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Age / Sex : 8 / F
Chief complaint: ankle pain for 2 weeks
1) What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of this case.
(Quiz는 quiz일 뿐이오니 답안은 한개만 보내주시기 바라오며, 복수의 답안을 보내주시는 분은 정답이 포함되어 있더라도 부득이 semi-correct answer로 처리토록 하겠습니다.)
Courtesy: 이재혁(Jae Hyuck, Yi), 경북대병원(Kyungpook National University Hospital)
Diagnosis: Tubercoulous osteomyelitis of distal tibia with ankle joint involvement in a child
Discussion
Findings:
AP and lateral radiographs of the ankle show an irregular
lytic lesion within the anterior metaphyseal region of the distal tibia with
extension into the epiphysis crossing the physeal plate. Subtle marginal
sclerosis and cortical destruction are also noted.
MR images show a well-marginated metaepiphyseal infiltrating
lesion of the distal tibia, and even and strong synovial enhancement with large
amount of the joint effusion indicating combined active synovitis of the ankle
joint.
Diagnosis: Tubercoulous osteomyelitis of distal tibia with
ankle joint involvement
Discussion:
Tuberculous
osteomyelitis is less common than spinal or articular TB and has been reported
to occur in only 11% of children with skeletal TB. TB osteomyelitis was more
often multifocal and disseminated as a result of haematogenous spread from a
primary focus in the lungs. However, recent reports indicate that solitary
lesions are now more commonly seen and a primary lung focus is often not
present. Multiple sites of involvement are usually seen in children, but in
adults involvement is more often confined to a single bone.
The skull vault, hands, feet and ribs are
most commonly involved. Several radiological patterns may be seen, with the
cystic form being the most commonly reported form. These well-defined
radiolucent lesions are round-to-ovoid, with marginal sclerosis seen in some
cases. Expansion of the bones and honeycombing is sometimes seen. A sequestrum
may be present within the cavity. These
cystic lesions may cross the epiphyseal plate to involve the epiphysis.
An infiltrative pattern of TB osteomyelitis may sometimes be. This pattern
resembles Ewing
s sarcoma, fungal infection and
chronic pyogenic osteomyelitis.
Spina ventosa
is a term used to describe a form
of TB osteomyelitis where there is underlying bone destruction, overlying
periosteal thickening and fusiform expansion of the bone. Radiographically,
these lesions appear as cyst-like cavities with expansion of the diaphyses.
These lesions usually occur in the short bones of the hands and feet where the
condition is known as TB dactylitis.
Several authors have reported a delay in the diagnosis of bone
tuberculosis. One of the great difficulties in diagnosing skeletal
tuberculosis is the non-specific clinical presentation. Furthermore, the
radiological features of osseous TB are not even pathognomonic, and so tissue
diagnosis with curettage and synovial biopsy is necessary to establish the
diagnosis.
References:
1. Osseous Manifestations
of Tuberculosis in Children. Journal of Pediatric Orthopaedics
2001;21(6):749-755
2. Tuberculous
osteomyelitis: a review of 125 cases. Int Orthop 1986;10:201-207
3. Tuberculous
osteomyelitis in young children. J Pediatr Orthop 1999;19:151-155
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