Tuberculous dactylitis: An easily missed diagnosis

Department of Paediatrics, The University of Melbourne and Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Flemington Road, Parkville, VIC 3052, Australia.
European Journal of Clinical Microbiology (Impact Factor: 2.67). 04/2011; 30(11):1303-10. DOI: 10.1007/s10096-011-1239-5
Source: PubMed


The prevalence of tuberculosis (TB) continues to rise worldwide. Current migration patterns and increased travel to high-prevalence TB countries will result in more frequent presentations of less common forms of TB. Tuberculous dactylitis, a form of tuberculous osteomyelitis, is well recognised in countries with a high prevalence of TB. We provide a systematic review of all published cases of tuberculous dactylitis in children and adolescents and describe a case to illustrate the typical features of the disease. Our review revealed 37 cases of tuberculous dactylitis in children and adolescents, all reported in the last 17 years. Children less than 10 years of age are most frequently affected and the hand is the most commonly affected site. Concurrent pulmonary TB is present in a fifth of cases and systemic symptoms are usually absent. Positive TST and IGRA support the presumptive diagnosis, but cannot be used as rule-out tests. The definitive diagnosis relies on the detection M. tuberculosis by PCR or culture. Treatment should comprise of a standard three to four drug anti-tuberculous regimen. The optimal treatment duration remains unknown. Surgery has a limited role in the treatment in general but may play a supportive role, and curettage of the cavity has been recommended for avascular lesions.

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    • "The optimal treatment duration for tubercular dactylitis remains unknown. Surgery has a limited role in the treatment in general but may play a supportive role, and curettage of the cavity has been recommended for avascular lesions.[15] "
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    ABSTRACT: Tuberculous dactylitis is a distinctly uncommon, yet well recognized form of tuberculosis involving the small bones of the hand or foot. It occurs in young children in endemic areas under 5 years of age. Tuberculosis of the short tubular bones like phalanges, metacarpals or metatarsals is quite uncommon beyond 6 years of age, once the epiphyseal centers are well established. The radiographic features of cystic expansion have led to the name "Spina Ventosa" for tuberculous dactylitis of the short bones. Scrofuloderma is a mycobacterial infection affecting children and young adults, representing direct extension of tuberculosis into the skin from underlying structures e.g. lymph nodes. An 8-year-old malnourished girl had multiple axillary ulcers with lymphadenopathy. Tuberculous dactylitis with ipsilateral axillary scrofuloderma was suspected on clinical and radiological grounds. The suspicion was confirmed by histology and bacteriology. The patient responded to antitubercular drugs with progressive healing of the lesions without surgery. Concomitant presence of these dual lesions suggesting active disseminated tuberculosis in immune-competent child over 6 years is very rare and hardly reported.
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    • "Among the various forms of extra pulmonary tuberculosis, tuberculous dactylitis and polyarticular tuberculosis are recognised presentations in patients who live in countries with a high prevalence rate of tuberculosis. It is frequently associated with disseminated disease [3]. Typical sinus formation of dactylitic bone may not always be present. "
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    ABSTRACT: Bone and joint tuberculosis is a chronic debilitating condition that leads to progressive damage and even deformity of joints. It may affect one or multiple sites. It could present in a myriad of ways which may result in an incorrect diagnosis being made. Common misdiagnoses include seronegative inflammatory arthritis, septic arthritis, malignancy, osteoporotic fractures and mechanical type back pain. It was initially only diagnosed in patients with previous active tuberculosis or latent tuberculosis. However, in recent years, it has also been reported in patients without a history of previous tuberculosis infection. Making a diagnosis of bone and joint tuberculosis is challenging. As the symptoms are not always typical, a delay in initiating anti-tuberculosis treatment is not uncommon in clinical practice. Systemic features are not always present in multi-drug resistant tuberculosis of joints which makes the diagnosis even more challenging. Multi-drug resistant tuberculosis is an increasingly common problem. It is not only limited to immunocompromised patients, but also found in immunocompetent patients. Multifocal tuberculous osteomyelitis is an uncommon condition and may involve any bone such as the skull, ribs, long bones, spine and phalanx. Tuberculous pyomyositis and tuberculous tenosynovitis may also be the presenting features of multifocal tuberculosis. Identification of mycobacterium tuberculosis in synovial fluid and biopsy, tissue culture, tissue fluid cytology and tissue polymerase chain reaction are crucial investigations in these cases. As the presentation of extra pulmonary tuberculosis can be very variable, it is important to maintain a high index of suspicion. The diagnosis and therefore treatment may be expedited using a clinically directed multidisciplinary approach. Keywords Bone and joint tuberculosis; Multi focal tuberculous osteomyelitis; Extra-pulmonary tuberculosis; Multi-drug resistant tuberculosis; Latent tuberculosis
    Full-text · Article · Feb 2012 · Journal of Clinical Medicine Research
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    ABSTRACT: Bacille Calmette-Guérin (BCG) vaccine is one of the most commonly administered vaccines worldwide. In countries with high tuberculosis (TB) prevalence, it is generally given shortly after birth. In a number of low TB prevalence countries, BCG is used as a travel vaccine, typically given to children outside the neonatal period prior to visiting regions where TB is common. In this setting, it is recommended that latent TB infection (LTBI) resulting from prior exposure to Mycobacterium tuberculosis is excluded by a tuberculin skin test (TST) before BCG immunisation. This is to avoid the risk of an accelerated local reaction that is more common in individuals who have LTBI. In addition, BCG immunisation in individuals with LTBI is unnecessary, as it does not provide protection against progression to active TB disease. We review and discuss current international guidelines and recommendations on the need to screen children for LTBI prior to BCG immunisation. Guidelines vary significantly regarding age-related cut-offs and additional selection criteria. This variation primarily reflects the lack of evidence on which to base recommendations. We suggest an alternative strategy using a risk assessment questionnaire to identify children who should have a TST before BCG immunisation. This targeted approach will reduce the number of children unnecessarily screened, whilst allowing the identification of those with LTBI, who need further evaluation and treatment.
    No preview · Article · Dec 2011 · Vaccine
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