Tuberculosis of Navicular Bone – A Rare Presentation

What to Learn from this Article?

Rare presentation of tuberculosis can be diagnosed by high index of suspicion. Tuberculosis can masquerade any infectious pathology specially in endemic areas.


Case Report | Volume 6 | Issue 1 | JOCR Jan-Mar 2016 | Page 76-78 | Vikram V Kadu, K A Saindane, Ninad Godghate, Neha Godghate DOI: 10.13107/jocr.2250-0685.384


Authors: Vikram V Kadu[1], K A Saindane[1,2], Ninad Godghate[1], Neha Godghate[1]

[1] Department of Orthopaedics, ACPM Medical College, Dhule – 424001, Maharashtra. India.
[2] Department of Orthopaedics, Suyog Accident Hospital, Dhule – 424001, Maharashtra. India

Address of Correspondence
Dr. Vikram Vilasrao Kadu,
C/O Vilas Shamrao Kadu, Plot no. 20, Kadu House, Barde layout, Friends colony, Katol Road, Nagpur – 440013. Maharashtra. India. Email : vikram1065@gmail.com


Abstract

Introduction: Tuberculosis of Navicular bone is a rare entity. Osteoarticular tuberculosis of foot is uncommon and that of navicular bone is extremely rare. It is important to recognize skeletal tuberculosis in the initial stages as early treatment can effectively eliminate long-term morbidity.
Case presentation: A 42 yrs old male presented to OPD with swelling and dull aching pain over dorsum of left foot. Radiograph of foot showed lytic puctate lesion in the navicular bone. Further investigations in the form of aspiration biopsy and ZN staining showed presence of multiple tuberculous bacilli. Anti-Kochs treatment was started immediately and patient was treated conservatively. Four drugs (HRZE) were given for a period of 12 months. Radiographs at 2 years follow-up showed a healed lesion.
Conclusion: TB navicular bone is a very rare condition and can be treated conservatively unless associated with metastatic changes or any other complications. Conservative treatment with AKT has excellent results without any complications.
Key words: Navicular bone, Tuberculosis, Rare.


Introduction

Tuberculosis remains a major public health problem in India today. Skeletal tuberculosis is a very rare disease comprising 1-3% of the total population of tubercular patients [1]. Tubercular involvement of the foot and ankle is uncommon and difficult to diagnose. Tuberculosis may involve virtually any organ, tissue or bone in the body. The diagnosis of navicular bone tuberculosis is often delayed due to uncommon site, lack of awareness, and ability to mimic other disorders clinically and radiographically. The early diagnosis and prompt treatment is of utmost importance for good clinical outcome.

Case Presentation
A 42 yrs old male presented to OPD with swelling, dull aching pain and unable to bear weight over left foot for past four months. The patient had trauma to his foot which was not taken care off at that time. Clinically, there was swelling over the antero medial surface of dorsum of the foot with tenderness on deep pressure over the navicular bone. The patient didn’t have any history of pulmonary kochs in the past. Patient had discharging sinus at the site and local temperature was also raised [Fig. 1]. Inguinal lymphnodes were not palpable. Radiograph of foot showed lytic puctate lesion in navicualr bone [Fig. 2]. The patient was further investigated and blood Investigations showed raised ESR with lymphocytosis. Aspiration biopsy and smear stained with Zeil Nelson stain showed presence of multiple tuberculous bacilli [Figs. 3,4]. Diagnosis was confirmed on CT scan [Fig. 5]. Anti-Kochs treatment was started immediately and patient was kept under close observation and was treated conservatively. Four drugs (HRZE) for the period of 12 months were given. Radiographs and blood tests in the form of CBC, ESR, CRP and LFT were performed every 3 months until completion of treatment. Foot was protected in a below knee slab for 6 weeks. Partial weight bearing was allowed at 6 weeks followed by full weight bearing at 10 weeks. Two years follow-up didn’t show any increase in the size of the lytic lesion [Fig. 6]. Clinically, pain and swelling subsided and discharging sinus had healed completely. Patient’s general condition also improved. Radiographs at 2 years follow-up showed a healed lesion [Fig. 7].

Discussion
Extrapulmonary M. tuberculosis is reportedly on the rise, and may manifest itself at a number of sites in the body including the peripheral skeleton. It is important to recognize skeletal tuberculosis in the initial stages because early treatment can effectively eliminate long-term morbidity.
Skeletal TB being extrapulmonary is more challenging than pulmonary TB as it is less common and less familiar to surgeons. The common site, lack of awareness, and ability to mimic other disorders clinically and radiographically leads to diagnostic and therapeutic delays. Foot tuberculosis is manifested in only 8-10 % of the patients with osteoarticular tuberculosis (approximately 0.1-0.3% of all patients with extra-pulmonary tuberculosis) [2-4].
Any of the foot joints can be affected either alone or in combination, but the midtarsal joints are the most common sites [4] for these pathologies. The bones involved are usually the calcaneum, talus, first metatarsal, navicular bone and medial and intermediate cuneiforms. Infection in the midfoot spreads rapidly to many joints because of their intercommunicating synovial spaces [5]. The radiological appearances of rheumatoid arthritis particularly when monoarticular, osteoarthritis, gout, neuropathic joints, sarcoidosis and neoplasms may be similar, but can be distinguished from those
of osteoarticular tuberculosis [6, 7-9]. The ESR is almost always elevated in patients with tuberculosis [10,11,6]. Pulmonary involvement is uncommon [12,13,14].
Anti-tubercular drugs are the mainstay of treatment modality. Unlike pulmonary lesions, bone and joint tuberculosis should be treated with anti-tuberculous drugs for more than nine and preferably for 18 months [15]. Debridement or resection, with or without arthrodesis should be reserved for cases resistant to AKT or for those with deformity or painful joint. In such cases except for biopsy, surgery has a limited role.

Conclusion
TB navicular bone is a very rare presentation leading to misdiagnosis. Lytic lesion with long standing history should never be ignored. We concluded that TB navicular bone is a very rare condition and can be treated conservatively unless associated with metastatic changes or any other complications. Conservative treatment with AKT has excellent results without any complications.

Clinical Message

TB navicular bone is very rare. Though highly uncommon, it should be evaluated cautiously when presented to OPD. These pathologies can be conserved with strict supervision on doses of AKT and blood profile. Surgical exploration and resection is the treatment of choice when associated with complications.

References

1. Ya JT, Yu CS. Diagnosis and Monitoring Treatment Response of Skeletal Tuberculosis of Foot by Three-phase Bone Scan: A Case Report. Ann Nucl Med Sci. 2010;23(3):175-180.
2. Gupta R, Dhillon MS, Bahadur R, et al. Multifocal involvement of the foot in tuberculosis. Ind J Foot Surg. 2000;15:55-59.
3. Mittal R, Gupta V, Rastogi S. Tuberculosis of the foot. J Bone Joint Surg(Br). 1999;81:997-1000.
4. Martni M, Adjrad. Tuberculosis of the ankle and foot joint. In: Martini M, ed. Tuberculosis of the bones and joint. Berlin: Springer Verlag;1988:143-149.
5. Tuli SM. Tuberculosis of the skeletal system (bones, joints, spine and bursal sheaths). Second ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 1991:3-122.
6. Hsu SH, Sun JS, Chen IH, Liu TK. Reappraisal of skeletal tuberculosis: role of radiological imaging. J Formos Med Assoc 1993;92:34-41.
7. Wolfgang CL. Tuberculosis joint infection. Clin Orthop 1978;136: 257-63.
8. Davidson PT, Horowitz I. Skeletal tuberculosis: a review with presentations and discussion. Am J Med 1970;48:77-84.
9. Cohen-Sobel E, Levitz SJ, Caselli M, Reilly K, Levitz SJ. Monoarthritic ankle pain, a diagnostic challenge. J Am Podiatr Med Assoc 1994;84:71-6.
10. Dhillon MS, Sharma S, Gill SS, Nagi ON. Tuberculosis of bones and
joints of the foot: an analysis of 22 cases. Foot Ankle 1993;14:
505-13.
11. Evanchick CC, Davis DE, Harrington TM. Tuberculosis of peripheral joints: an often missed diagnosis. J Rheumatol 1986;13:187-9.
12. Newton P, Sharp J, Barnes KL. Bone and joint tuberculosis in Greater Manchester 1969-1979. Ann Rheum Dis 1982;41:1-6.
13. Hunt DD. Problems in diagnosing osteoarticular tuberculosis. JAMA 1964;190:95-8.
14. Berney S, Goldstein M, Bishko F. Clinical and diagnostic features of tuberculous arthritis. Am J Med 1972;53:36-42.
15. Watts HG, Lifeso RM. Current concepts review: tuberculosis of bone and joints. J Bone Joint Surg [Am] 1996;78-A:288-98.


How to Cite This Article: Kadu VV, Saindane KA, Godghate N, Godghate N. Tuberculosis of Navicular Bone – A Rare Presentation. Journal of Orthopaedic Case Reports 2016 Jan-Mar;6(1): 76-78. Available from: http://www.jocr.co.in/wp/2016/01/02/2250-0685-384-fulltext/

Authors


[Full Text HTML] [Full Text PDF       [XML]


View ratings
Rate this article


Dear Reader, We are very excited about New Features in JOCR. Please do let us know what you think  by Clicking on the Sliding “Feedback Form” button on the  <<< left of the page or sending a mail to us at editor.jocr@gmail.com