Outline Epidemiology Presentation Investigations Optimal management.

Outline

• Epidemiology

• Presentation

• Investigations

• Optimal management

Tuberculosis notifications by site of disease (pulmonary/non-pulmonary), England and Wales, 1982-

2009

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TB - Epidemiology

• Rising prevalence nationally and locally

• Traditionally mostly pulmonary TB– 60%– 40% extra-pulmonary TB

• Increasing proportion of EPTB (50%)

• 10% of EPTB are joint TB

Joint TB - presentation

• Presentation is often insidious and atypical

• Can be sub-acute and therefore there can be a delay in diagnosis

• Painful joints may precede systemic symptoms by several weeks

• Sometimes is the tip of the iceberg of a multi-focal TB

Joint TB - presentation

• Early– Usually a single joint– Painful– No swelling or deformity

• Later joints may become warm and swollen• Sometimes they have a fever• Look for other symptoms eg cough

Coventry TB rate by year 1999-2006

Rate per 100,000 population

0

5

10

15

20

25

30

35

1999 2000 2001 2002 2003 2004 2005 2006

rate

Coventry PCT

West Midlands

England & Wales

Linear (Coventry PCT)

Coventry 2007

Courtesy Dr Gee

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Figure 4. Tuberculosis case reports and rates by age group and place of birth, UK, 2008

Tuberculosis case reports and rates by place of birth and ethnic group, UK, 2008

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World health organisation

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Three-year average tuberculosis case rates by primary care organisation, UK, 2006-2008

Joint TB -presentation

• Ask about previous TB/contact history– But absence does not rule out TB or make it

unlikely

• Ethnicity is important• Think osteo-articular TB …• Have a high index of suspicion..

– In a young patient with a single chronic painful joint and from an area of high background incidence of TB

TB

• Beware of the young patient (from an area of high incidence) with backache that doesn’t go away

• Must also consider the diagnosis in pregnant ladies

Joint TB - Investigations

• Plain x-rays often normal• MRI can be helpful in diagnosis1

– But there needs to be a high index of suspicion to request this

• Aspiration of synovial fluid for TB culture • Synovial biopsy

– ie tissue for TB culture should sent in saline or water

– Higher yield2

1. Desai.J Bone Joint surg Br.19942. osteoarticular TB in a general hospital in the last decade.ruiz.clin microbiol

infect.2003

Joint TB - Management

• Standard quadruple therapy*• Rifampicin• Isoniazid• Pyrazinamide• Ethambutol

*short course chemotherapy for spinal Tb.parthasarathy.journal of bone and joint surgery.1999

How long for?

Joint TB - management

• Usually 6 months is standard

• No controlled trials for peripheral joint TB

• 6 months?

• 12 months?

• Do they require surgery?

Joint TB - management

• 1A multicentre MRC study of spinal tuberculosis suggests good results can be achieved with 6-9 months of treatment and this is currently the recommendation of The British Thoracic Society Guidelines/NICE

1.Fourteenth report of the Medical Research Council Working Party on Tuberculosis of the Spine.

Int Orthop. 1999; 23(2): 73-81

Outcome at 5 yearsOutcome Hong Kong

Surgery+6HRsNo %

Hong KongSurgery+9HRsNo %

MadrasSurgery+6HRNo %

Madras6HRNo %

Madras9HRNo %

Favourable 23 96 25 96 72 88 75 91 84 98

Unfavourable 1 4

1 4 10 9 7 8 2 2

Total 24 26 82 82 86

Joint TB - management

• Even quite extensive joint disease with severe radiographic changes can resolve with medical treatment alone

Joint TB - management

• However, if treatment is delayed, there can be considerable loss of function and a requirement for extensive surgical intervention.

Key messages

• Peripheral joint tuberculosis should be considered in any patient with chronic joint pain

• and particularly if there is swelling present • and especially if the patient is from an ethnic

group with a high background incidence of tuberculosis.

• Biopsy and culture is important to identify MDR-TB

• Chemotherapy is sufficient in many cases and surgery is helpful in selected cases

Supplementary slides

Short course chemotherapy

• MRC working party on TB of spine

• 3 countries: Hong Kong, India and Korea

• 3 randomised trials

• 5 year assessment

International Orthopaedics 1999 23 : 73-81

International Orthopaedics 1999 23 : 73-81

Short course chemotherapy

• Comparison of ….– Hong Kong radical resection +6HRS– Ambulant therapy 6HR (medical)– Ambulant therapy 9HR (medical)

International Orthopaedics 1999 23 : 73-81

Short course chemotherapy

• Outcomes– Unfavourable outcome– Favourable outcome

• (full functional activity, radiologically quiescent, no myelopathy with functional impairment, modification of therapy)

Therapy

• Medical therapy usually sufficient

• Surgery in selected cases (cord compression, progressive neurology, marked kyphosis)

• 6(-9) months therapy – 2HRZE+ 4HR

Indications for surgery

• patients aged less than 15 years, in whom the initial angle of kyphosis is more than 30º

• patients started on ambulant chemotherapy who develop progressive kyphosis

Indications for surgery

• children aged less than ten years with destruction of vertebral bodies who have partial or no fusion even during programme

• patients with compression of the spinal cord in whom the neurological status deteriorates in spite of chemotherapy