An important role is played by the identification of the primary focus of infection: pulmonary tuberculosis, renal tuberculosis, genital tuberculosis, positive tuberculin tests. As part of the diagnostic search, the following is performed:
- lung x-ray
- sputum analysis for a CUBE
- bacteriological urine culture
- microscopy and PCR-examination of urogenital smears
- of blood ELISA (quantiferon test, T-SPOT)
In case of tuberculous arthritis, synovial fluid and discharge of fistula passages are examined, arthroscopy, synovial membrane biopsy is performed. Radiography of the joints reveals signs of osteoporosis (rarefaction of bone tissue); narrowing of the articular gap, violation of the integrity of the cortical layer. In doubtful cases, magnetic resonance or computed tomography of the joints, MRI and CT of the spine are performed. Differential diagnosis is carried out with rheumatoid arthritis, other infectious arthritis.
The osteoarticular form of tuberculosis requires long-term phased treatment in specialized anti-tuberculosis institutions. General health measures include high-calorie nutrition, vitamin therapy, aerotherapy, ultraviolet irradiation. In the acute phase of tuberculous arthritis, restriction of movements, immobilization of the affected limb with removable or plaster bandages is shown, with tuberculous spondylitis – wearing a special corset.
Specific drug therapy involves the appointment of anti-tuberculosis antibacterial drugs (streptomycin, rifampicin, isoniazid, etc.). If necessary, nonsteroidal anti-inflammatory drugs are additionally used. To remove the accumulated intra-articular effusion, a joint puncture is performed. With the formation of foci of destruction, various surgical interventions may be required: sequestrectomy, rehabilitation of foci of infection with subsequent arthrodesis, etc. After the active process subsides, the treatment of tuberculosis arthritis continues in a specialized sanatorium, where rehabilitation and rehabilitation measures (physical therapy, massage, physiotherapy, balneotherapy) are carried out.
Prognosis and prevention
With the current detection and initiation of therapy of tuberculous arthritis, the prognosis of the disease is relatively favorable – the functional capabilities of the joints can be preserved in about half of the patients. In other cases, residual, irreversible changes in the joints develop, often leading to disability. Reducing the incidence of osteoarticular tuberculosis requires increased vigilance on the part of pediatricians, general practitioners, rheumatologists, orthopedists in relation to patients infected with tuberculosis or contact persons. General prevention of tuberculosis includes vaccination of children, provision of favorable sanitary living conditions, mass examination of the population with the help of preventive fluorography.