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Radiology Quiz Case 1: Diagnosis

Radiology Quiz Case 1: Diagnosis Diagnosis: Tuberculous arthritis of the TMJ Mycobacterium tuberculosis (TB) infection is a worldwide disease. An estimated 14 million cases occurred in 2009, with especially high prevalence rates in Asia and Africa.1 The lung is the most commonly affected site. However, the infection can also occur in extrapulmonary sites such as lymph nodes, spine, and joints.2,3 Tuberculous infection of joints often appears as monoarthritis. Weight-bearing joints such as the hip and knee are most commonly affected, but the involvement of small joints of the extremities has also been reported. In most cases, the infection leads to bony destruction and spread to adjacent soft tissues. Tuberculous arthritis is usually difficult to diagnose, and only a small percentage of cases involve concomitant pulmonary infection. On the other hand, patients with extrapulmonary TB usually do not have classic symptoms such as low-grade fever, cough, weight loss, anorexia, and night sweating.4 As a result, tuberculous arthritis is often diagnosed late and is followed by joint destruction with limitation of movement. Primary TB of the TMJ is rare, with very few cases reported to date. Most patients present with a unilateral painful preauricular swelling, occasionally associated with trismus.4,5 Because of the nonspecific presentation, tuberculous arthritis of the TMJ may be misdiagnosed as tumor, bacterial arthritis, or osteomyelitis. In the great majority of individuals, empirical antibiotics are used first but are usually ineffective.4,5 Phemister6 proposed a triad suggestive of tuberculous arthritis, consisting of periarticular osteoporosis, peripherally located osseous erosion, and gradual diminution of the joint space. For a more definitive imaging-based diagnosis, CT or magnetic resonance imaging (MRI) should be performed. Computed tomograms demonstrated osteolytic bony destruction of the mandibular condyle in all the reported cases and perilesional calcifications and rim-enhanced fluid collections in some of them.4,5 Because most cases of tuberculous arthritis initially present with synovitis, subsequently progressing to synovial proliferation, MRI can also be used to show hypertrophic synovium, which is often hypointense on T2-weighted images.7 After contrast medium is administered, moderate to marked enhancement may indicate acute rather than chronic synovitis.8 Differential diagnoses in imaging studies for tuberculous arthritis include pyogenic and fungal arthritis, pigmented villonodular synovitis (PVNS), gout, pseudogout, and autoimmune arthritis. In the acute stage of pyogenic arthritis, there are fewer bony or synovial changes. Owing to accumulated joint effusion, joint space widening can be demonstrated on a CT scan, and increased fluid signal is obvious on MRI, compared with the imaging findings of TB arthritis.9 Clinicians can distinguish TB arthritis from PVNS and advanced gouty arthritis by the rim-enhanced fluid collections on CT images. Also, the masses of PVNS are usually more lobulated.9 Once TB infection is suspected, the diagnosis should be confirmed with fine-needle aspiration for cytologic examination by acid-fast staining or polymerase chain reaction assay, which is a specific method for TB diagnosis with high sensitivity and specificity.10 If the results of both techniques are negative, open surgical biopsy is suggested to confirm the diagnosis.4 Anti-TB therapy, as for treatment of pulmonary TB, should be started once the diagnosis is confirmed. The standard protocol consists of 4 drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) administered for 2 months, followed by 4 months of treatment with isoniazid and rifampicin.5 Most patients recover after administration of anti-TB medications and show regeneration of the condylar head.4 If there is no response to pharmacotherapy, surgical excision and decortication should be considered.4 In the current case, the patient underwent surgical biopsy; the specimen was positive by acid-fast staining, and bacterial culture indicated TB. Anti-TB medication was administered immediately, and the preauricular mass disappeared rapidly. There was no evidence of recurrence or any complications during regular follow-up visits. In any case of tuberculous arthritis, prompt and proper differential diagnosis and timely management are essential to avoid delays in treatment, which may result in irreversible joint destruction. Return to Quiz Case. References 1. World Health Organization. Global Tuberculosis Control—Epidemiology, Strategy, Financing. Geneva, Switzerland: World Health Organization; 2010:1-3 2. Chandir S, Hussain H, Salahuddin N, et al. Extrapulmonary tuberculosis: a retrospective review of 194 cases at a tertiary care hospital in Karachi, Pakistan. J Pak Med Assoc. 2010;60(2):105-10920209695PubMedGoogle Scholar 3. Seersholm N, Wilcke T. Diagnosis of extrapulmonary tuberculosis is a challenge [in Danish]. Ugeskr Laeger. 2011;173(12):886-88921419058PubMedGoogle Scholar 4. Helbling CA, Lieger O, Smolka W, Iizuka T, Kuttenberger J. Primary tuberculosis of the TMJ: presentation of a case and literature review. Int J Oral Maxillofac Surg. 2010;39(8):834-83820605408PubMedGoogle ScholarCrossref 5. Gandhi S, Ranganathan LK, Bither S, Koshy G. Tuberculosis of temporomandibular joint: a case report. J Oral Maxillofac Surg. 2011;69(6):e128-e13021367504PubMedGoogle ScholarCrossref 6. Phemister DB. The effect of pressure on articular surfaces in pyogenic and tuberculous arthritides and its bearing on treatment. Ann Surg. 1924;80(4):481-50017865104PubMedGoogle ScholarCrossref 7. Sanghvi DA, Iyer VR, Deshmukh T, Hoskote SS. MRI features of tuberculosis of the knee. Skeletal Radiol. 2009;38(3):267-27319050872PubMedGoogle ScholarCrossref 8. De Backer AI, Mortelé KJ, Vanhoenacker FM, Parizel PM. Imaging of extraspinal musculoskeletal tuberculosis. Eur J Radiol. 2006;57(1):119-13016139465PubMedGoogle ScholarCrossref 9. Cai XY, Yang C, Chen MJ, Zhang SY, Yun B. Arthroscopic management of septic arthritis of temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(1):24-3020123377PubMedGoogle ScholarCrossref 10. Malbruny B, Le Marrec G, Courageux K, Leclercq R, Cattoir V. Rapid and efficient detection of Mycobacterium tuberculosis in respiratory and non-respiratory samples. Int J Tuberc Lung Dis. 2011;15(4):553-55521396219PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 1: Diagnosis

Archives of Otolaryngology - Head & Neck Surgery , Volume 138 (2) – Feb 1, 2012

Radiology Quiz Case 1: Diagnosis

Abstract

Diagnosis: Tuberculous arthritis of the TMJ Mycobacterium tuberculosis (TB) infection is a worldwide disease. An estimated 14 million cases occurred in 2009, with especially high prevalence rates in Asia and Africa.1 The lung is the most commonly affected site. However, the infection can also occur in extrapulmonary sites such as lymph nodes, spine, and joints.2,3 Tuberculous infection of joints often appears as monoarthritis. Weight-bearing joints such as the hip and knee are most commonly...
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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archoto.2011.1161b
Publisher site
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Abstract

Diagnosis: Tuberculous arthritis of the TMJ Mycobacterium tuberculosis (TB) infection is a worldwide disease. An estimated 14 million cases occurred in 2009, with especially high prevalence rates in Asia and Africa.1 The lung is the most commonly affected site. However, the infection can also occur in extrapulmonary sites such as lymph nodes, spine, and joints.2,3 Tuberculous infection of joints often appears as monoarthritis. Weight-bearing joints such as the hip and knee are most commonly affected, but the involvement of small joints of the extremities has also been reported. In most cases, the infection leads to bony destruction and spread to adjacent soft tissues. Tuberculous arthritis is usually difficult to diagnose, and only a small percentage of cases involve concomitant pulmonary infection. On the other hand, patients with extrapulmonary TB usually do not have classic symptoms such as low-grade fever, cough, weight loss, anorexia, and night sweating.4 As a result, tuberculous arthritis is often diagnosed late and is followed by joint destruction with limitation of movement. Primary TB of the TMJ is rare, with very few cases reported to date. Most patients present with a unilateral painful preauricular swelling, occasionally associated with trismus.4,5 Because of the nonspecific presentation, tuberculous arthritis of the TMJ may be misdiagnosed as tumor, bacterial arthritis, or osteomyelitis. In the great majority of individuals, empirical antibiotics are used first but are usually ineffective.4,5 Phemister6 proposed a triad suggestive of tuberculous arthritis, consisting of periarticular osteoporosis, peripherally located osseous erosion, and gradual diminution of the joint space. For a more definitive imaging-based diagnosis, CT or magnetic resonance imaging (MRI) should be performed. Computed tomograms demonstrated osteolytic bony destruction of the mandibular condyle in all the reported cases and perilesional calcifications and rim-enhanced fluid collections in some of them.4,5 Because most cases of tuberculous arthritis initially present with synovitis, subsequently progressing to synovial proliferation, MRI can also be used to show hypertrophic synovium, which is often hypointense on T2-weighted images.7 After contrast medium is administered, moderate to marked enhancement may indicate acute rather than chronic synovitis.8 Differential diagnoses in imaging studies for tuberculous arthritis include pyogenic and fungal arthritis, pigmented villonodular synovitis (PVNS), gout, pseudogout, and autoimmune arthritis. In the acute stage of pyogenic arthritis, there are fewer bony or synovial changes. Owing to accumulated joint effusion, joint space widening can be demonstrated on a CT scan, and increased fluid signal is obvious on MRI, compared with the imaging findings of TB arthritis.9 Clinicians can distinguish TB arthritis from PVNS and advanced gouty arthritis by the rim-enhanced fluid collections on CT images. Also, the masses of PVNS are usually more lobulated.9 Once TB infection is suspected, the diagnosis should be confirmed with fine-needle aspiration for cytologic examination by acid-fast staining or polymerase chain reaction assay, which is a specific method for TB diagnosis with high sensitivity and specificity.10 If the results of both techniques are negative, open surgical biopsy is suggested to confirm the diagnosis.4 Anti-TB therapy, as for treatment of pulmonary TB, should be started once the diagnosis is confirmed. The standard protocol consists of 4 drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) administered for 2 months, followed by 4 months of treatment with isoniazid and rifampicin.5 Most patients recover after administration of anti-TB medications and show regeneration of the condylar head.4 If there is no response to pharmacotherapy, surgical excision and decortication should be considered.4 In the current case, the patient underwent surgical biopsy; the specimen was positive by acid-fast staining, and bacterial culture indicated TB. Anti-TB medication was administered immediately, and the preauricular mass disappeared rapidly. There was no evidence of recurrence or any complications during regular follow-up visits. In any case of tuberculous arthritis, prompt and proper differential diagnosis and timely management are essential to avoid delays in treatment, which may result in irreversible joint destruction. Return to Quiz Case. References 1. World Health Organization. Global Tuberculosis Control—Epidemiology, Strategy, Financing. Geneva, Switzerland: World Health Organization; 2010:1-3 2. Chandir S, Hussain H, Salahuddin N, et al. Extrapulmonary tuberculosis: a retrospective review of 194 cases at a tertiary care hospital in Karachi, Pakistan. J Pak Med Assoc. 2010;60(2):105-10920209695PubMedGoogle Scholar 3. Seersholm N, Wilcke T. Diagnosis of extrapulmonary tuberculosis is a challenge [in Danish]. Ugeskr Laeger. 2011;173(12):886-88921419058PubMedGoogle Scholar 4. Helbling CA, Lieger O, Smolka W, Iizuka T, Kuttenberger J. Primary tuberculosis of the TMJ: presentation of a case and literature review. Int J Oral Maxillofac Surg. 2010;39(8):834-83820605408PubMedGoogle ScholarCrossref 5. Gandhi S, Ranganathan LK, Bither S, Koshy G. Tuberculosis of temporomandibular joint: a case report. J Oral Maxillofac Surg. 2011;69(6):e128-e13021367504PubMedGoogle ScholarCrossref 6. Phemister DB. The effect of pressure on articular surfaces in pyogenic and tuberculous arthritides and its bearing on treatment. Ann Surg. 1924;80(4):481-50017865104PubMedGoogle ScholarCrossref 7. Sanghvi DA, Iyer VR, Deshmukh T, Hoskote SS. MRI features of tuberculosis of the knee. Skeletal Radiol. 2009;38(3):267-27319050872PubMedGoogle ScholarCrossref 8. De Backer AI, Mortelé KJ, Vanhoenacker FM, Parizel PM. Imaging of extraspinal musculoskeletal tuberculosis. Eur J Radiol. 2006;57(1):119-13016139465PubMedGoogle ScholarCrossref 9. Cai XY, Yang C, Chen MJ, Zhang SY, Yun B. Arthroscopic management of septic arthritis of temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(1):24-3020123377PubMedGoogle ScholarCrossref 10. Malbruny B, Le Marrec G, Courageux K, Leclercq R, Cattoir V. Rapid and efficient detection of Mycobacterium tuberculosis in respiratory and non-respiratory samples. Int J Tuberc Lung Dis. 2011;15(4):553-55521396219PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Feb 1, 2012

Keywords: diagnostic radiologic examination,radiology specialty

References