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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 82-84

Unusual presentation of tuberculous osteitis distal fibula


Department of Orthopaedics, Pushpagiri Institute of Medical Sciences and Research, Thiruvalla, Kerala, India

Date of Submission17-Sep-2021
Date of Acceptance19-Sep-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
John Ponnezhathu Sebastian
Department of Orthopaedics, Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla - 689 101, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joasis.joasis_23_21

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  Abstract 


We present the case of a 10-year-old boy presenting with pain and swelling on the lateral aspect of the left ankle associated with occasional fever of 1-month duration. Before he presented to us, he was treated with antibiotics and anti-inflammatory agents on two occasions in a local hospital for the same complaints. The swelling disappeared and mild pain persisted. The inflammatory markers were high, and the X-ray was not typical of either pyogenic infection or Ewing's sarcoma. Hence, a biopsy was done and the material was sent for histopathological and bacteriological studies. The histopathology report was typical of tuberculosis. The child became asymptomatic after antituberculous treatment. The case is presented because of the unusual clinical and radiological presentation of tuberculosis in one of the rarest sites reported in the literature.

Keywords: Tuberculosis, distal fibula, histopathology


How to cite this article:
John AM, Thomas V, Pillai MG, Theckanal JG, Sebastian JP. Unusual presentation of tuberculous osteitis distal fibula. J Orthop Assoc South Indian States 2021;18:82-4

How to cite this URL:
John AM, Thomas V, Pillai MG, Theckanal JG, Sebastian JP. Unusual presentation of tuberculous osteitis distal fibula. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 May 27];18:82-4. Available from: https://www.joasis.org/text.asp?2021/18/2/82/336654




  Introduction Top


Tuberculosis of bone and joints is always secondary to a primary infection like pulmonary tuberculosis, genitourinary tuberculosis, gastrointestinal tuberculosis, glandular tuberculosis, or tuberculosis of dermis. Osteoarticular tuberculosis accounts for 1% to 3% of tuberculosis.[1] It commonly affects the axial skeleton followed by the major weight-bearing joints such as the hip and the knee joints. Further diaphysis involvement of long bones in skeletal tuberculosis has very low incidence even in endemic areas (1%–3%).[2] Tuberculosis in long bones presents mostly as a solitary lesion with no specific signs and symptoms,[3] which leads a physician or surgeon think of more common pathology[4] like cystic bone lesions, bone tumors, Brodie's abscess, chronic pyogenic osteomyelitis, or fungal/bacterial granulomatous lesions. Furthermore, due to the rarity of tuberculosis in tubular bones[5] with no characteristic radiological features,[6] the diagnosis is often missed. Diagnosis of tubercular lesions in tubular bones requires a very high index of suspicion. The radiological findings should be confirmed with subsequent histopathological and culture sensitivity results to reach a definitive diagnosis.

A review of literature has revealed that tuberculosis of long bones is very rare and tuberculosis of fibula is extremely rare.[7],[8] Hardly do we find any report of tuberculosis of the distal fibula. Abdel Wahab et al. have reported two cases of tuberculosis of proximal fibula. Muhammedh I. UL. aq et al. have published a case report of pulmonary tuberculosis with tuberculous osteomyelitis of the distal fibula. We reported this case to emphasize the unusual occurrence of long bone tuberculosis at unusual site as in our case in the distal fibula.


  Case Report Top


A 10-year-old boy was referred to our center with 1-month history of pain and swelling of his right ankle. He was treated with antibiotics and anti-inflammatory agents in a local hospital for the same complaints. The onset was not associated with constitutional features. He sustained a sprained ankle 2 months ago which was treated in the same hospital. On clinical examination, he was a healthy-looking boy and was apyrexic. There was a mildly tender swelling of 5 cm × 4 cm around the distal fibula and lateral malleolus [Figure 1]. The ankle joint had a full range of movements without pain. There was no association of loss of appetite, swinging pyrexia, or rigors.
Figure 1: Clinical picture showing swelling on the lateral aspect of the ankle

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The results of laboratory investigations were all within normal limits except a marginally elevated erythrocyte sedimentation rate. The X-ray of the ankle including anteroposterior and lateral views revealed sclerosis and thickening of the distal fibula with moth-eaten type lytic lesions in the lateral malleolus [Figure 2].
Figure 2: X-ray showing moth-eaten appearance with periosteal reaction and thickening of the fibula

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The magnetic resonance imaging (MRI) study showed periosteal thickening with multiple intramedullary cystic lesions. The radiological and MRI features were suggestive of either a subacute type of osteomyelitis or Ewing's sarcoma.

Hence, an open biopsy was done and the specimen was sent for histopathological and bacteriological examination. There was no pus and the medullary cavity was filled with granulation tissue, which was curetted and washed [Figure 3].
Figure 3: Intraoperative picture showing granulation tissue in the medullary cavity

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The histopathology examination revealed caseating tubercles suggestive of tuberculosis. All the tests for tuberculosis were positive. The boy became asymptomatic with a full course of antituberculous therapy.


  Discussion Top


As in any other system, skeletal tuberculosis in long bones is a great mimicker in medicine.[6],[9] Despite recent advances, tuberculosis in long bones remains a widespread problem due to its nonspecific presentation with diffuse pain and swelling and very few signs of inflammation. A study by Akgul T et al. mentioned an average delay of 6.6 months in the diagnosis of bony tuberculosis.[10],[11] Published reports in the literature are more on adults[12],[13] and report typical presentation in adults. In children, the cystic tubercular lesions in the long bones[14] present mostly as a single solitary intramedullary lytic lesion and cause confusion with other more common diseases.[2],[5],[15] In certain cases, although imaging can help a surgeon in reaching a possible diagnosis, the radiographic imaging of the involved bone is not characteristic. Very often, the nonspecific features of osteopenia, sclerosis, and periosteal reaction are more likely to be confusing to the surgeon.[16] Frequently, diagnosis may be confused with Brodie's abscess and should be differentiated from tubercular osteomyelitis[17] as there are very few characteristic radiological findings and the diagnosis is established by histopathological and microbial culture validation.[4],[18] The absence of response to salicylates helps to rule out the possibility of osteoid osteoma.[19],[20] The absence of contrast enhancement on MRI can very often rule out the possibility of hemangioma.[7] Few case reports relating to diaphysis long bone tuberculosis have been mentioned in the literature. Richter et al.[21] have emphasized the importance of biopsy in diagnosing long bone tuberculosis. Gahlot et al.[22] and Chattopadhyay et al.[23] have each reported a single case of diaphyseal tibia tuberculosis in 2 years old and 28 years old, respectively.

Tuberculosis of the distal fibula is extremely rare. Only a very few cases are reported till date. The clinical presentation and radiological features were not suggestive of tuberculosis. The clinical course was more suggestive of an acute pyogenic infection turning to subacute osteomyelitis, and the radiological appearance was more suggestive of a malignant tumor with moth-eaten appearance, periosteal thickening, and sclerotic layering. In this age group, the possibility of Ewing's sarcoma was considered. The MRI examination was also suggestive of Ewing's sarcoma. The histopathological examination has confirmed it to be another rare presentation of tuberculosis, the greatest mimicker. This case highlights the fact that tuberculosis should be considered a major possibility when clinical and radiological features of a lesion are highly atypical.


  Conclusion Top


In the absence of classic clinical features and radiological findings of the common diseases, the possibility of atypical presentation of tuberculosis should be considered. The awareness of the very rare tuberculous involvement of the distal fibula and a high index of suspicion are the keys to make the correct diagnosis. The role of histopathological examination cannot be further overemphasized for early diagnosis and accurate treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am 1996;78:288-98.  Back to cited text no. 1
    
2.
Mahmood T, Nassiri MC, Mohamed O, Yaqoub O, Grady PO. Diaphyseal tuberculosis of tibia-Rare occurrence: Case report and review of literature. J Bone Rep Recomm 2016;2:3. [doi: 10.4172/2469-6684.100027].  Back to cited text no. 2
    
3.
Hsieh C, Miltner LE, Chang C. Tuberculosis of the shaft of the large long bones of the extremities. J Bone Jt Surg 1934;16:545-63.  Back to cited text no. 3
    
4.
Roberts JM, Drummond DS, Breed AL, Chesney J. Subacute hematogenous osteomyelitis in children: A retrospective study. J Pediatr Orthop 1982;2:249-54.  Back to cited text no. 4
    
5.
Abdelwahab IF, Present DA, Gould E, Klein MJ, Nelson J. Case report 473: Tuberculosis of the distal metaphysis of the femur. Skeletal Radiol 1988;17:199-202.  Back to cited text no. 5
    
6.
Mathew K, Paulose S, Jose TM. Tuberculosis of proximal Tibia. Kerala J Orthop 2013;26:51-2.  Back to cited text no. 6
    
7.
Khan GM, Humail SM, Hafeez K. Primary diaphyseal tuberculous osteomyelitis of Tibia. Prof Med J 2014;21:1282-4.  Back to cited text no. 7
    
8.
Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler AJ, Orgill DP, et al. The SCARE 2018 statement: Updating consensus surgical case report (SCARE) guidelines. Int J Surg 2018;60:132-6.  Back to cited text no. 8
    
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Singh V. Pediatric TB Management under RNTCP: What and Why? Indian J Pediatr 2019;86:707-13.  Back to cited text no. 9
    
10.
Carrell WB, Childress HM. Tuberculosis of the large long bones of the extremities. JBJS 1940;22:569-88.  Back to cited text no. 10
    
11.
Akgül T, Ozger H, Göksan BS, Eren I. Cystic transphyseal bone tuberculosis: A report of two cases. Acta Orthop Traumatol Turc 2012;46:316-9.  Back to cited text no. 11
    
12.
Aharmim M, Bouti K, Soualhi M, Hanim FZ, Marc K, Zahraoui R, et al. Pediatric tuberculosis at Moulay Youssef University Hospital – Morocco. Int J Med Surg 2014;1:17-22.  Back to cited text no. 12
    
13.
López Ávalos GG, Prado Montes de Oca E. Classic and new diagnostic approaches to childhood tuberculosis. J Trop Med 2012;2012:818219.  Back to cited text no. 13
    
14.
Rasool MN, Govender S, Naidoo KS. Cystic tuberculosis of bone in children. J Bone Joint Surg Br 1994;76:113-7.  Back to cited text no. 14
    
15.
Benkeddache Y, Gottesman H. Skeletal tuberculosis of the wrist and hand: A study of 27 cases. J Hand Surg Am 1982;7:593-600.  Back to cited text no. 15
    
16.
O'Connor BT, Steel WM, Sanders R. Disseminated bone tuberculosis. J Bone Joint Surg Am 1970;52:537-42.  Back to cited text no. 16
    
17.
Griffith JF, Kumta SM, Leung PC, Cheng JC, Chow LT, Metreweli C. Imaging of musculoskeletal tuberculosis: A new look at an old disease. Clin Orthop Relat Res 2002;398:32-9.  Back to cited text no. 17
    
18.
Colmenero JD, Jiménez-Mejías ME, Reguera JM, Palomino-Nicás J, Ruiz-Mesa JD, Márquez-Rivas J, et al. Tuberculous vertebral osteomyelitis in the new millennium: Still a diagnostic and therapeutic challenge. Eur J Clin Microbiol Infect Dis 2004;23:477-83.  Back to cited text no. 18
    
19.
Noordin S, Allana S, Hilal K, Nadeem N, Lakdawala R, Sadruddin A, et al. Osteoid osteoma: Contemporary management. Orthop Rev (Pavia) 2018;10:7496.  Back to cited text no. 19
    
20.
Jacobs P. Osteo-articular tuberculosis in coloured immigrants: A radiological study. Clin Radiol 1964;15:59-69.  Back to cited text no. 20
    
21.
Richter R, Krause FJ. Primary diaphyseal tuberculosis of the long bones. Rofo 1983;139:549-52.  Back to cited text no. 21
    
22.
Gahlot N, Saini UC, Chouhan DK. Diaphyseal tuberculosis – A rare manifestation. BMJ Case Rep 2017;2017:r-221617.  Back to cited text no. 22
    
23.
Chattopadhyay P, Bandyopadhyay A, Ghosh S, Kundu AJ. Primary diaphyseal tuberculosis of the tibia. Singapore Med J 2009;50:e226-8.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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