SESSION TYPE: Infectious Disease Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Tuberculosis (TB) is still a major public health problem worldwide. Isolated TB osteomyelitis of the talus bone is rare [1,2]. We report a patient with isolated TB of the ankle who made good recovery with combination of medical and surgical intervention.
CASE PRESENTATION: A 25 year old lady presented with right ankle pain and swelling for 1 year. She denied having trauma, night sweats, fever, prolonged cough, loss appetite or weight but had previous TB exposure. Examination revealed tenderness and swelling over the talonavicular region. BCG scar was seen on her left arm. Her ESR was slightly elevated at 45mm , ELISA testing for HIV infection was negative and her tuberculin skin testing measured 10mm. MRI of her right foot showed a synovial-based pathology involving the right talonavicular joint (Figure 1). Her chest radiograph was normal. Open biopsy of the ankle was done and partial destruction of the talus head with preservation of the articular cartilage was seen intraoperatively. Histopathological examination of the synovium showed granulomas (Figure 2). Synovial fluid for acid fast bacilli stain was negative but had positive growth on TB culture. Patient was started on anti-tubercular therapy and partial-weight bearing pneumatic cast. After an initial 3 months of anti-tubercular therapy, she underwent right talonavicular joint debridement and arthrodesis. She recovered well and resumed painless walking. She completed 1 year of antitubercular therapy.
DISCUSSION: Dhilon and Naji  report the calcaneum as most commonly involved bone in ankle TB. Our patient presented with isolated TB of the talus, sparing other bones. Although she had previous TB exposure, her symptoms were subtle and most laboratory tests were negative. Hence the uncommon osseous site, atypical clinical presentation and lack of awareness seem to contribute to delay in diagnosis and treatment. Our patient showed significant clinical improvement with combination of prolonged anti-tubercular therapy, partial weight bearing treatment and joint arthrodesis. Similar finding was described in a Japanese series on ankle TB .
CONCLUSIONS: A high index of clinical suspicion, MR imaging and histological evaluation are necessary to confirm a diagnosis of ankle TB. Anti-tubercular therapy and surgical intervention is the recommended treatment with promising outcome.
1) Isolated tuberculosis of the talus bone.Ebrahimzadeh MH, Sadri E. Arch Iran Med. 2006 Apr;9(2):159-60.
2) Tuberculosis of the foot and ankle.Dhillon MS,Nagi ON.Clin Orthop Res.2002,1:107-113.
3) Ankle tuberculosis: a report of four cases in a Japanese hospital. Inoue S, Matsumoto S, Iwamatsu Y, Satomura M. J Orthop Sci. 2004;9(6):668
DISCLOSURE: The following authors have nothing to disclose: Lalitha Pereirasamy, Narinder Gill Singh, Brinder Kaur Nijhar, Mohana Rao, Irfhan Ali Hyder Ali
No Product/Research Disclosure InformationDepartment of Respiratory Medicine, Penang General Hospital, Malaysia, Georgetown, Malaysia