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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 194-196

Tuberculosis of patella: Nonspecific presentation, treated conservatively


Department of Orthopaedics, PGIMS, Rohtak, Haryana, India

Date of Web Publication9-Aug-2017

Correspondence Address:
Pankaj Kumar Sharma
House no 313, sector 14, Rohtak, 124001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_16_16

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  Abstract 


Skeletal tuberculosis (TB) accounts for 8% of extrapulmonary TB, and patella accounts for 0.1% of all skeletal TB. Patella TB in early stages is very difficult to diagnose because of no constitutional signs and symptoms. It may be found in immunocompromised states, endemic areas, and in chronic debilitated patients. Isolated TB of patella is very rare, so early diagnosis and management is quite difficult without clinical and histopathological examination. There is a significant improvement in clinical outcome after taking antitubercular multidrug therapy and surgery is rarely required.

Keywords: Antitubercular therapy, histopathological examination, immunocompromised states, patella, skeletal tuberculosis


How to cite this article:
Sharma PK, Madegowda A, Mittal R. Tuberculosis of patella: Nonspecific presentation, treated conservatively. Int J Health Allied Sci 2017;6:194-6

How to cite this URL:
Sharma PK, Madegowda A, Mittal R. Tuberculosis of patella: Nonspecific presentation, treated conservatively. Int J Health Allied Sci [serial online] 2017 [cited 2020 Aug 9];6:194-6. Available from: http://www.ijhas.in/text.asp?2017/6/3/194/212589




  Introduction Top


Tuberculosis is a common communicating disease in developing countries including India. Skeletal tuberculosis (TB) accounts for 8% of extrapulmonary TB, and patella accounts for 0.1% of all skeletal TB.[1],[2] Early diagnosis of ailment is difficult in extrapulmonary cases because of lack of specific signs and symptoms. Management of infection varies from sites affected in the body. It may affect various components of knee joint including either soft tissue or bony parts. Cartilage is a natural barrier for infection and patella has the thickest cartilage in the body. We present two cases of patella TB in young immunocompetent patients diagnosed by bacteriology and histopathological examination. Both were treated by antitubercular treatment (ATT) multidrug therapy. No surgery was required.


  Case Reports Top


Two patients of TB of patella were evaluated and managed as described below.

Case 1

A 28-year-old male presented with pain and swelling of the right knee for 2 months. He had mild fever on few occasions. General condition of the patient was fair and there was no weight loss. He had a family history of TB. There was mild effusion in prepatellar region mimicking prepatellar bursitis. Active and passive movements of knee joint were less than the opposite limb and painful over 90° of flexion. Range of movements was 5°–100° of flexion, and full extension was not possible due to pain. Blood counts were within normal range, while erythrocyte sedimentation rate (ESR) value was 22 mm/1 h. Anteroposterior and lateral views of the radiographs showed osteolytic lesion in patella which was well contained by surrounding normal bone, as shown in [Figure 1]. The patient underwent image-guided core biopsy which showed intratrabecular spaces with chronic lymphocytic infiltration and ill-defined collection of epithelioid histiocytes, suggestive of TB. After the biopsy, skin wound failed to heal normally. There was an open wound of around 3 cm over the patella with everted margins as shown in [Figure 2]. Skin around the ulcer had inflammatory changes such as erythema, swelling, and shiny appearance. The patient was started on ATT multidrug therapy which showed good healing of wound and lesion in patella as shown in [Figure 3] and [Figure 4]. At the end of one month, there was painless full range of movements and complete resolution of swelling in the diseased knee joint. He did not undergo any surgical intervention.
Figure 1: X-ray, anteroposterior and lateral view of the knee, showing osteolytic lesion and sequestrum in patella surrounded by sclerotic bone

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Figure 2: Nonhealing ulcer over the patella and suprapatellar effusion

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Figure 3: Wound in healing stage after 1 month of antitubercular treatment

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Figure 4: Clinical picture showing complete healing of ulcer and recovery of complete range of painless movements of the knee after ATT and physiotherapy

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Case 2

A 30-year-old male presented with mild pain and swelling over the anterior aspect of the knee for the past 5 months. The patient was of average built with no history of fever or weight loss. He had been treated with ATT for cervical lymph node TB in the past. On examination, there was minimal swelling over the anterior part of knee without obvious signs and symptoms of inflammation. Laboratory investigations included total leukocyte count, 7600/mm 3; ESR, 11 mm/1 h; and hemoglobin, 13.3 gm%. X-ray lateral view showed osteolytic lesion with a sequestrum in the patella [Figure 5]. Magnetic resonance imaging (MRI) revealed focal erosion involving the inferior aspect of the patella with moderate synovial effusion along with lymphadenopathy [Figure 6]. Biopsy of the patella revealed it to be TB. The patient improved symptomatically with ATT and physiotherapy. He did not require any surgical intervention.
Figure 5: X-ray, lateral view of the knee, showing osteolytic lesion/sequestrum in inferior part of patella

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Figure 6: Magnetic resonance imaging (noncontrast) of knee, T1-weighed image showing osteolysis and sequestrum in the patella and minimal effusion

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  Discussion Top


TB of the skeletal system is common in developing countries. Three most common sites are spine, hip, and knee joint. Patella is one of the sesamoid bones which accounts for around 0.1% (0.09%–0.15%) incidence in musculoskeletal system TB.[1],[2] It is very difficult to diagnose TB of patella in early stages because there are no constitutional symptoms. Even local signs and symptoms are not specific for it. The patient may present with local swelling over the knee joint and effusion either in whole of the knee or around the patella. Sometimes, it may be diagnosed with prepatellar fistula formation.[3] Culture tests for joint effusion are nonspecific and rarely acid-fast bacilli are found in reactive fluid.[4] Sometimes, laboratory findings of blood samples correlate with disease, for example, elevated ESR and C-reactive protein levels, but these are more prognostic than diagnostic value and reflect disease severity or efficacy of treatment. Mantoux test is not specific in areas of high endemicity. X-ray and MRI are useful for making diagnosis. The most usual finding is sequestration of bone surrounded by peripheral sclerosis.[2],[5],[6],[7],[8],[9] However, it may be also in mild form of osteolysis limited by the surrounding normal bone. Severe form occurs with osteolysis which communicates with the knee joint.[9],[10] The location and extension of lesion can be determined by MRI, but confirmation of diagnosis is made by histopathological examination. For histopathology, sample is taken out from superficial part of the involved patella without contaminating the knee joint. Treatment in majority is based on anti-tubercular multidrug therapy (ATT). The duration of treatment varies from 12 to 18 months. We recommend an 18-month course of ATT. Surgery has a limited role in management and can be done either in the form of curettage of lesion at the time of diagnostic arthroscopy for biopsy or in the form of debridement of joint. Debridement and curettage are required for severe forms, which present with an abscess or bone lesions resistant to drugs.[1],[11] Mild form of disease limited to patella has a better prognosis, while severe forms with degenerative changes and those which are resistant to drugs stand with a poor outcome.[2],[6],[10],[11]


  Conclusion Top


There should be a high suspicion of the condition in endemic areas for an early diagnosis. Imaging is quite suggestive, but for confirmation of lesion, histopathological examination should be done. Complete ATT multidrug therapy course and physiotherapy should be started as early as possible for avoidance of complications. Most of the lesions heal with complete antitubercular therapy regimen and surgery is rarely required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tuli SM. Tuberculosis of the Skeletal System (Bones, Joints, Spine and Bursal Sheaths). New Delhi: Jaypee Brothers; 2004.  Back to cited text no. 1
    
2.
Mittal R, Trikha V, Rastogi S. Tuberculosis of patella. Knee 2006;13:54-6.  Back to cited text no. 2
    
3.
Galois L, Chary-Valckenaere I, Mainard D, Pourel J, Delagoutte JP. Tuberculosis of the patella. Arch Orthop Trauma Surg 2003;123:192-4.  Back to cited text no. 3
    
4.
Fnini S, Hassoun J, Garches A, Largab A. Patella tuberculosis: A case report. Orthop Traumatol Surg Res 2009;95:649-51.  Back to cited text no. 4
    
5.
Dhillon MS, Rajasekhar C. Tuberculosis of the patella: Report of a case and review of the literature. Knee 1995;2:56.  Back to cited text no. 5
    
6.
Dhillon MS, Rao SS, Sandhu MS, Vasisht RK, Nagi ON. Tuberculosis of the patella. Skeletal Radiol 1998;27:40-2.  Back to cited text no. 6
    
7.
Hernández Gimenez M, Tovar Beltran JV, Frieyro Segui MI, Pascual Gómez E. Tuberculosis of the patella. Pediatr Radiol 1987;17:328-9.  Back to cited text no. 7
    
8.
Shah P, Ramakantan R. Tuberculosis of the patella. Br J Radiol 1990;63:363-4.  Back to cited text no. 8
    
9.
Dhillon MS, Rajasekhar C, Nagi ON. Tuberculosis of the patella: Report of a case and review of the literature. Knee 1995;2:53-6.  Back to cited text no. 9
    
10.
George Hartofilakidis-Garofalidis. Cystic tuberculosis of the patella. Report of three cases. J Bone Joint Surg Am 1969;51:582-5.  Back to cited text no. 10
    
11.
Roy DR. Osteomyelitis of the patella. Clin Orthop Relat Res 2001; 389:30-4.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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