Tuberculous Arthritis of Peripheral Joints

Tuberculosis in the peripheral joints runs an insidious, chronic course as tuberculosis elsewhere. For the most part, the mode of infection of tuberculous arthritis is blood-borne with a primary focus usually in the lung. It may also arise from direct contamination with tuberculosis in the neighboring bone. Granulomatous tissue and pannus erode and dissolve articular cartilages and subchondral bones, causing irregular narrowing and disfiguring. Tuberculosis affects any joint (Enarson et al. 1979), but larger joints such as the hip, knee, and sacroili-ac joint are sites of predilection (Lee et al. 1995; Campbell and Hoffman 1995). The sternocla-vicular joint, glenohumeral joint, elbow, wrist, ankle, and joints of the hand and foot are less commonly affected. The occurrence is usually monarticular (Evanchick et al. 1986).

Radiographic features include osteopenia, subchondral erosions, periarticular bone des-

Soft Tissue Dissolving Hip Area

truction, articular narrowing, and soft-tissue swelling (Figs. 8.22A and 8.23A). Unlike in py-arthrosis or rheumatoid arthritis, the bone destruction tends to be eccentric in the noncont-act or marginal areas of a joint, resulting in asymmetrical narrowing of the joint. The articular narrowing is severer in the weight-bea-

Tuberculous Sacroiliitis

Fig. 8.22A-C Tuberculous sacroiliitis with abscess formation. A Anteroposterior radiograph of the right sacroiliac joint in a 53-year-old female with tuberculous infection shows a large irregular area of bone destruction with unimpressive marginal osteosclerosis (arrowheads). This contrasts with prominent sclerosis seen in chronic pyogenic infection (see Fig. 8.20A). B CT shows irregular bone destruction (arrows) and a large abscess in front of the joint (abscess). C Anterior pinhole scan reveals diffuse tracer uptake with a relatively small photopenic area in the central zone (arrowheads)

Fig. 8.22A-C Tuberculous sacroiliitis with abscess formation. A Anteroposterior radiograph of the right sacroiliac joint in a 53-year-old female with tuberculous infection shows a large irregular area of bone destruction with unimpressive marginal osteosclerosis (arrowheads). This contrasts with prominent sclerosis seen in chronic pyogenic infection (see Fig. 8.20A). B CT shows irregular bone destruction (arrows) and a large abscess in front of the joint (abscess). C Anterior pinhole scan reveals diffuse tracer uptake with a relatively small photopenic area in the central zone (arrowheads)

ring joints (Fig. 8.23A). In late stages the infection spreads to the upper compartment, featuring a bizarre pattern with bone destruction, especially when an abscess is formed (Fig. 8.22A). Ankylosis is a common outcome. CT is highly informative (Fig. 8.22B).

Pinhole scintigraphy shows intense tracer uptake in the destroyed joint and periarticular bones (Figs. 8.22C and 8.23A). Articular narrowing is a constant feature, which is more severe in the weight-bearing joints of the spine, hip, knee, or ankle (Fig. 8.23) than in the non-weight-bearing glenohumeral or sternoclavicular joints (Fig. 8.24). The interphalangeal joints of the hand and foot are also affected as

Intense Tracer Bearing

Fig. 8.23A, B Tuberculosis in the subtalar joint. A Lateral pinhole scan of the left ankle in a 37-year-old female shows intense tracer uptake in the subtalar and talona-vicular joints with reduced height of the hindfoot bones (arrows). B Lateral radiograph reveals comparable arthritic changes with narrowed and flattened joint spaces (arrows) and diffuse porosis

Fig. 8.23A, B Tuberculosis in the subtalar joint. A Lateral pinhole scan of the left ankle in a 37-year-old female shows intense tracer uptake in the subtalar and talona-vicular joints with reduced height of the hindfoot bones (arrows). B Lateral radiograph reveals comparable arthritic changes with narrowed and flattened joint spaces (arrows) and diffuse porosis

Tubercuiosis The Clavicle

Fig. 8.24 Tuberculosis in the sternoclavicular joint. Anterior pinhole scintigraph of the sternum in a 33-year-old woman reveals intense tracer uptake in the medial end of the right clavicle and the apposing sternum. The articular space is irregularly narrowed (curved arrow)

Tubercuiosis The Clavicle

Fig. 8.25A, B Phalangeal tuberculosis. A Dorsopalmar pinhole scan of the right third metacarpophalangeal joint in a 35-year-old female shows intense tracer uptake in the narrowed joint sided by less intense watershed uptake (arrow). B Radiograph reveals complete articular narrowing with prominent osteopenia but without osteoscle-rosis (arrow)

Fig. 8.24 Tuberculosis in the sternoclavicular joint. Anterior pinhole scintigraph of the sternum in a 33-year-old woman reveals intense tracer uptake in the medial end of the right clavicle and the apposing sternum. The articular space is irregularly narrowed (curved arrow)

Fig. 8.25A, B Phalangeal tuberculosis. A Dorsopalmar pinhole scan of the right third metacarpophalangeal joint in a 35-year-old female shows intense tracer uptake in the narrowed joint sided by less intense watershed uptake (arrow). B Radiograph reveals complete articular narrowing with prominent osteopenia but without osteoscle-rosis (arrow)

Tubercuiosis The Clavicle

Fig. 8.26 Obscurity of the local anatomy and stunted growth in chronic tuberculous arthritis in a child. Anterior pinhole scan of the lower pelvis in a 6-year-old girl with known tuberculosis of the left hip reveals obliteration of the local anatomy with closed joint. The regional bones are small and slender due to atrophy and stunted growth which is indicated by the absence of tracer in the physis, the sign of arrested bone growth (arrow)

B

Fig. 8.27A, B Simple infective fasciitis. A Soft-tissue technique radiograph of the left leg in a 22-year-old male shows fish flesh-like derangement of subcutaneous tissue with blurred intermuscular fascial plane (arrows). B Bone scintigraphy reveals long curvilinear uptake in the fascial plane (arrowheads)

separate tuberculous arthritis. Unlike dactylitis with diffuse involvement of a digit in a child (spina ventosa), the tuberculous infection of an adult finger joint is limited to the joint and pe-riarticular bones, causing fusiform uptake that is composed of more intense uptake in the joint with less intense watershed uptake to the side (Fig. 8.25).

In general, tuberculous joints tend to remain relatively preserved until the late stage compared to pyogenic joints, especially when the affected joint is non-weight-bearing (Fig. 8.24). With the progress of tuberculosis, the joint becomes obliterated or seemingly widened due to para-articular bone destruction (Fig. 8.22A) and the regional bones deformed. In children, the bones in the affected limb are reduced in size due to premature physeal fusion and hypoplasia with decreased uptake. Pinhole scintigraphy can clearly indicate the precocious closure of the physis by the absence of tracer uptake in the growth cartilage (Fig. 8.26).

Nuclear Angiography

Fig. 8.28A, B Nuclear angiography in cellulitis. A Arterial phase angiography of the left leg in a 33-year-old male shows a segmental area of increased blood flow and blood pool in the subcutaneous layer (arrows). B Equilibrium phase scan reveals incomplete clearance of tracer but without bone uptake reflecting oosing (arrows)

Fig. 8.28A, B Nuclear angiography in cellulitis. A Arterial phase angiography of the left leg in a 33-year-old male shows a segmental area of increased blood flow and blood pool in the subcutaneous layer (arrows). B Equilibrium phase scan reveals incomplete clearance of tracer but without bone uptake reflecting oosing (arrows)

Peripheral Joints
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