Tuberculosis Of Bones And Joints - Causes, Symptoms, Diagnosis And Treatment Of Tuberculosis Of Bones

2024 Author: Josephine Shorter | [email protected]. Last modified: 2023-12-16 21:43

Causes, symptoms, diagnosis and treatment of tuberculosis of bones and joints

Content:

• What is bone tuberculosis?
• Bone tuberculosis symptoms
• Causes of bone tuberculosis
• Phases of the tuberculous process
• Diagnosis of tuberculosis of bones
• Bone tuberculosis treatment

What is bone tuberculosis?

Tuberculosis of bones and joints is a disease of the musculoskeletal system, which is characterized by progressive destruction of bones and leads to anatomical and functional disorders of the affected parts of the skeleton.

The disease is infectious in nature and is caused by tuberculous bacteria - Koch's rods, which infect the spongy substance of bones. As the disease progresses, abscesses and fistulas form in the joints, and the end result may be their complete destruction.

Bone tuberculosis accounts for 3.4% of the total number of all tuberculosis diseases. However, it is the most common extrapulmonary site of this infection, accounting for 20% of extrapulmonary cases.

The most common is tuberculosis of the spine (40%), followed by the defeat of the hip and knee joints (20%, respectively). Tuberculosis of other joints is diagnosed much less frequently.

Before the introduction of BCG vaccination, antibiotic treatment and chemotherapy, the proportion of multiple bone lesions reached 30%. Today it is 10-12%.

At present, the mortality rate from osteoarticular tuberculosis is practically zero. But due to too late diagnosis, the severity of the disease itself and the lack of timely treatment, more than 50% of patients become disabled with long-term disability.

There are several clinical forms of this disease:

• tuberculous osteitis (osteomyelitis);
• tuberculous arthritis (osteoarthritis, synovitis);
• tuberculous tendovaginitis.

Depending on localization, the following types of osteoarticular tuberculosis are distinguished:

• Tuberculous spondylitis (spine);
• Tuberculous drives (knee joints);
• Tuberculous coxitis (hip joints);
• Tuberculous Omarthritis (shoulder joints);
• Tuberculous deer (elbow joints);
• Tuberculosis of the ankle joints and foot bones;
• Tuberculosis of the wrist joints;
• Tuberculosis of tubular bones.

Spondylitis causes curvature of the back, hump growth and paralysis of the limbs (in severe cases). Consequences of coxitis - deformation and pathological dislocation of the hip joint; tuberculosis of the ankle - immobility of the joint as a result of fusion of its surfaces. Tuberculosis of the wrists is uncommon, it is characterized by the defeat of both hands and a combination with persecution or deenitis. Tuberculosis of tubular bones (affecting the phalanges of the hands and metacarpal bones) is a very rare type, observed mainly in children under three years of age.

In childhood, spondylitis is usually diagnosed at 2-4 years, coxitis, persecution - at 4-7 years, tuberculosis of the upper extremities - at 15-18 years.

Bone tuberculosis symptoms

In the first phase of the disease, the symptoms are very blurred and mild. Many people do not pay attention to the feeling of heaviness in the spine, minor back pain or joint pain, which stop during rest. Children have increased irritability, lethargy, fatigue, poor appetite, sleep disturbances, a slight increase in temperature, and autonomic disorders. This phase can last from several weeks to several months.

In the second phase, severe pains in the spine and joints appear, similar to the pain syndrome in intercostal neuralgia or radiculitis. Back muscles lose elasticity and become stiff. Limited joint mobility leads to stiffness of movement.

Signs of intoxication are possible, the severity of which is determined by the activity and prevalence of the tuberculous process. Usually, intoxication is more pronounced in children and is often absent in adults.

External manifestations of the disease are changes in gait, lameness, raised shoulders, clubfoot. In the area of the affected joint or vertebra, there is swelling, muscle spasms, and soft tissue atrophy. The local temperature rises, in parallel with muscle atrophy, a thickening of the skin fold over the affected area is noted.

With the development of an abscess, the skin becomes inflamed, then a fistula forms, through which liquid gray pus is released, interspersed in the form of crumbs. At this stage, the likelihood of a secondary infection is very high.

In the phase of attenuation, the inflammatory process gradually fades away, the general condition of the patient improves. Residual deformations are observed. With timely diagnosis and treatment, it is possible to restore the normal functioning of the bone sections affected by tuberculosis.

Causes of bone tuberculosis

Bone tuberculosis is an infectious disease caused by Koch's tubercle bacillus. Infection can occur through airborne droplets, with food, through dirty hands. The infection spreads through the blood vessels and lymphatic tract throughout the body, reaching all tissues and organs, including bone tissue. In some cases, secondary infection is possible when pathogenic microorganisms enter the bones and joints from the already affected lungs.

However, getting an infection into the body does not always lead to the development of the disease. With strong immunity, the incipient pathological process is arrested and self-destructed. The development of tuberculosis can begin against the background of a weakening of the immune system in conjunction with the influence of other negative factors.

Specific reasons for this may be:

• Excessive load on the musculoskeletal system;
• Hypothermia;
• Insufficient and unbalanced nutrition;
• Musculoskeletal system injuries;
• Relapses of other infectious diseases;
• Unfavorable living conditions;
• Long-term contact with patients with tuberculosis;
• Difficult working conditions.

Phases of the tuberculous process

I - Primary osteitis (focal);

II - Progressive osteitis, in this phase there are three stages:

1. Uncomplicated osteitis (synovitis);
2. Complicated osteitis (arthritis, spondylitis);
3. Total destruction of segments of bones or joints;

III - metatuberculous osteoarthritis.

In the first phase, tuberculous granulomas are formed in the spongy substance of the bones. Most of them undergo reverse development, only a few remain, which gradually increase in number and merge with each other. The primary focus develops slowly and may be asymptomatic for a long time.

In the second phase, the spread of the tuberculous process to the joints begins. The synovial membranes are primarily affected. Pus accumulates in the joint cavity, the tissues of the articular cartilage die off, the articular surfaces become bare. In the second stage of the second phase, necrosis of the joint capsule leads to the formation of fistulas and the development of an abscess. There is deformation and stiffness of the joints, a change in the length of the limbs. In the third stage of the second phase, the joint is destroyed.

In the third phase, the inflammatory process subsides, the joint loses its functions.

Diagnosis of tuberculosis of bones

Bone tuberculosis diagnostics includes clinical, radiological and laboratory studies. Diagnosis is initially clinical. With the help of radiography, the diagnosis is confirmed and specified, dynamic monitoring of the course of the disease is carried out.

Laboratory methods consist in bacteriological, histological and cytological examination of material taken by puncture or biopsy. The leukocyte formula, ROE and other indicators of the general blood test are analyzed.

Clinical picture

Anamnesis consists of finding out the following points:

• contact with patients with tuberculosis;
• positive Mantoux tests;
• previous infectious diseases;
• time of occurrence of general symptoms;
• changes in the motor function of the affected organ;
• the presence of signs of intoxication.

During a visual examination, the position of the affected section of the skeleton, its contours, volume (thickening of the joint and skin fold), density of the joint capsule, skin color, local temperature, tissue edema, muscle tone are assessed, pain points are identified.

The diseased limb is compared with the healthy one to determine the change in its length and the degree of muscle atrophy. The volume of passive and active movements in the joint is checked.

Limited mobility of the spine is detected when bending forward until the hands touch the floor and when the body is slowly tilted back. The mobility of the spinous processes of the affected vertebrae is greatly reduced in comparison with healthy vertebrae. With tuberculosis of the spine, knee reflexes can also be impaired.

X-ray picture

The typical and earliest sign of articular tuberculosis on X-ray images is osteoporosis of the bones, resulting from the intensive resorption of lime and the bone septa themselves. It is observed not only in the lesion focus, but throughout the entire bone.

X-ray data reflect each phase of the disease, but lag behind their clinical manifestations, especially in adults, in whom bone density and powerful bone trabeculae (plates and septa) resist destruction for a long time.

X-ray images clearly show such bone changes as narrowing of joint spaces, uneven surfaces of cartilage, blurred outlines of damaged bones, formation of cavities, stratification of intermuscular spaces caused by edema. A tuberculous abscess is projected in the form of a shadow near the lesion.

In the active phase of the disease, with systematic observation, the dynamics of the process is traced: the lesion focus gradually increases, the intervertebral and inter-articular gaps narrow and disappear completely, the trabecular network collapses, cavities with small inclusions or caseous (soft protein) contents are formed in the bones, the pathological process begins to capture neighboring bones …

Uniform calcification of an abscess has a more positive prognosis than a motley pattern with impregnations of salts in the picture. The latter indicates the activity of the process and a high likelihood of relapses.

In the decaying phase, the network of restored bone trabeculae and the outlines of the bone itself becomes clearer and more pronounced, osteoporosis and atrophy decrease.

With tuberculosis of the spine (1st place in prevalence), the focus is formed in the center of one vertebra and then spreads to several vertebrae, which is accompanied by their pathological fractures. As the process progresses, intoxication increases, severe pain syndrome and muscle stiffness occurs.

Complications of spinal tuberculosis are neurological disorders (paresis, paralysis, disruption of the pelvic organs), which are caused by deformation of the spinal canal and compression (squeezing) of the spinal cord due to an epidural abscess. Another complication is the formation of fistulas, which is often accompanied by the addition of a secondary purulent infection, for example, infection with staphylococcus, and seriously aggravates the course of the disease.

With timely treatment, it is possible to fully restore the functions of the spine or with minor partial disturbances. With a widespread process, after its stabilization and attenuation, deformities of the vertebral bodies and the spine itself remain, with varying degrees of disruption of its supporting function.

Tuberculosis of the hip joint (2nd most common) begins with a focus in the acetabulum, head and neck of the femur. With the progression of the process, tuberculous arthritis develops, hypotonia of the gluteal muscles, limitation of movements, and disturbance of trophism (nutrition) of tissues are noted.

The abscess is usually localized on the outer surface of the thigh and in the adductor muscles. After treatment, in some cases, violations of the anatomical relationships in the joint, immobility (ankylosis) of the joint, and shortening of the leg are observed.

Tuberculosis of the knee joint (3rd place in prevalence) develops slowly, gradually swelling, limitation of flexion, and muscle wasting appear at the site of the lesion. Local symptoms prevail over general ones. The incidence of abscesses and fistulas is high.

Laboratory research methods

The same methods are used as for other types of tuberculosis. If the diagnosis is questioned, a negative tuberculin test will disprove the tuberculous origin of the disease.

During bacterioscopic examination, Mycobacterium tuberculosis is rarely found. Of great importance for diagnosis is a cytological examination of a puncture of the bone marrow, lymph nodes, bone tissue, tumors of soft tissues, effusions (excessive accumulation of synovial fluid) in the joints, but only with a diffuse process. With a limited lesion, the local pathological focus may not get into the contents of the puncture.

Open biopsy is used only in doubtful cases of bone tuberculosis. To determine the degree and extent of spinal cord compression, magnetic resonance imaging, myelography, and computed tomography using a contrast agent are used.

With progressive osteitis, complications in the form of abscesses and fistulas in the blood test, neutrophilic leukocytosis and an increase in ESR are noted.

Differential diagnosis of osteoarticular tuberculosis is carried out with three groups of diseases:

• nonspecific lesions (rheumatoid, infectious, traumatic);
• dystrophic lesions of bones and joints (arthrosis of various etiologies);
• tumors (hemangioma, chondroblastoma, osteoblastoclastoma, eosinophilic granuloma, sarcoma, etc.).

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Bone tuberculosis treatment

Treatment of the disease is long-term, complex and takes from 1.5 to 3 years. When determining therapeutic tactics, the phase of the disease, the body's response to infection, the state of internal organs, etc., are taken into account. Complex therapy consists of general strengthening measures aimed at increasing the body's resistance, and specific means aimed at destroying the infectious pathogen.

For effective treatment, comfortable living conditions are very important, including good nutrition, frequent and prolonged exposure to the fresh air and psychological peace. Shown sanatorium treatment, with a well-oiled regimen of the day and nutrition.

Local orthopedic treatment

Local orthopedic treatment consists in unloading and immobilizing the affected organs. With tuberculosis of the spine and hip joint, the patient is placed in a plaster bed. With spondylitis, the bed repeats the shape of the back, captures the head and reaches the acetabulum of the hip joints; with coxitis, a plaster cast can only cover the affected limb. The patient remains in the crib throughout the active phase of the disease. In this case, it is necessary to constantly monitor the correct position of the pelvis and legs. When you drive and the ankle is damaged, plaster splints are applied.

In the decaying phase of the process in the presence of deformities, violations of the ratio of the surfaces of joints or vertebral bodies, wearing a corset, removable orthopedic appliances is shown.

Antibacterial therapy

Antibiotic therapy is most effective in the initial phase of the disease, it inhibits the multiplication of pathogenic microorganisms, suppresses developing inflammation, prevents the development of complications, and promotes accelerated attenuation of the tuberculous process. From antibacterial agents, Streptomycin, Kanamycin, Viomycin, Rifampicin, Cycloserine are used.

Anti-TB chemotherapy drugs are divided into 3 groups:

1. isonicotinic acid hydrazide, its derivatives and analogues (tubazide, ftivazide, megiazide, etc.;
2. derivatives of para-aminosalicylic acid: sodium para-aminosalicylate (PAS), as well as ethionamide, propionamide, terizidone, pyrazinamide;
3. thioacetazone, solutisone, ethoxide (rarely used).

Streptomycin is administered by intramuscular injection in combination with oral administration of PASK and Ftivazide. Treatment is always carried out in a complex, with two, in special cases - three drugs at the same time, with a maximum dosage. The average duration of treatment is 12-18 months.

When using these medications, in 95% of cases, the course of the tuberculous process successfully stops and a complete cure occurs. Group 2 drugs are used when group 1 drugs do not bring a therapeutic effect.

To improve the general condition, reduce local inflammation, resorb scars in the joint capsule, as well as if antibiotics are poorly tolerated, hormonal drugs can be prescribed. Their choice is determined by the state of the adrenal cortex. Cortisone is used, for intra-articular injections - hydrocortisone. Hormone therapy requires constant clinical monitoring and blood and urine tests.

Surgical methods

They are used in case of insufficient effectiveness of conservative treatment and acutely progressive course of the disease. They make it possible to shorten the duration of treatment, finally eliminate the pathological process in the tissues, and restore the necessary motor functions.

Surgical treatment can be used at all stages and phases of the disease, regardless of the depth and extent of the pathological process, including with complications in the form of contractures, fistulas and abscesses. Contraindications for him are the presence of severe concomitant somatic diseases.

Surgical interventions are divided into three groups:

• Radical (removal of the focus);
• Restorative (corrective);
• Reconstructive.

The type of surgical intervention is selected taking into account the location and degree of damage. One of its advantages is the ability to examine the removed tissue, which helps to clarify the diagnosis and develop a more effective and rational therapeutic program.

In radical operations (resection, necrectomy), the affected tissues of the bones and joints affected by the disease (foci of bone destruction) are completely removed. This helps prevent the spread of infection and the formation of new lesions.

During restorative operations (alloplasty), the consequences of the tuberculous process are eliminated - the anatomical structure of destroyed or resected bones and joints is restored with the help of artificial materials. For example, in case of deformity as a result of coxitis, a corrective osteotomy is performed, in which the limb is brought into a functionally comfortable position by sawing the bone of the distal part of the leg.

Reconstructive surgeries (endoprosthetics) are used for large destruction of bones and joints and involve the replacement of part of the bone or the entire joint with an artificial prosthesis.

After stabilization and attenuation of the process, a smooth transition of the patient to a normal lifestyle is possible, with the obligatory observance of the daily regimen and rest and the absence of excessive physical exertion.

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Physiotherapy

Medical gymnastics is a mandatory and important part of complex therapy. In the active phase, this is a general hygienic procedure, the purpose of which is to prevent muscle atrophy, prevent secondary deformities, and improve overall well-being. The affected part of the body, fixed in a plaster cast, remains motionless.

In the stage of reducing the activity of the process, exercises are performed involving the movement of the affected organ, massage of the lower limbs, gluteal muscles and paravertebral muscles of the back is performed. The massage does not apply to the affected joints. Active movements in the affected joint are possible with osteitis, arthritis with superficial destruction, but in the absence of caseous-necrotic foci and abscesses.

When the process subsides and stabilizes, the patient gradually moves from exercises in a prone position to exercises performed in a standing position, aimed at developing correct posture and learning to walk correctly. In addition to physiotherapy exercises, salt-coniferous baths can be used to more quickly restore range of motion and physical activity.

The author of the article: Makarova Evgenia Vladimirovna, pulmonologist