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Isolated tuberculosis of talus, an extremely rare occurrence
The Foot 15 (2005) 59–61
Case report
Isolated tuberculosis of talus, an extremely rare occurrence M.H. Ebrahimzadeh ∗ , A.S. Fattahi Department of Orthopedic Surgery, Ghaem Hospital Medical School, Ahmad abad Street, Mashad, Iran
Abstract In view of rarity of isolated talus tuberculosis a case is reported here. A 7-year-old boy referred us with 3 months history of swelling and pain of left ankle. On laboratory evaluation, he had an elevated ESR only. X-ray showed an extensive lytic lesion of talus. Chest radiograph was normal. The Mantou skin test was negative. Histologic examination of biopsy tissue showed granulomatous and caseating necrosis of tuberculosis. Talectomy and 6 month of antituberculous chemotheraphy resulted good clinical outcome. Review of the literature showed less than 10 cases of isolated tuberculosis of talus. © 2005 Elsevier Ltd. All rights reserved. Keywords: Tuberculous osteomylitis; Talus tuberculosis; Bone tuberculosis; Foot tuberculosis; Extrapulmonary tuberculosis
1. Introduction Tuberculosis is still a major infectious health problem for both developed and developing countries. It can affect any organ system of the body and bone involvement account 1–3% of all tuberculosis cases. It most commonly affects spinal skeleton, then weight bearing major joints such as hip and knee. Isolated tuberculosis of talus bone is a very rare occurrence.
2. Case presentation The patient is a 7-year-old boy from Eastern Iranian city of Torbat Jam, in the neighbourhood of Afghanistan’s west border. He was referred to our clinic with 3 months history of swelling and pain and painful motion of left ankle. On physical examination the ankle had warmth, tenderness, redness and limited painful range of motion of left ankle. There was no history of trauma. ∗ Corresponding author. Tel.: +98 511 840 9612; +98 511 840 47 88; fax: +98 511 840 9612.
0958-2592/$ – see front matter © 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2004.12.003
The parents complained of the low appetite and ill condition of their son. Laboratory findings were normal except for an elevated erythrocyte sedimentation rate (ESR: 50 Westergren first hour) and positive CRP. Mantuex skin test was negative. AP and lateral radiographs of ankle showed an extensive irregular lytic lesion of talus without involvement of calcaneum and distal tibia and fibula. On T 99 whole body scan, there was increased uptake only at ankle area. Chest radiograph was normal (Fig. 1). Histological examination of biopsy sample showed granulomata and caseeous necrosis, compatibel with tuberculosis of talus. Because of extended destruction of the talus, the patient underwent talectomy then the tibiocalcaneal articulation was fixed provisionally with pins and a long leg cast applied (Fig. 2). At 6 weeks after talectomy the pins were removed and after 12 weeks cast was removed (Fig. 3). The patient received 6 month of antituberculous chemotherapy consisting of 2 months of four- drugs (INH, Pyrazinamide, Ethambutol, Rifampicin), and the next 4 months continued with two agents (INH, Rifampicin). At the end of antibiotic therapy he had no pain, no significant limp and achieved a good range of motion. ESR declined to normal at 2 months postoperatively.
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M.H. Ebrahimzadeh, A.S. Fattahi / The Foot 15 (2005) 59–61
Fig. 2. Post operative AP and lateral ankle X-rays.
Fig. 1. Normal chest X-ray of the patient.
Discussion Despite the rather scant attention given to tuberculosis, it remains a leading infections cause of death worldwide [1,2].
Extra pulmonary involvement is noted in 23–30%percent of patients with tuberculosis affections [13], with 1–3% of them having osseous disease. Thirty to fifty percent of bone tuberculosis is vertebral involvement [2,3]. Less frequently observed appendicular skeleton involvement usually affects major weight bearing joint of the lower extremity such as hip and knee. The ankle and foot are rarely affected and account for only1% of all tuberculosis infections [1,2,5,6]. Tuberculosis osteomyelitis of the talus is extremely rare and the English literature review shows less than 10 cases reported [4,12]. In a report of 74 cases of foot and ankle tuberculosis, Dhillon et.al only showed one case of talus tuberculosis [2]. Operative treatment by talectomy affords a satisfactory weight bearing foot, along with medical chemotherapy. In local involvement of the talus bone, curettage and bone graft-
Fig. 3. Ap and lateral ankle X-rays 3 months after operation.
M.H. Ebrahimzadeh, A.S. Fattahi / The Foot 15 (2005) 59–61
ing with systemic-chemotherapy is the treatment of choice [7,8,9,10,11]. We reported this case because of its rarity and the excellent outcome of talectomy, together with medical treatment.
References [1] Ruggieri M, Pavon V, Polizzi A, Smilar P, Di Fede GF, Sorge G, et al. Tuberculosis of the ankle in childhood, clinical, roentgengraphic and computed tomography findings. Clin Pediart (Phila) 1997;36(9):529–34. [2] Dhillon, Mandeep S, Nagi Onkar N. Tuberculosis of the foot and ankle. Clin Orthop 2002;1(398):107–18. [3] Anand A, Sood LK. Isolated tuberculosis of talus without ankle and subtalar joint involvement. Med J Malaysia 2002;57(3):371–3. [4] Boussouga M, Tanane M, Bousselmame N, Lazrak K, Taobane H. Tuberculosis of the talus: a rare localization of Koch, s bacillus. Rev Chir Orthop Reparatrice Appar Mot 2002;88(5):522–5. [5] Anderson JR, Ritchie AW, Scobie WG. Tuberculous osteitis of the talus. Tubercle 1979;60(2):115–8.
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[6] Mittal R, Gupta V, Rastogi S. Tuberculosis of the foot. J Bone Joint Surg (Br) 1999;81(6):997–1001. [7] Khan FA, Khoshhal K, Saadeddin M. Tuberculosis of talus and cuboid — a report of 2 children. Acta Orthop Scand 1999;70(6):637–9. [8] Nielson FF, Helmig ode Carvalho A. Case report 533: Tuberculosis of calcaneus and talus with negative tuberculin skin test. Skeletal Radiol 1989;18(2):153–5. [9] Goksan A, Yazicioglu O, Ozer H, Temelli Y, Tozun R, Turkmen M. Isolated bone tuberculosis of the talus; a case report. Z Orthop Ihre Grenzgeb 1984;122(5):657–8. [10] Kotevoglu N, Tezer M, Kabukcuoglu F. Tuberculous osteitis of tarsal bone:a case report. Acta Orthop Tramatol Turc 2003;37(1):84–7. [11] Richad K, Chkoura M, Mouden A. Rare localizations of bone tuberculosis.Three case reports. Rev Chir Reparatrice Appar Mot 2001;87(2):176–9. [12] Jockheck M, Meeder PJ, Weller S. Tuberculous destruction of the talus – a rare form of extrapulmonary skeletal TBC—a case report. Z Orthop Ihre Grenzgeb 1992;130(2):163–5. [13] According to annual, report of tuberculous incidence in Khorasan Area, Iranian Ministery of Health and Medical Education, 2001–2002.
Case report
Isolated tuberculosis of talus, an extremely rare occurrence M.H. Ebrahimzadeh ∗ , A.S. Fattahi Department of Orthopedic Surgery, Ghaem Hospital Medical School, Ahmad abad Street, Mashad, Iran
Abstract In view of rarity of isolated talus tuberculosis a case is reported here. A 7-year-old boy referred us with 3 months history of swelling and pain of left ankle. On laboratory evaluation, he had an elevated ESR only. X-ray showed an extensive lytic lesion of talus. Chest radiograph was normal. The Mantou skin test was negative. Histologic examination of biopsy tissue showed granulomatous and caseating necrosis of tuberculosis. Talectomy and 6 month of antituberculous chemotheraphy resulted good clinical outcome. Review of the literature showed less than 10 cases of isolated tuberculosis of talus. © 2005 Elsevier Ltd. All rights reserved. Keywords: Tuberculous osteomylitis; Talus tuberculosis; Bone tuberculosis; Foot tuberculosis; Extrapulmonary tuberculosis
1. Introduction Tuberculosis is still a major infectious health problem for both developed and developing countries. It can affect any organ system of the body and bone involvement account 1–3% of all tuberculosis cases. It most commonly affects spinal skeleton, then weight bearing major joints such as hip and knee. Isolated tuberculosis of talus bone is a very rare occurrence.
2. Case presentation The patient is a 7-year-old boy from Eastern Iranian city of Torbat Jam, in the neighbourhood of Afghanistan’s west border. He was referred to our clinic with 3 months history of swelling and pain and painful motion of left ankle. On physical examination the ankle had warmth, tenderness, redness and limited painful range of motion of left ankle. There was no history of trauma. ∗ Corresponding author. Tel.: +98 511 840 9612; +98 511 840 47 88; fax: +98 511 840 9612.
0958-2592/$ – see front matter © 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2004.12.003
The parents complained of the low appetite and ill condition of their son. Laboratory findings were normal except for an elevated erythrocyte sedimentation rate (ESR: 50 Westergren first hour) and positive CRP. Mantuex skin test was negative. AP and lateral radiographs of ankle showed an extensive irregular lytic lesion of talus without involvement of calcaneum and distal tibia and fibula. On T 99 whole body scan, there was increased uptake only at ankle area. Chest radiograph was normal (Fig. 1). Histological examination of biopsy sample showed granulomata and caseeous necrosis, compatibel with tuberculosis of talus. Because of extended destruction of the talus, the patient underwent talectomy then the tibiocalcaneal articulation was fixed provisionally with pins and a long leg cast applied (Fig. 2). At 6 weeks after talectomy the pins were removed and after 12 weeks cast was removed (Fig. 3). The patient received 6 month of antituberculous chemotherapy consisting of 2 months of four- drugs (INH, Pyrazinamide, Ethambutol, Rifampicin), and the next 4 months continued with two agents (INH, Rifampicin). At the end of antibiotic therapy he had no pain, no significant limp and achieved a good range of motion. ESR declined to normal at 2 months postoperatively.
60
M.H. Ebrahimzadeh, A.S. Fattahi / The Foot 15 (2005) 59–61
Fig. 2. Post operative AP and lateral ankle X-rays.
Fig. 1. Normal chest X-ray of the patient.
Discussion Despite the rather scant attention given to tuberculosis, it remains a leading infections cause of death worldwide [1,2].
Extra pulmonary involvement is noted in 23–30%percent of patients with tuberculosis affections [13], with 1–3% of them having osseous disease. Thirty to fifty percent of bone tuberculosis is vertebral involvement [2,3]. Less frequently observed appendicular skeleton involvement usually affects major weight bearing joint of the lower extremity such as hip and knee. The ankle and foot are rarely affected and account for only1% of all tuberculosis infections [1,2,5,6]. Tuberculosis osteomyelitis of the talus is extremely rare and the English literature review shows less than 10 cases reported [4,12]. In a report of 74 cases of foot and ankle tuberculosis, Dhillon et.al only showed one case of talus tuberculosis [2]. Operative treatment by talectomy affords a satisfactory weight bearing foot, along with medical chemotherapy. In local involvement of the talus bone, curettage and bone graft-
Fig. 3. Ap and lateral ankle X-rays 3 months after operation.
M.H. Ebrahimzadeh, A.S. Fattahi / The Foot 15 (2005) 59–61
ing with systemic-chemotherapy is the treatment of choice [7,8,9,10,11]. We reported this case because of its rarity and the excellent outcome of talectomy, together with medical treatment.
References [1] Ruggieri M, Pavon V, Polizzi A, Smilar P, Di Fede GF, Sorge G, et al. Tuberculosis of the ankle in childhood, clinical, roentgengraphic and computed tomography findings. Clin Pediart (Phila) 1997;36(9):529–34. [2] Dhillon, Mandeep S, Nagi Onkar N. Tuberculosis of the foot and ankle. Clin Orthop 2002;1(398):107–18. [3] Anand A, Sood LK. Isolated tuberculosis of talus without ankle and subtalar joint involvement. Med J Malaysia 2002;57(3):371–3. [4] Boussouga M, Tanane M, Bousselmame N, Lazrak K, Taobane H. Tuberculosis of the talus: a rare localization of Koch, s bacillus. Rev Chir Orthop Reparatrice Appar Mot 2002;88(5):522–5. [5] Anderson JR, Ritchie AW, Scobie WG. Tuberculous osteitis of the talus. Tubercle 1979;60(2):115–8.
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[6] Mittal R, Gupta V, Rastogi S. Tuberculosis of the foot. J Bone Joint Surg (Br) 1999;81(6):997–1001. [7] Khan FA, Khoshhal K, Saadeddin M. Tuberculosis of talus and cuboid — a report of 2 children. Acta Orthop Scand 1999;70(6):637–9. [8] Nielson FF, Helmig ode Carvalho A. Case report 533: Tuberculosis of calcaneus and talus with negative tuberculin skin test. Skeletal Radiol 1989;18(2):153–5. [9] Goksan A, Yazicioglu O, Ozer H, Temelli Y, Tozun R, Turkmen M. Isolated bone tuberculosis of the talus; a case report. Z Orthop Ihre Grenzgeb 1984;122(5):657–8. [10] Kotevoglu N, Tezer M, Kabukcuoglu F. Tuberculous osteitis of tarsal bone:a case report. Acta Orthop Tramatol Turc 2003;37(1):84–7. [11] Richad K, Chkoura M, Mouden A. Rare localizations of bone tuberculosis.Three case reports. Rev Chir Reparatrice Appar Mot 2001;87(2):176–9. [12] Jockheck M, Meeder PJ, Weller S. Tuberculous destruction of the talus – a rare form of extrapulmonary skeletal TBC—a case report. Z Orthop Ihre Grenzgeb 1992;130(2):163–5. [13] According to annual, report of tuberculous incidence in Khorasan Area, Iranian Ministery of Health and Medical Education, 2001–2002.