Tuberculous arthritis in clinical practise

Tuberculous arthritis  accounts for approximately 1% of all cases of tuberculosis and 10% of extrapulmonary cases.

Clinical presentation of tuberculous arthritis

• The most common clinical presentation is chronic granulomatous monarthritis.
• An unusual syndrome, Poncet’s disease, is a reactive symmetric form of polyarthritis that can affects persons with visceral or disseminated tuberculosis. No mycobacteria are identified in the joints, and symptoms resolve with antituberculous treatment.Unlike the tuberculous osteomyelitis which typically affect  the thoracic and lumbar spine in about 50% of cases, tuberculous arthritis primarily involves the large weight-bearing joints, especially  the hips, knees, and ankles, and only occasionally involves smaller non-weight-bearing joints. Progressive monarticular swelling and pain may develop over months or years, and systemic symptoms are seen in only half of all cases.

Tuberculous arthritis usually occurs as part of a disseminated primary infection or through late reactivation particularly  in persons with HIV infection or other immunocompromised hosts. Coexistent with arthritis active pulmonary tuberculosis is unusual.

Diagnosis of  tuberculous arthritis

Aspiration of the involved joint yields synovial fluid with  the following findings

• An average cell count of 20,000/μL, with approximately 50% neutrophils.
• Acid-fast staining of the fluid yields positive results in fewer than one-third of cases,
• Cultures are positive in 80%.
• Culture of synovial tissue taken at biopsy is positive in ~90% of cases and shows granulomatous inflammation
• NAA methods can shorten the time to diagnosis to 1 or 2 days.

Radiographs may reveal the following findings

• Peripheral erosions at points of synovial attachment
• Periarticular osteopenia,
•  Eventually jointspace narrowing

Therapy for tuberculous arthritis

This  is the same as that for tuberculous pulmonary disease, administration of multiple agents for 6–9 months. Therapy is more prolonged in immunosuppressed individuals such as those infected with HIV.