Midfoot Osteoarticular Tuberculosis: Case Report

Special Article – Arthritis and Rheumatic Diseases

Austin J Musculoskelet Disord. 2015;2(3): 1024.

Midfoot Osteoarticular Tuberculosis: Case Report

Oriundo MA¹ and Sampaio ML¹*

Department of Medical Imaging, University of Ottawa, Canada

*Corresponding author: Sampaio ML, Department of Medical Imaging, University of Ottawa, L2121 CPCR Building, 501 Smyth Road, Ottawa, Canada

Received: June 17, 2015; Accepted: July 07, 2015; Published: July 10, 2015


Tuberculous osteomyelitis/arthritis in the foot is a rare manifestation of the osteoarticular tuberculosis, usually secondary to pulmonary tuberculosis with hematogenous spread. Its overlap with gout is even more unusual. We report the case of a patient that was diagnosed with tuberculous osteomyelitis of the midfoot overlapped with gouty arthritic changes. Mycobacterium tuberculosis was isolated in a bone biopsy culture and the patient received antibiotic treatment for 15 months due to the bone involvement.

Keywords: Tuberculosis; Gout; Tuberculous osteomyelitis; Tuberculous arthritis; Arthritis; Infection; Foot


NSAIDs: Non-Steroid Anti-Inflammatory Drugs; Anti-CPP: Antibody Cyclic Citrullinated Peptide; CT: Computed Tomography; MTP: Metatarsophalangeal; TMT: Tarsometatarsal; PAS: Periodic Acid-Schiff

Case Presentation

A caucasian north-American 60 year-old-male with right midfoot pain and medical history of bilateral feet gouty arthritis on treatment, with previous working history at a correctional facility. No other relevant previous medical history. The patient started to develop severe right midfoot pain and tenderness with swelling on January 2013. He was treated as a new acute onset of gouty arthritis with acetaminophen and NSAIDs, but without relief of the symptoms. On follow-up, a screening of autoimmune serology tests was requested and it revealed mild-positive anti-CCP (late May 2013). He was then treated with methotrexate orally weekly and prednisone for 7 days for presumed rheumatoid arthritis. By mid-June 2013 the patient presented some chills, rigors and night sweats, but he denied any cough, chest pain, hemoptysis, rash, eye redness or abdominal pain. On July 2013 chest x-rays and a chest CT (Figures 1 and 2) were performed and they showed a spiculated nodule within the right upper lobe, together with diffuse parenchymal centrilobular nodules in a miliary pattern. This was diagnosed as highly concerning for post-primary respiratory tuberculosis and on the following week a diagnostic bronchoscopy with bronchial washing was performed. The microbiology examination demonstrated acid fast bacilli on the Ziehl- Neelsen stain (July 2013), confirming the diagnosis of pulmonary tuberculosis. At this point the patient was admitted to our institution. On admission the right foot physical examination demonstrated tenderness, swelling and warmth along the right lateral aspect of the midfoot. No other areas appear to be involved. Radiographs of the feet were done and demonstrated mild asymmetric joint space narrowing and small periarticular erosions bilaterally at the two firsts MTP joints, with adjacent soft tissue swelling and mildly mineralized soft tissue nodules, compatible with tophi (Figure 3A). Also, there was severe right midfoot arthropathy involving the navicularcuneiform, intercuneiform and the 1st to 5st TMT joints, particularly the latter (Lisfranc joint), with periarticular bone demineralization. There were also subchondral cyst/erosions at the talar body and minimal peripheral osteophytes and joint effusion at the ankle. These finding were most in keeping with severe polyarticulargouty arthritis. However, the possibility of superimposed infection was raised, including the possibility of tuberculous arthritis, and both a fluoroscopy-guided aspiration of the first TMT joint with a 22G needle and a fluoroscopy-guided bone biopsy of the base of the first metatarsal bone with a 18G bone biopsy needle (Figure 4) were performed during the first week of his admission. The histopathological results of the bone biopsy showed a benign bone with necrotizing granulomatous inflammation. No micro-organism were seen with the special stains (PAS, Grocott, Ziehl-Neelsen). No crystals were identified by polarized light. Microbiological studies to rule out aerobic or anaerobic micro-organism were negative in both the samples from the joint aspiration and bone biopsy. Also, non-acid fast bacilli were not found in the samples. The diagnosis at this point was then of respiratory tuberculosis and gouty arthritis of the foot. The patient was treated with quadruple therapy anti-tuberculosis (isoniazid, rifampin, pyrazinamide and ethambutol) and colchicine plus NSAIDs for the gouty arthritis. He was discharged 10 days after the start of the antituberculosis therapy, also presenting improvement of the general symptoms and no complications from treatment. However, 5 weeks later, Mycobacterium tuberculosis complexes were isolated in the culture of the samples from both the bronchoalveolar lavage and the bone biopsy. So, the suspected previous diagnosis of tuberculous osteomyelitis of the midfoot was confirmed. As a result, the duration of the anti-tuberculosis treatment was prolonged to 15 months. The culture also showed that the Mycobacterium tuberculosis were sensible to the first line anti-tuberculous drugs. Ethambutol was discontinued in the fourth week of treatment due to a paradoxical treatment reaction and pyrazinamide was given until the seventh week of treatment as planned. Two months after the beginning of the anti-tuberculous therapy the foot symptomatology presented a gradual improvement.