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Review Article Open Access

Tuberculosis Arthritis: Epidemiology, Diagnosis, Treatment

Chi-Chou Tseng1, Ruay-Ming Huang2 and Kow-Tong Chen3,4*
1Department of Orthopedics, Chi-Mei Medical Center, Liouying, Tainan, Taiwan
2Hualien Hospital, Ministry of Health and Welfare, Hualien, Taiwan
3Department of Occupational Medicine, Tainan Municipal Hospital, Tainan, Taiwan
4Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
Corresponding Author : Kow-Tong Chen
Department of Occupational Medicine
Tainan Municipal Hospital, Tainan, Taiwan. No. 670
Chongde Road, East District, Tainan, Taiwan
Tel: +886-6-2609926
Fax: +886-6-2606351
E-mail: kowton@ms81.hinet.net; ktchen@mail.ncku.edu.tw
Received December 11, 2013; Accepted February 27, 2014; Published March 05, 2014
Citation: Tseng C, Huang R M ,Chen K T (2014) Tuberculosis Arthritis: Epidemiology, Diagnosis, Treatment. Clin Res Foot Ankle 2:131. doi:10.4172/2329-910X.1000131
Copyright: © 2014 Chen KT, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

Tuberculosis (TB) arthritis accounts for approximately 1-3% of all cases of tuberculosis and for approximately 10-11% of extrapulmonary cases. TB arthritis primarily involves the large weight-bearing joints, in particular the hips, knees, and ankles, and occasionally involves smaller nonweight-bearing joints. The diagnosis of TB arthritis is often delayed due to lack of awareness, insidious onset, lack of characteristic early radiographic findings and often lack of constitutional or pulmonary involvement. Intense current and previous efforts into diagnostic, therapeutic, and preventive interventions have focused on pulmonary TB in adults, but TB arthritis has been relatively neglected. Additional research, understanding, and prevention of TB arthritis are urgently needed. In this article, we review the epidemiology, diagnosis, and principles of treatment of TB arthritis.

Abstract
Tuberculosis (TB) arthritis accounts for approximately 1-3% of all cases of tuberculosis and for approximately 10-11% of extrapulmonary cases. TB arthritis primarily involves the large weight-bearing joints, in particular the hips, knees, and ankles, and occasionally involves smaller nonweight-bearing joints. The diagnosis of TB arthritis is often delayed due to lack of awareness, insidious onset, lack of characteristic early radiographic findings and often lack of constitutional or pulmonary involvement. Intense current and previous efforts into diagnostic, therapeutic, and preventive interventions have focused on pulmonary TB in adults, but TB arthritis has been relatively neglected. Additional research, understanding, and prevention of TB arthritis are urgently needed. In this article, we review the epidemiology, diagnosis, and principles of treatment of TB arthritis.
Keywords
Tuberculosis; Tuberculosis arthritis; Diagnosis; Treatment
Introduction
Musculoskeletal TB is a relatively rare extrapulmonary complication of Mycobacterium tuberculosis. Skeletal involvement is seen in 1% to 3% of patients with TB [1]. Among them, approximately one half of these affect the spine and the rest are extraspinal osteoarticular joint [2-7]. Poncet’s disease or tubercular rheumatism is a nondestructive polyarthritis that occurs during acute TB infection in which neither evidence of direct mycobacterial involvement of the joints nor any other known cause of polyarthritis detected [8-11]. It is a different entity from tuberculosis arthritis (TB arthritis). TB arthritis is usually monoarticular and in which the organism can be isolated from the joint [10].
Osteoarticular TB occurs primarily by haematogenous spread from a primary focus like lung, kidney, lymph node, etc. or infrequently by contiguous spread from adjacent tissues of direct inoculation [8-13]. TB of joint may be due direct invasion of synovium, e.g. Poncet’s arthritis [8-11]. It may also affect nonweight-bearing joint such as wrist, elbow, and small joints of hands. The mode of transmission is haematogenous from visceral foci such as the lung, kidneys, lymph node or other viscera [14-18].
Articular disease often starts as a synovitis progressing to periarticular demineralization, marginal erosions, and finally joint destruction [19,20]. The time period from synovitis to joint destruction can be rapid, particularly in weight-bearing joints. When tubercular arthritis complicated by secondary infection like Staphylococcus aureus presents, it results in accelerated joint destruction associated with severe systemic features [21,22]. Joint tissue necrosis secondary to other disease such as osteonecrotic joints, due to sickle cell disease and chondrocalcinosis may predispose to tubercular infection [23-26]. Before the advent of effective anti-TB chemotherapy, TB tenosynovitis and septic arthritis due to mycobacterial infections are now less common.
Patients generally have mild local and constitutional symptoms, frequently leading to significant delays in diagnosis. The diagnosis of tubercular arthritis is also frequently delayed due to its varied clinical presentation and often lack of constitutional features [6,27,28]. The delay in diagnosis and treatment may result in additional bone or joint destruction, especially in patients with either of those diseases with septic arthritis due to infection caused by mycobactrial species [6,29,30]. Therefore, it is important to understand the epidemiology, diagnosis and treatment of TB arthritis. In this study, we reviewed the epidemiology, diagnosis and treatment of TB arthritis.
Data Collection
We initially collected all of the articles that were published from January 1990 through October 2013, which described people who were affected by TB arthritis. These articles were obtained by searching MEDLINE (National Library of Medicine, Bethesda, Maryland, USA) using the key words “tuberculosis arthritis” or “osteoarticular tuberculosis”. Articles that were not published in the English language, manuscripts without an abstract (which were assumed to not be original), and opinion articles were excluded from the review. After selecting the articles, the relevant information was extracted and classified according to TB arthritis epidemiology, TB arthritis diagnosis, TB arthritis management, the country of the first named author, the year of the publication, and the study design.
The searches were performed in July 2013 and August 2013. Using the search terms previously described, a total of 151 documents were retrieved from MEDLINE. After screening the articles, a total of 109 articles were considered to be relevant. The first authors were primarily from India, the United States, Turkey, Korea, Taiwan, Germany and other countries. The country that produced the most original information was India, with 35% of the articles. After analyzing the abstracts, we found that 83% of the studies were case report, 10% were retrospective, and 7% referenced other designs.
Epidemiology
Tuberculosis (TB) remains a major health problem worldwide. In 2001 the World Health Organization (WHO) reported 2.4 million cases and approximately 2 billion people worldwide have latent TB infection [31,32]. During 2008, an estimated 9.4 million new TB cases were diagnosed, with most cases living in Africa and Asia [33], but no estimates of childhood TB were included. In a prospective community-based survey performed in an area of South Africa, children less than 13 years of age contributed 14% of the total TB disease burden, with an annual incidence of 408/100, 000 [34,35]. More recent estimates suggest that children less than 15 years of age contribute 10-20% of the disease burden in TB-endemic areas [36,37]. Tuberculosis is endemic in certain areas such as Asia, the Middle East, and Africa. The incidence of the disease in developed countries has been rising. Tuberculosis is most common in areas with crowding, poor sanitation, and malnutrition [31,32].
Skeletal involvement is seen in 1% to 3% of patients with TB and for approximately 10-11% of extrapulmonary cases [1]. Among them, approximately one half of these affect the spine and the rest are extraspinal osteoarticular joint [4-7]. The most common musculoskeletal sites are the spine, hip, and knee [38-41].
Diagnosis
There is usually long delay in diagnosis, due partly to the fact that it can mimic other disease due to its varied clinical presentation and radiographic appearance [42,43]. Early diagnosis of arthritis due to TB is essential to preserve the articular cartilage and joint space. Early diagnosis, specific and adequate treatment can be rewarding for maintaining good joint function. The diagnosis of TB small joint arthritis is often delayed due to lack of awareness, insidious in onset, lack of characteristic early radiographic findings and often lack of constitutional or pulmonary involvement. A high index of suspicion is necessary, especially in the context of persistent monoarthritis in a susceptible host. The immunocompromised individuals, elderly or children in close contact to TB or patient who under treatment with corticosteroid and/or immunosuppressive and biologic agent or history of trauma should undergo microbiological or histological tests for TB which remains the gold standard in the diagnosis of TB.
Clinical Presentation
TB arthritis is most commonly monoarticular and of insidious onset. It is commonly presented with chronic joint paint and only minimum sign of inflammation. Tubercular arthritis is characteristically monoarticular and most commonly affects the spine and weight-bearing joints such as the knee, hip, and ankle synovial type of TB arthritis is more commonly involved in the knee, hip, and ankle joint [12].
Most common symptom is local pain and swelling followed by restriction of movement of the affected area. There is wasting of the regional muscle and deformity may occur. Less commonly, painless cold abscess was the only clinical presentation. Involvement of multiple sites is seen in 5-30% cases of tubercular arthritis [44,45]. Reactivation of tubercular arthritis after treatment occurs in 17-34% of individuals. Reactivation most commonly occurs in hip joint [10,46,47].
Joints swelling and evidence of effusion, periarticular abscess and chronic sinus formation occur late. Multiple joint involvements has been reported [48-50]. Systemic symptoms of fever, weight loss, and night sweat may or may not be present during active TB arthritis. Less than 50% of individuals with tubercular arthritis have active pulmonary TB at the time of diagnosis [51,52]. Patients with TB may have hypersensitivity phenomena like erythema nodosum, episcleritis, uveitis and Poncet’s arthritis.
Clinically, TB arthritis has been classified into 5 stages [53-58]. Stage I or the synovitis stage presents with soft tissue swelling, no bony lesion, localized osteoporosis, and outcome after treatment is excellent. Stage II is early arthritis with marginal erosions (one or more erosions or lytic lesion in the bone; discrete diminution of joints space). The outcome is good with only mild stiffness. Stage III is advanced arthritis with subperichondral cyst and loss of joint space. The outcome is fair with notable loss of motion. Stage IV is more advanced arthritis with joint destruction and no motion at the joint after treatment. Stage V is ankylosis of joint.
Bacteriology
A confirmation of acid fast bacillus (AFB) from any body fluid or tissue is the gold standard for the diagnosis of tuberculosis. Several studies have reported bacteriological positivity rates as high as 33% even for primary disease states, such as hilar adenopathy [59,60]. Therefore, every attempt must be made to bacteriologically prove the diagnosis in every case of suspected tuberculosis. Whatever method a clinician uses, he/she needs to collect at least two, preferably three, samples.
A Ziehl-Neelsen stain can reveal AFB only if the sample contains greater than 10,000 bacilli per mL. Different culture methods, such as Lowenstein-Jensen medium, radiometric (Bactec 12B liquid medium), and non-radiometric (Bactec MGIT 960 system), can be used for confirming diagnosis in the paucibacillary state [61,62]. The newer methods are capable of providing faster results and may be used if available. Mycobacterial culture assumes special significance in cases of suspected drug resistance [61,62].
Radiology
Radiographic features are usually noted 2 to 5 months after disease onset [6]. The classical triad of radiologic characteristics of TB arthritis is juxta articular osteoporosis, peripheral osseous erosion and gradual narrowing of intraarticular space [63-66]. In contrast to the Rheumatoid arthritis, the joints space is relatively preserved in early TB arthritis. In children, there may be enlargement of the epiphysis. Bone scan shows increased uptake, but bone scan finding are non-pathognomonic.
Imaging
Computerized tomography (CT) and magnetic resonance imaging (MRI) are helpful in defining the disease further [67]. MRI defines soft tissues better, while CT is good for bony lesions. The MRI features of tubercular arthritis include synovitis, effusion, central and peripheral erosions, active and chronic pannus, abscess, bone chips, and hypo-intense synovium. MRI is the investigation of choice to reveal both extent and severity of damage [25]. An MRI is also nonspecific but evaluate the extent of the lesion better than X-rays. These imaging features in an appropriate clinical setting may help in the diagnosis of tubercular arthritis [65].
Tuberculin Skin Test
The Mantoux test is the recommended standard tuberculin skin test [TST]. Tuberculin is commercially available in 1, 2, and 5 Tuberculin Unit (TU) PPD (purified protein derivative, RT23 equivalent) forms [68-71]. For the test, it is important to raise a wheal of approximately 6 mm after the intra-dermal injection. The test is read 48-72 hours after an injection. Ballpoint or palpatory methods are used to read the induration. A prior Bacillus Calmette-Guérin (BCG) vaccine has influence on the PPD reaction depends on the following conditions, such as the intervals between BCG vaccination and TST, the age at vaccination [72,73]. If the prevalence of TB infection is high enough, the positive predictive value of TST would be higher [74]. If the patient returns for a reading beyond 72 hours but before the 7th post-injection day, a positive test can still be read. A repeat test may be needed if there is no induration and the wheals present beyond the stipulated time for reading. A repeat tuberculin test, when required, should preferably be performed on the other arm.
Interferon Gamma Release Assays (IGRAs)
In addition to the traditional TST, which is known to lack both sensitivity and specificity, blood-based assays have recently become available. These T-cell assays rely on the stimulation of host blood cells with M. tuberculosis-specific antigens and measure the production of interferon γ. Several studies have compared the two available commercial assays, T-Spot TB (Oxford Immunotec, UK) and Quantiferon-TB Gold (Cellestis, Australia), with the TST for both the detection of active disease and latent tuberculosis infection [75,76]. The T-cell assays have proven to be more specific than the TST but are currently unable to distinguish between active disease and latent tuberculosis infection [75,76]. Therefore, interpretation of the results remains dependent on the clinical context. Several studies have presented pediatric T-cell assay data; however, none have provided an assessment of age-related performance, and reservations remain regarding their performance in very young children and immunocompromised populations, such as those with HIV infection [77-79]. The costs and technical demands of IGRAs will most likely limit their wider use in resource-poor settings, where better tests are the most needed.
T-SPOT, Quantiferon-TB and TST have their good diagnostic values for chronic inflammatory arthritis, however, indeterminate results may complicate the use of them [80,81].
PCR Testing
Nucleic acid amplification tests using polymerase chain reaction (PCR) cannot differentiate living bacilli from dead bacilli. Thus, these tests continue to give positive results even after successful treatment. The PCR tests are positive in 95% to 100% of culture positive cases and in 50% to 60% of culture negative cases [82]. Over the past several decades, the diagnostic methods for M. tuberculosis have improved, and nucleic acid amplification techniques now allow rapid and sensitive detection in clinical setting [83].
Synovial Fluid Examination
Synovial fluid is usually nonhaemorrhagic and turbid with moderate elevation of white blood cell, ranging between10,000 and 20,000 cells/mL with predominance of polymorphonuclear leukocyte. Culture for M. tuberculosis is also to be planned. Joint fluid aspiration from the affected joint for standard/routine investigation and TB culture is recommended when possible for at-risk patients, even where previous cultures have been negative. Synovial fluid culture is positive in roughly 20-40% of cases [51]. PCR analysis in synovial fluid, tissue samples, bone marrow aspirate, and peripheral blood is faster and more specific, but less sensitive and less widely available [84,85].
Synovial Biopsy
The gold standard for diagnosis of tubercular arthritis is synovial biopsy, with positive results in 80% of cases [86,87]. It shows caseating granulomas, lymphocytes, and giant cells with caseation, which is very characteristic of tubercular arthritis.
Treatment
Splints may be used for a short time to relieve acute symptoms and for long time in specific cases of tuberculosis of joints to prevent deformities of infected extremities [40,88,89]. Operative treatment is usually limited and includes obtaining a biopsy and performing open or arthroscopic debridement, incision and drainage of abscess, and synovectomy [40]. A randomized trial performed primarily among ambulatory patients by the Medical Research Council Working Party on Tuberculosis of the Spine [90] demonstrated no additional benefit of surgical debridement or radical operation (resection of the spinal focus and bone grafting) in combination with chemotherapy compared with chemotherapy alone. In some circumstance, however, surgery appears to be beneficial and may be indicated. Such situations include failure to respond to chemotherapy with evidence of ongoing infection, the relief of cord compression in patients with persistent of recurrence of neurological deficits, or instability of the spine. Surgical procedures should be restricted to joints with severe cartilage destruction, joint deformity, large abscesses, multiple drug resistance or atypical mycobacteria [88-92].
The mainstay treatment of tuberculosis arthritis is appropriate anti-TB drug therapy (Table 1). Early antimicrobial therapy can result in near-complete resolution and preservation of function. In TB arthritis without pulmonary involvement, the risk of transmission to contacts is minimal and thus constitutes little threat to public health. Antimicrobial therapy in general should be of at least 12-18 months, but to be continued longer in children and immunocompromised hosts [12,14,19]. The basic principles that underlie the treatment of pulmonary tuberculosis also apply to extrapulmonary forms of the disease [63,93,94] (Table 2). Although many fewer treatment studies have examined treatment of extrpulmonary tuberculosis, compared with pulmonary disease, increasing evidence, including some randomized controlled trials, suggests the 6 to 9 months regimens (2 months of isoniazid (INH) and rifampicin (RIF), pyrazinamide (PZA), and ethambutol (EMB) followed by 4-7 months of INH and RIF is recommended as initial therapy unless the organisms are known or strongly suspected of being resistant to the first-line drugs. If PZA cannot be used in the initial phase, the continuation phase must be increased to 7 months, as describe for pulmonary tuberculosis. Several studies have examined treatment of bone and joint tuberculosis and have shown that 6-9-month regimens containing RIF are at least as effective as 18-month regimens that do not contain RIF [90,95-99]. Myelopathy with or without functional impairment most often responds to chemotherapy. In two Medical Research Council studies conducted in Korea, 24 of 30 patients in one study [95] and 74 of 85 patients in an earlier study [100,101] had complete resolution of myelopathy or complete functional recovery when treated medically.
Conclusions
TB is still an important public health problem in the world. TB arthritis accounts for approximately 1-3% of all cases of tuberculosis and for approximately 10-11% of extrapulmonary cases. Nonspinal skeletal TB is a rare and insidious in onset that is often difficult to diagnose. Early diagnosis, specific and adequate treatment can be rewarding for maintaining good joint function. The diagnosis of tubercular arthritis is largely clinical and required exclusions of other causes of mono/oligo and polyarthritis and high degree of suspicion. The mainstay of treatment is multidrug anti-TB therapy (for 12-18 months) and active-assisted nonweight-bearing exercises of the involved joint throughout the period of healing. Operative intervention (synovectomy and debridement) is required when the patient is not responding after 4-5 months of anti-TB therapy.
References

References

  1. value="1" id="Reference_Titile_Link">Malaviya AN, Kotwal PP (2003) Arthritis associated with tuberculosis. Best Pract Res ClinRheumatol 17: 319-343.

  2. value="2" id="Reference_Titile_Link">Iademarco MF, Castro KG (2003) Epidemiology of tuberculosis. SeminRespir Infect 18: 225-240.

  3. value="3" id="Reference_Titile_Link">Peto HM, Pratt RH, Harrington TA, LoBue PA, Armstrong LR (2009) Epidemiology of extrapulmonary tuberculosis in the United States, 1993-2006. Clin Infect Dis 49: 1350-1357.

  4. value="4" id="Reference_Titile_Link">Narang S (2012) Tuberculosis of the entheses. IntOrthop 36: 2373-2378.

  5. value="5" id="Reference_Titile_Link">Mateo L, Ruiz Manzano J, Olivé A, Manterola JM, Pérez R, et al. (2007) [Ostearticular tuberculosis. Study of 53 cases]. Med Clin (Barc) 129: 506-509.

  6. value="6" id="Reference_Titile_Link">Samuel S, Boopalan PR, Alexander M, Ismavel R, Varghese VD, et al. (2011) Tuberculosis of and around the ankle. J Foot Ankle Surg 50: 466-472.

  7. value="7" id="Reference_Titile_Link">Harisinghani MG, McLoud TC, Shepard JA, Ko JP, Shroff MM, et al. (2000) Tuberculosis from head to toe. Radiographics 20: 449-470.

  8. value="8" id="Reference_Titile_Link">Poncet A (1897) De la polyarthritestuberculeusedeformanteoupseudorheumatismechroniquetuberculeux. CongresFrancaise de chirurgerie 1: 732.

  9. value="9" id="Reference_Titile_Link">Abdelwahab IF, Bianchi S, Martinoli C, Klein M, Hermann G (2006) Atypical extraspinal musculoskeletal tuberculosis in immunocompetent patients: part II, tuberculous myositis, tuberculous bursitis, and tuberculoustenosynovites. Can AssocRadiol J: 278-286.

  10. value="10" id="Reference_Titile_Link">Abdulaziz S, Almoallim H, Ibrahim A, Samannodi M, Shabrawishi M, et al. (2012) Poncet's disease (reactive arthritis associated with tuberculosis): retrospective case series and review of literature. Clin Rheumatol 31: 1521-1528.

  11. value="11" id="Reference_Titile_Link">Netval M, Hudec T, Hach J (2007) [Our experience with total knee arthroplasty following tuberculous arthritis (1980-2005)]. ActaChirOrthopTraumatolCech 74: 111-113.

  12. value="12" id="Reference_Titile_Link">Sequeira W, Co H, Block JA (2000) Osteoarticular tuberculosis: current diagnosis and treatment. Am J Ther 7: 393-398.

  13. value="13" id="Reference_Titile_Link">ChenskiÄ­ EP, Omirova KT, SuleÄ­manovBSh (1980) [Characteristics of osteoarticular tuberculosis patient contingents in Kazakhstan and the ways for their detection]. ProblTuberk 6-8.

  14. value="14" id="Reference_Titile_Link">Tuli SM (2002) General principles of osteoarticular tuberculosis. ClinOrthopRelat Res: 11-19.

  15. value="15" id="Reference_Titile_Link">Leibe H, Köhler H, Kessler P (1982) [Osteoarticular tuberculosis. Review - current status of diagnosis and therapy]. ZentralblChir 107: 322-342.

  16. value="16" id="Reference_Titile_Link">Magnussen A, Dinneen A, Ramesh P (2013) Osteoarticular tuberculosis: increasing incidence of a difficult clinical diagnosis. Br J Gen Pract 63: 385-386.

  17. value="17" id="Reference_Titile_Link">Scanzello CR, Goldring SR (2012) The role of synovitis in osteoarthritis pathogenesis. Bone 51: 249-257.

  18. value="18" id="Reference_Titile_Link">de Lange-Brokaar BJ, Ioan-Facsinay A, Yusuf E, Visser AW, Kroon HM, et al. (2013) Degree of synovitis on MRI by comprehensive whole knee semi-quantitative scoring method correlates with histologic and macroscopic features of synovial tissue inflammation in knee osteoarthritis. Osteoarthritis Cartilage

  19. value="19" id="Reference_Titile_Link">Furia JP, Box GG, Lintner DM (1996) Tuberculous arthritis of the knee presenting as a meniscal tear. Am J Orthop (Belle Mead NJ) 25: 138-142.

  20. value="20" id="Reference_Titile_Link">Ponce de León D, Acevedo-Vásquez E, Sánchez-Torres A, Cucho M, Alfaro J, et al. (2005) Attenuated response to purified protein derivative in patients with rheumatoid arthritis: study in a population with a high prevalence of tuberculosis. Ann Rheum Dis 64: 1360-1361.

  21. value="21" id="Reference_Titile_Link">Al-Shaikh R, Goodman SB (2003) Delayed-onset Mycobacterium tuberculosis infection with staphylococcal superinfection after total knee replacement. Am J Orthop (Belle Mead NJ) 32: 302-305.

  22. value="22" id="Reference_Titile_Link">Besser MI (1980) Total knee replacement in unsuspected tuberculosis of the joint. Br Med J 280: 1434.

  23. value="23" id="Reference_Titile_Link">Varango G, Bamba I, Kodo M, Dao A, Lambin Y (1998) Osteonecrosis of the hip in sickle-cell disease associated with tuberculous arthritis. A review of 15 cases. IntOrthop 22: 384-389.

  24. value="24" id="Reference_Titile_Link">Moon MS, Kim SS, Lee SR, Moon YW, Moon JL, et al. (2012) Tuberculosis of hip in children: A retrospective analysis. Indian J Orthop 46: 191-199.

  25. value="25" id="Reference_Titile_Link">Pointud P, Prudat M, Laluque S, Amouroux J (1993) [Tuberculous arthritis and chondrocalcinosis. Apropos of 2 cases]. Rev Rhum Ed Fr 60: 617-620.

  26. value="26" id="Reference_Titile_Link">Brode SK, Jamieson FB, Ng R, Campitelli MA, Kwong JC, et al. (2014) Risk of mycobacterial infections associated with rheumatoid arthritis in Ontario, Canada. Chest.

  27. value="27" id="Reference_Titile_Link">Walker GF (1968) Failure of early recognition of skeletal tuberculosis. Br Med J 1: 682-683.

  28. value="28" id="Reference_Titile_Link">Carli P, Landais C, Aletti M, Cournac JM, Poisnel E, et al. (2009) [Current treatment of rheumatoid arthritis]. Rev Med Interne 30: 1067-1079.

  29. value="29" id="Reference_Titile_Link">Hsiao CH, Cheng A, Huang YT, Liao CH, Hsueh PR (2013) Clinical and pathological characteristics of mycobacterial tenosynovitis and arthritis. Infection 41: 457-464.

  30. value="30" id="Reference_Titile_Link">Foocharoen C, Nanagara R, Foocharoen T, Mootsikapun P, Suwannaroj S, et al. (2010) Clinical features of tuberculous septic arthritis in KhonKaen, Thailand: a 10-year retrospective study. Southeast Asian J Trop Med Public Health 41: 1438-1446.

  31. value="31" id="Reference_Titile_Link">Nelson LJ, Wells CD (2004) Global epidemiology of childhood tuberculosis. Int J Tuberc Lung Dis 8: 636-647.

  32. value="32" id="Reference_Titile_Link">Esposito S, Tagliabue C, Bosis S (2013) Tuberculosis in Children. Mediterr J Hematol Infect Dis 5: e2013064.

  33. value="33" id="Reference_Titile_Link">WHO Report (2011) Global tuberculosis control. Epidemiology, strategy, financing. Geneva: World Health Organization

  34. value="34" id="Reference_Titile_Link">Marais BJ, Hesseling AC, Gie RP, Schaaf HS, Beyers N (2006) The burden of childhood tuberculosis and the accuracy of community-based surveillance data. Int J Tuberc Lung Dis 10: 259-263.

  35. value="35" id="Reference_Titile_Link">Nemir RL, Krasinski K (1988) Tuberculosis in children and adolescents in the 1980s. Pediatr Infect Dis J 7: 375-379.

  36. value="36" id="Reference_Titile_Link">Marais BJ, Graham SM, Cotton MF, Beyers N (2007) Diagnostic and management challenges for childhood tuberculosis in the era of HIV. J Infect Dis 196: S76-85.

  37. value="37" id="Reference_Titile_Link">Tinsa F, Essaddam L, Fitouri Z, Nouira F, Douira W, et al. (2009) Extra-pulmonary tuberculosis in children: a study of 41 cases. Tunis Med 87: 693-698.

  38. value="38" id="Reference_Titile_Link">St Clair Strange FG (1998) Current concepts review. Tuberculosis of bones and joints (78-A:288-298, Feb. 1996) by Watts and Lifeso. J Bone Joint Surg Am 80: 604.

  39. value="39" id="Reference_Titile_Link">Höpfner S, Becker-Gaab C, Hahn K (2000) [Chronic pain in the mid-foot area. Osteoarticular tuberculosis of the tarsal bones]. Radiologe 40: 1183-1185.

  40. value="40" id="Reference_Titile_Link">Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Omawi M (2011) Tuberculosis of the hand. J Hand Surg Am 36: 1413-1421.

  41. value="41" id="Reference_Titile_Link">Dlimi F, Bellarbi S, Mahfoud M, Berrada MS, El Bardouni A, et al. (2011) [Tuberculosis of the hand and wrist: different aspects of 30 cases]. Chir Main 30: 198-204.

  42. value="42" id="Reference_Titile_Link">Ellis ME, el-Ramahi KM, al-Dalaan AN (1993) Tuberculosis of peripheral joints: a dilemma in diagnosis. Tuber Lung Dis 74: 399-404.

  43. value="43" id="Reference_Titile_Link">Tsuduki E, Kawada H, Takeda Y, Toyoda E, Kobayashi N, et al. (2002) [A case of multiple bone and joint tuberculosis which had been misdiagnosed as the rheumatoid arthritis and treated with prednisolone for eleven months]. Kekkaku 77: 361-366.

  44. value="44" id="Reference_Titile_Link">Hanza M (1994) Joint and spine tuberculosis. Rev Rheum 60: 83-86.

  45. value="45" id="Reference_Titile_Link">Parasca I, Damian L, Albu A (2006) Infectious muscle disease. Rom J Intern Med 44: 131-141.

  46. value="46" id="Reference_Titile_Link">Enarson DA, Fujii M, Nakielna EM, Grzybowski S (1979) Bone and joint tuberculosis: a continuing problem. Can Med Assoc J 120: 139-145.

  47. value="47" id="Reference_Titile_Link">MushkinAIu (2007) [Osteoarticular tuberculosis of the bones and joints in children: the present situation and prognosis]. ProblTuberkBoleznLegk 13-16.

  48. value="48" id="Reference_Titile_Link">Valdazo JP, Perez-Ruiz F, Albarracin A, Sanchez-Nievas G, Perez-Benegas J, et al. (1990) Tuberculous arthritis. Report of a case with multiple joint involvement and periarticulartuberculous abscesses. J Rheumatol 17: 399-401.

  49. value="49" id="Reference_Titile_Link">ChocarroMartínez A, GarcíaGarcía I, González López A (2005) [Arthritis tuberculosis]. An Med Interna 22: 255-256.

  50. value="50" id="Reference_Titile_Link">Chawla KP, Pandit AA, Jaiswal PK, Ahuja A (1990) Osteoarticular tuberculosis with involvement of multiple sites (a case report). J Postgrad Med 36: 171-172.

  51. value="51" id="Reference_Titile_Link">Krama SB, Lee SHS, Abramson SB (2004) Nonvertibral infections of musculoskeletal tuberculosis. In: Rom WN, Garay SM (eds.)Tuberculosis. (2ndedn), Lippincott, William & Wilkins, 577-591

  52. value="52" id="Reference_Titile_Link">Lesic AR, Pesut DP, Markovic-Denic L, Maksimovic J, Cobeljic G, et al. (2010) The challenge of osteo-articular tuberculosis in the twenty-first century: a 15-year population-based study. Int J Tuberc Lung Dis 14: 1181-1186.

  53. value="53" id="Reference_Titile_Link">Martini M, Ouahes M (1988) Bone and joint tuberculosis: a review of 652 cases. Orthopedics 11: 861-866.

  54. value="54" id="Reference_Titile_Link">Sandher DS, Al-Jibury M, Paton RW, Ormerod LP (2007) Bone and joint tuberculosis: cases in Blackburn between 1988 and 2005. J Bone Joint Surg Br 89: 1379-1381.

  55. value="55" id="Reference_Titile_Link">Spiegel DA, Singh GK, Banskota AK (2005) Tuberculosis of the musculoskeletal system. Tech Orthop 20: 167-178.

  56. value="56" id="Reference_Titile_Link">Koskinen S (2011) Musculoskeletal tuberculosis: are you ready to diagnose it? ActaRadiol 52: 591.

  57. value="57" id="Reference_Titile_Link">Wang MN, Chen WM, Lee KS, Chin LS, Lo WH (1999) Tuberculous osteomyelitis in young children. J PediatrOrthop 19: 151-155.

  58. value="58" id="Reference_Titile_Link">Rafiqi K, Yousri B, Arihi M, Bjitro C, Aboumaarouf M, et al. (2013) Unusual locations of osteoarticular tuberculosis in children: a report of 12 cases. OrthopTraumatolSurg Res 99: 347-351.

  59. value="59" id="Reference_Titile_Link">Singh M, Moosa NV, Kumar L, Sharma M (2000) Role of gastric lavage and broncho-alveolar lavage in the bacteriological diagnosis of childhood pulmonary tuberculosis. Indian Pediatr 37: 947-951.

  60. value="60" id="Reference_Titile_Link">Forssbohm M, Zwahlen M, Loddenkemper R, Rieder HL (2008) Demographic characteristics of patients with extrapulmonary tuberculosis in Germany. EurRespir J 31: 99-105.

  61. value="61" id="Reference_Titile_Link">Siddiqi S, Ahmed A, Asif S, Behera D, Javaid M, et al. (2012) Direct drug susceptibility testing of Mycobacterium tuberculosis for rapid detection of multidrug resistance using the Bactec MGIT 960 system: a multicenter study. J Clin Microbiol 50: 435-440.

  62. value="62" id="Reference_Titile_Link">Moudgil H, Leitch AG (1994) Extra-pulmonary tuberculosis in Lothian 1980-1989: ethnic status and delay from onset of symptoms to diagnosis. Respir Med 88: 507-510.

  63. value="63" id="Reference_Titile_Link">WHO (2010) Treatment of Tuberculosis: Guidelines - 4th edition. World Health Organization, Geneva

  64. value="64" id="Reference_Titile_Link">Ramachandran S, Clifton IJ, Collyns TA, Watson JP, Pearson SB (2005) The treatment of spinal tuberculosis: a retrospective study. Int J Tuberc Lung Dis 9: 541-544.

  65. value="65" id="Reference_Titile_Link">Sawlani V, Chandra T, Mishra RN, Aggarwal A, Jain UK, et al. (2003) MRI features of tuberculosis of peripheral joints. ClinRadiol 58: 755-762.

  66. value="66" id="Reference_Titile_Link">Sturdza VR, Sturdza M (1990) [Multiple localizations of osteoarticular tuberculosis]. Rev Med ChirSoc Med Nat Iasi 94: 579-580.

  67. value="67" id="Reference_Titile_Link">Gehlot PS, Chaturvedi S, Kashyap R, Singh V (2012) Pott's Spine: Retrospective Analysis of MRI Scans of 70 Cases. J ClinDiagn Res 6: 1534-1538.

  68. value="68" id="Reference_Titile_Link">Chan PC, Chang LY, Wu YC, Lu CY, Kuo HS, et al. (2008) Age-specific cut-offs for the tuberculin skin test to detect latent tuberculosis in BCG-vaccinated children. Int J Tuberc Lung Dis 12: 1401-1406.

  69. value="69" id="Reference_Titile_Link">Kamaeva NG, ChugaevIuP, Grinberg LM, Anisimova NA, Golubeva TV, et al. (2009) [Clinical and epidemiological features of tuberculosis ostitis in BCG-vaccinated children]. ProblTuberkBoleznLegk 16-20.

  70. value="70" id="Reference_Titile_Link">Wang PD (2009) Assessment of the need for universal BCG vaccination of children in Taipei. Public Health 123: 74-77.

  71. value="71" id="Reference_Titile_Link">Sun L, Yan HM, Hu YH, Jiao WW, Gu Y, et al. (2010) IFN-γ release assay: a diagnostic assistance tool of tuberculin skin test in pediatric tuberculosis in China. Chin Med J (Engl) 123: 2786-2791.

  72. value="72" id="Reference_Titile_Link">Menzies D (2000) What does tuberculin reactivity after bacilleCalmette-Guérin vaccination tell us? Clin Infect Dis 31: S71-74.

  73. value="73" id="Reference_Titile_Link">Maes M, Verhagen LM, Ortega D, Sánchez GL, Segovia Y, et al. (2014) Influence of BacilleCalmette-Guérin on tuberculin skin testing in Venezuelan Amerindians in high tuberculosis burden areas. J Infect DevCtries 8: 176-183.

  74. value="74" id="Reference_Titile_Link">Araujo Z, de Waard JH, de Larrea CF, Borges R, Convit J (2008) The effect of BacilleCalmette-Guérin vaccine on tuberculin reactivity in indigenous children from communities with high prevalence of tuberculosis. Vaccine 26: 5575-5581.

  75. value="75" id="Reference_Titile_Link">Arend SM, Thijsen SF, Leyten EM, Bouwman JJ, Franken WP, et al. (2007) Comparison of two interferon-gamma assays and tuberculin skin test for tracing tuberculosis contacts. Am J RespirCrit Care Med 175: 618-627.

  76. value="76" id="Reference_Titile_Link">Efthimiou P, Sood S (2007) QuantiFERON TB Gold Test: the new standard for screening of latent tuberculosis in patients with rheumatoid arthritis? Ann Rheum Dis 66: 276.

  77. value="77" id="Reference_Titile_Link">Rangaka MX, Wilkinson KA, Seldon R, Van Cutsem G, Meintjes GA, et al. (2007) Effect of HIV-1 infection on T-Cell-based and skin test detection of tuberculosis infection. Am J RespirCrit Care Med 175: 514-520.

  78. value="78" id="Reference_Titile_Link">Lertsrisatit P, Nantiruj K, Totemchokchyakarn K, Janwityanujit S (2007) Extraspinaltuberculous arthritis in HIV era. Clin Rheumatol 26: 319-321.

  79. value="79" id="Reference_Titile_Link">Jellis JE (2002) Human immunodeficiency virus and osteoarticular tuberculosis. ClinOrthopRelat Res 27-31.

  80. value="80" id="Reference_Titile_Link">Costantino F, de CarvalhoBittencourt M, Rat AC, Loeuille D, Dintinger H, et al. (2013) Screening for Latent Tuberculosis Infection in Patients with Chronic Inflammatory Arthritis: Discrepancies Between Tuberculin Skin Test and Interferon-? Release Assay Results. J Rheumatol

  81. value="81" id="Reference_Titile_Link">Allali F, Mahfoud-Filali S, Hajjaj-Hassouni N (2005) Lymphocytic joint fluid in tuberculous arthritis. A review of 30 cases. Joint Bone Spine 72: 319-321.

  82. value="82" id="Reference_Titile_Link">Papaventsis D, Ioannidis P, Karabela S, Nikolaou S, Syridou G, et al. (2012) Impact of the Gen-Probe Amplified MTD® Test on tuberculosis diagnosis in children. Int J Tuberc Lung Dis 16: 384-390.

  83. value="83" id="Reference_Titile_Link">Kim JH, Kim YJ, Ki CS, Kim JY, Lee NY (2011) Evaluation of CobasTaqMan MTB PCR for detection of Mycobacterium tuberculosis. J Clin Microbiol 49: 173-176.

  84. value="84" id="Reference_Titile_Link">Verettas D, Kazakos C, Tilkeridis C, Dermon A, Petrou H, et al. (2003) Polymerase chain reaction for the detection of Mycobacterium tuberculosis in synovial fluid, tissue samples, bone marrow aspirate and peripheral blood. ActaOrthopBelg 69: 396-399.

  85. value="85" id="Reference_Titile_Link">Popescu E, Munteanu E, Zeligsohn M (1980) Results of bacteriological examinations in lymph-node and osteoarticular tuberculosis. Rev IgBacteriolVirusolParazitolEpidemiolPneumoftiziolPneumoftiziol 29:191-192.

  86. value="86" id="Reference_Titile_Link">Arthanari S, Yusuf S, Nisar M (2008) Tuberculosis of the knee complicating seronegative arthritis. J Rheumatol 35: 1227-1228.

  87. value="87" id="Reference_Titile_Link">Lidder S, Lang K, Haroon M, Shahidi M, El-Guindi M (2009) Tuberculosis of the knee. Orthop Rev (Pavia) 1: e24.

  88. value="88" id="Reference_Titile_Link">Chen SH, Lee CH, Wong T, Feng HS (2013) Long-term retrospective analysis of surgical treatment for irretrievable tuberculosis of the ankle. Foot Ankle Int 34: 372-379.

  89. value="89" id="Reference_Titile_Link">Dixon WG, Hyrich KL, Watson KD, Lunt M, Galloway J, et al. (2010) Drug-specific risk of tuberculosis in patients with rheumatoid arthritis treated with anti-TNF therapy: results from the British Society for Rheumatology Biologics Register (BSRBR). Ann Rheum Dis 69: 522-5228.

  90. value="90" id="Reference_Titile_Link">[No authors listed] (1999) Five-year assessment of controlled trials of short-course chemotherapy regimens of 6, 9 or 18 months' duration for spinal tuberculosis in patients ambulatory from the start or undergoing radical surgery. Fourteenth report of the Medical Research Council Working Party on Tuberculosis of the Spine. IntOrthop 23: 73-81.

  91. value="91" id="Reference_Titile_Link">Kishore D, Singh NN, Verma R, Chauhan SS, Verma A, et al. (2002) Spinal tuberculosis. J Assoc Physicians India 50: 1332-1333.

  92. value="92" id="Reference_Titile_Link">Bhargava AD, Malaviya AN, Kumar A (1998) Tuberculous rheumatism (poncet’s disease)—a case series. Ind J Tub 45: 215.

  93. value="93" id="Reference_Titile_Link">Chen SC, Chen KL, Chen KH, Chien ST, Chen KT (2013) Updated diagnosis and treatment of childhood tuberculosis. World J Pediatr 9: 9-16.

  94. value="94" id="Reference_Titile_Link">Fonseca JE, Lucas H, Canhão H, Duarte R, Santos MJ,et al. (2006) Guidelines for the diagnosis and treatment of latent tuberculosis infection and active tuberculosis in patients with inflammatory joint diseases proposed for treatment with tumour necrosis factor alpha antagonist drugs. Rev Port Pneumol 12:603-613.

  95. value="95" id="Reference_Titile_Link">Medical Research Council Working Party on Tuberculosis of the Spine (1993) Controlled trial of short-course regimens of chemotherapy in ambulatory treatmen of spinal tuberculosis: results at three years of a study in Korea. J Bone Joint Surg Br 240-248

  96. value="96" id="Reference_Titile_Link">Abou-Raya S, Abou-Raya A (2006) Spinal tuberculosis: overlooked? J Intern Med 260: 160-163.

  97. value="97" id="Reference_Titile_Link">Seong SS, Choi CB, Woo JH, Bae KW, Joung CL, et al. (2007) Incidence of tuberculosis in Korean patients with rheumatoid arthritis (RA): effects of RA itself and of tumor necrosis factor blockers. J Rheumatol 34: 706-711.

  98. value="98" id="Reference_Titile_Link">[No authors listed] (1986) A controlled trial of six-month and nine-month regimens of chemotherapy in patients undergoing radical surgery for tuberculosis of the spine in Hong Kong. Tenth report of the Medical Research Council Working Party on Tuberculosis of the Spine. Tubercle 67: 243-259.

  99. value="99" id="Reference_Titile_Link">Molenaar ET, Bultink IE, Dijkmans BA, Lems WF (2005) Development of fatal tuberculosis in a patient with rheumatoid arthritis after three years of treatment with infliximab: comment on the article by Wolfe et al. Arthritis Rheum 52: 1334-1336.

  100. value="100" id="Reference_Titile_Link">Pattisson PR (1986) Pott's paraplegia: an account of the treatment of 89 consecutive patients. Paraplegia 24: 77-91.

  101. value="101" id="Reference_Titile_Link">Vilar FC, Neves FF, Colares JK, da Fonseca BA (2006) [Spinal tuberculosis (Pott's disease) associated to psoas abscess: report of two cases and a literature review]. Rev Soc Bras Med Trop 39: 278-282.

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Tuberculosis Arthritis: Epidemiology, Diagnosis, Treatment
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