TB and MSK infections in children Dr Joanna Kasznia-Brown Consultant Radiologist Bristol, UK 55 th ESPR meeting May 2019, Helsinki
TB and MSK infections in children
Dr Joanna Kasznia-Brown
Consultant Radiologist
Bristol, UK
55th ESPR meeting
May 2019, Helsinki
TB epidemiology
➢ TB is a global health problem !!!➢ 8.6 million cases worldwide
➢ the most common cause of death from a single infectious agent➢ 1.3 million died in 2017
➢ TB prevalence: ➢ Asia – 58%
➢ Africa regions – 27%
➢ Eastern Mediterranean – 8%
➢ Europe – 4%
WHO Global Tuberculosis Report 2018
TB in children
➢ epidemiology➢ 530,000 cases
➢ 64,000 deaths per year
➢ difficult to diagnose➢ non-specific symptoms
➢ culture not usually performed
➢ skin test – false positive and negative results
➢ medical imaging plays a crucial role in diagnosis and follow-up
TB vaccination
Skeletal TB in children
➢ accounts for 10– 35% of pediatric extra-pulmonary TB
➢ systemic symptoms found in only 33% of patients
➢ less than 50% of children have concurrent pulmonary TB
➢ lesions can develop more than 10 years after the initial infection
➢ typical presentation – solitary bone lesion with local signs of inflammation
➢ early diagnosis is crucial to prevent serious bone and joint destruction
Common skeletal manifestations
➢ spondylitis – 50%
➢ arthritis – 35%
➢ osteomyelitis – 11%
➢ multifocal – 5 -10%
TB corner, World Federation of Paediatric Imaging
Tuberculosis spondylitis
➢ most common manifestations of skeletal tuberculosis
➢ found in younger children, even < 5 years
➢ clinical symptoms➢ intermittent
➢ relatively long bouts of fever
➢ insidious progression
➢ common site – lower thoracic and upper lumbar spine
➢ venous spread in the paravertebral Batson’s venous plexus
Tuberculosis spondylitis
➢ typically involves anterior vertebral body
➢ spread along anterior longitudinal ligament
➢ involvement of multiple vertebra
➢ homogenous enhancement with contrast
➢ well-defined enhancing paravertebral soft tissue
Tuberculosis spondylitis
➢ relative presentation of disks
➢ bone destruction
➢ thoraco-lumbar junction
TB spondylitis
➢ well-defined enhancing paravertebral soft tissue
➢ para-spinal abscess – thin and smooth walls
➢ vertebral intra-osseous abscess
Pyogenic spondylitis
➢ less than 2 vertebra involved
➢ usually starts from intervertebral disk
➢ moderate to complete disk destruction at early phases
➢ disc abscess
➢ infrequent bone destruction
➢ ill-defined enhancing para-spinal soft tissue –less common
➢ abscess – thick and irregular walls
Tuberculous vs. Pyogenic spondylitis
Tuberculosis Pyogenic
Well defined paraspinal
abnormal mass
Ill-defined paraspinal
abnormal mass
Thin and smooth abscess
wall
Thick and irregular abscess
wall
Presence of paraspinal or
intraosseous abscess
Absence of paraspinal or
intraosseous abscess
Multiple body involvement Involvement ≤ 2 vertebral
bodies
Early TB spondylitis
➢ spread along anterior longitudinal ligament
➢ relative preservation of disks
Early TB spondylitis
Early TB spondylitis
TB arthritis
➢ 2nd most common involvement of skeletal system
➢ typically mono-arthritis
➢ hip and knee most commonly affected, followed by SIJs, shoulder and elbow
➢ can mimic rheumatoid arthritis when hands and feet are effected
➢ spread➢ origin in metaphysis with trans-physeal spread
➢ direct spread to joint space and synovium
TB arthritis
➢ juxta-articular osteopenia
➢ joint effusion
➢ synovial involvement
➢ peripheral osseous erosions
➢ gradual tapering of joint space
➢ cartilage loss – late in disease, as no proteolytic enzymes in exudates
➢ para-articular soft tissue masses and cold abscesses
➢ fistulas and sinus tracts
TB arthritis
TB arthritis
TB osteomyelitis
➢ multifocal and/or disseminated from hematogenous spread – previously
➢ solitary bone involvement – more recent
➢bone destruction at metaphysis or epiphysis
➢ growth plate can be effected
➢ trans-physeal spread in children > 1.5 years
TB osteomyelitis
➢ permeative destructive pattern
➢ lack of sclerosis
➢ less sequestra
➢ less periosteal reaction in comparison to pyogenic infection
➢ types➢ cystic
➢ infiltrative
➢ focal erosions
➢ spina ventosa
TB osteomyelitis
➢ non – specific clinical symptoms
➢ lack of sclerosis
➢ less sequestra
➢ less periosteal reaction in comparison to pyogenic infection
Patient 1
TB osteomyelitis
Patient 2
TB osteomyelitis
Patient 3
TB osteomyelitis
TB skeletal infections
➢ recent increase in European countries and US
➢ non-specific clinical symptoms
➢ difficult to diagnose
➢ early imaging and diagnosis is crucial !!!
THANK YOU