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Primary Musculoskeletal Mycobacterium Infection With Large Cystic Masses After Total Hip Arthroplasty
The Journal of Arthroplasty Vol. 28 No. 2 2013
Case Report
Primary Musculoskeletal Mycobacterium Infection With Large Cystic Masses After Total Hip Arthroplasty Han-Jun Lee, MD,* Kyoung-Woon Kim, MD,*y Ki Seong Kim, MD,z Sung Hwa Ryu, MD,* and Yong-Chan Ha, MD*
Abstract: Primary mycobacterial infections in the musculoskeletal system are rare with a limited number of published case reports. This report describes a case involving a primary musculoskeletal tuberculous abscess. A 62-year-old male patient who had a right total hip arthroplasty performed 8 years earlier, using metal-on-metal articulation presented with a 1-year history of non-tender masses on his right thigh. Initially, it was assumed he had metallosis. Intraoperatively, an incision into the mass was conducted which resulted in draining of a whitish-grey pus like fluid. A diagnosis of tuberculosis was confirmed with both microscopic and histological examination. The patient was treated over a course of six months with an anti-tuberculosis medication regimen following the confirmation of a solitary soft tissue tuberculosis infection. At the 24 month followup, the patient was asymptomatic with no relapse of the mass. Keywords: hip, total hip arthroplasty, primary musculoskeletal infection, mycobacterial infection, tuberculous abscess. © 2013 Published by Elsevier Inc.
A primary musculoskeletal mycobacterium infection, which is caused by the direct introduction of bacilli through a skin injury or defect, is a rare condition. The diagnostic confirmation of this infection has been notoriously difficult, due to various clinical features and a low rate of yield in culture tests [1-3]. There have been sporadic reports of primary tuberculous abscesses in the gluteal region that are presumed to have been transmitted through a syringe, with used needles or due to coughing over the injection site by an infected nursing-staff member [4]. However, there are a limited number of reports that describe a tuberculous abscess following surgery. We report the case of a patient with a history of total hip From the *Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea; yDepartment of Orthopaedic Surgery, Nanoori Gangseo Hospital, Seoul, South Korea; and zDepartment of Orthopaedic Surgery, Seoul-Uri Spine & Joint Hospital, Cheonan-si, South Korea. Submitted October 4, 2011; accepted May 6, 2012. The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2012.05.009. Reprint requests: Kyoung-Woon Kim, MD, Department of Orthopaedic Surgery, Nanoori Gangseo Hospital, Seoul, South Korea, 377–8 Hwagok-dong, Ganseo-ku, Seoul 157–011, South Korea. © 2013 Published by Elsevier Inc. 0883-5403/2802-0029$36.00/0 http://dx.doi.org/10.1016/j.arth.2012.05.009
arthroplasty, who developed large tuberculous abscesses on the thigh eight years after surgery.
Case Report A 62-year-old man presented to our hospital with palpable masses around the previous surgical incision site on the right thigh. Ten years earlier, the patient suffered a fracture of the right femur neck and underwent internal fixation with screws. Two years after surgery, he was converted to a metal- on- metal total hip replacement (THA) due to nonunion of the femoral neck fracture. Eight years postoperatively, he complained of mild discomfort in the thigh and exhibited a gradual enlargement of non-tender cystic masses throughout the previous 1-year. Upon physical examination, two movable masses (11 cm × 10 cm and 10 cm × 10 cm, respectively) were located on the anterlolateral aspect of the thigh (Fig. 1). There were no external signs of infection, including pain, local heating sense, or erythematous alterations. The levels of inflammatory biomarkers were slightly elevated. The inflammatory biomarkers included;, a blood leukocyte count (8.12 × 10 9/L; normal range, 4.8 to 10.8 × 10 9/L), the erythrocyte sedimentation rate (24 mm/Hr; normal range, 0 to 9 mm/Hr) and the highly sensitive C-reactive protein
374.e1
374.e2 The Journal of Arthroplasty Vol. 28 No. 2 February 2013
Fig. 1. 8 years after total hip arthroplasty, the patient presented with large cystic mass located slightly distal from a previous wound.
(1.32 mg/dl; normal range, 0 to 0.5 mg/dl). Due to the presence of the lesions, we suspected an initial diagnosis of metallosis secondary to the metal-on-metal THA. Radiographs of the right hip revealed a well-seated total hip prosthesis without evidence of loosening or implant failure (Fig. 2). Preoperative ultrasonographic findings revealed that the plate-like homo-echotexure lesions corresponded with the old hematoma. The radiologist
recommended an MRI for a more accurate diagnosis. However, a computed tomography scan was conducted due to the expense, which detected soft-tissue swelling without abnormalities within the hip joint and the periarticular region. During the surgical procedure, a whitish-grey pus poured out of the masses (Fig. 3). The infection was limited to the soft tissue layer, which corresponded with the findings of the computed tomography scan. Microscopic analysis of the adjacent soft tissue demonstrated necrosis and exhibited chronic active inflammation, with the presence of numerous neutrophils. The acid-fast bacilli staining test was positive, which was consistent with tuberculosis. Approximately two months later, M. tuberculi was grown in special media. The chest radiographs and abdomen computed tomography scan were used to detect any other primary lesions from tuberculosis. However, there were no active lesions. The patient was treated with a six month regimen of anti-tuberculosis medication following the confirmation of the solitary soft tissue tuberculosis infection. At the 24 month follow-up, the patient was totally asymptomatic with a healed wound.
Discussion Primary musculoskeletal tuberculosis is generally considered to be caused by the hematogenous spread or direct introduction of Mycobacterium tuberculosis via the skin [2]. Although Mycobacterium cannot penetrate
Fig. 2. A-B. (A) Anteroposterior radiograph obtained at admission shows a mass shadow at right thigh but the implants showed no significant abnormal findings except radiolucent lesions in greater trochanter area (B) Anteroposterior radiograph obtained at postoperative 2-years shows dissolution of the mass and no progression of the radiolucent lesions.
Musculoskeletal Mycobacterium Infection With Cystic Mass After THA Lee et al
Fig. 3. An incision and drainage of the mass. Intraoperative findings were whitish-grey pus through the mass. The infection was limited to only a soft tissue layer.
intact skin, a breach in the normal barrier function of the skin from a minor abrasion or injury could lead to the potential penetration of the tubercle bacilli [5]. Primary tuberculosis with a direct infection has been reported after an intralesional steroid injection, needle stick injury and blepharoplasty [6]. A recent case report described an incision infection with mycobacterium after THA, which occurred four months after surgery with inflammatory signs [7]. These findings contrast with the results from our study. This patient did not present with signs of infection or inflammation. Specifically, there was no erythema, induration or rubor. He did have cystic masses which we attributed to metal debris from the bearing surface. Initially, he was assumed to suffer from metallosis associated with metalon-metal THA. However, the simple radiographs and computed tomography scans demonstrated no radioopaque lesions or bubble signs, which are pathognomonic of metallosis [8] (Fig. 2). Iliopsoas pseudobursa or obscuring phenomenon of the actual joint capsule by a metal artifact was also not observed. Two stage revision is a well-established technique for the treatment of late onset infection after THA. However, in this case, there were several contradictions because the infection was located on the soft tissue with cystic formation and no definite signs of inflammation. The intraoperative frozen pathologic findings exhibited cassation necrosis corresponding with the tuberculosis infection. We decided to retain a well fixed prosthesis
374.e3
and resect infected soft tissue along with the two cystic masses. Several studies had demonstrated the possibility of retaining the total hip prosthesis thorough debridement of the infected tissues and postoperative antituberculosis therapy [9,10]. Yoon et al [9] reported an excellent outcome after a primary THA in 7 patients with active tuberculous arthritis of the hip. They found that there was no reactivation of the infection at the average time of 4.8 years after operation. In conclusion, we experienced successful treatment of primary musculoskeletal tuberculous abscesses after THA using surgical debridement and anti-tuberculosis agents with retention of the prosthesis. Although there may be debate, thorough debridement and treatment with anti-tuberculosis agents could be a reasonable alternative option for musculoskeletal tuberculous abscesses that are limited to the soft tissue level.
References 1. Farina MC, Gegundez MI, Pique E, et al. Cutaneous tuberculosis: a clinical, histopathologic, and bacteriologic study. J Am Acad Dermatol 1995;3:433. 2. Ho CK, Ho MH, Chong LY. Cutaneous tuberculosis in Hong Kong: an update. Hong Kong Med J 2006;4:272. 3. Zouhair K, Akhdari N, Nejjam F, et al. Cutaneous tuberculosis in Morocco. Int J Infect Dis 2007;3:209. 4. Heycock JB, Noble TC. Four cases of syringe-transmitted tuberculosis. Tubercle 1961;25. 5. Wong HW, Tay YK, Sim CS. Papular eruption on a tattoo: a case of primary inoculation tuberculosis. Australas J Dermatol 2005;2:84. 6. Kim JK, Kim TY, Kim DH, et al. Three cases of primary inoculation tuberculosis as a result of illegal acupuncture. Ann Dermatol 2010;3:341. 7. Cansu E, Erdogan F, Ulusam AO. Incision infection with Mycobacterium tuberculosis after total hip arthroplasty without any primary tuberculosis focus. J Arthroplasty 2011;3:505 e1. 8. Heffernan EJ, Alkubaidan FO, Nielsen TO, et al. The imaging appearances of metallosis. Skeletal Radiol 2008;1: 59. 9. Yoon TR, Rowe SM, Santosa SB, et al. Immediate cementless total hip arthroplasty for the treatment of active tuberculosis. J Arthroplasty 2005;7:923. 10. Wang Y, Wang J, Xu Z, et al. Total hip arthroplasty for active tuberculosis of the hip. Int Orthop 2010;8:1111.
Case Report
Primary Musculoskeletal Mycobacterium Infection With Large Cystic Masses After Total Hip Arthroplasty Han-Jun Lee, MD,* Kyoung-Woon Kim, MD,*y Ki Seong Kim, MD,z Sung Hwa Ryu, MD,* and Yong-Chan Ha, MD*
Abstract: Primary mycobacterial infections in the musculoskeletal system are rare with a limited number of published case reports. This report describes a case involving a primary musculoskeletal tuberculous abscess. A 62-year-old male patient who had a right total hip arthroplasty performed 8 years earlier, using metal-on-metal articulation presented with a 1-year history of non-tender masses on his right thigh. Initially, it was assumed he had metallosis. Intraoperatively, an incision into the mass was conducted which resulted in draining of a whitish-grey pus like fluid. A diagnosis of tuberculosis was confirmed with both microscopic and histological examination. The patient was treated over a course of six months with an anti-tuberculosis medication regimen following the confirmation of a solitary soft tissue tuberculosis infection. At the 24 month followup, the patient was asymptomatic with no relapse of the mass. Keywords: hip, total hip arthroplasty, primary musculoskeletal infection, mycobacterial infection, tuberculous abscess. © 2013 Published by Elsevier Inc.
A primary musculoskeletal mycobacterium infection, which is caused by the direct introduction of bacilli through a skin injury or defect, is a rare condition. The diagnostic confirmation of this infection has been notoriously difficult, due to various clinical features and a low rate of yield in culture tests [1-3]. There have been sporadic reports of primary tuberculous abscesses in the gluteal region that are presumed to have been transmitted through a syringe, with used needles or due to coughing over the injection site by an infected nursing-staff member [4]. However, there are a limited number of reports that describe a tuberculous abscess following surgery. We report the case of a patient with a history of total hip From the *Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea; yDepartment of Orthopaedic Surgery, Nanoori Gangseo Hospital, Seoul, South Korea; and zDepartment of Orthopaedic Surgery, Seoul-Uri Spine & Joint Hospital, Cheonan-si, South Korea. Submitted October 4, 2011; accepted May 6, 2012. The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2012.05.009. Reprint requests: Kyoung-Woon Kim, MD, Department of Orthopaedic Surgery, Nanoori Gangseo Hospital, Seoul, South Korea, 377–8 Hwagok-dong, Ganseo-ku, Seoul 157–011, South Korea. © 2013 Published by Elsevier Inc. 0883-5403/2802-0029$36.00/0 http://dx.doi.org/10.1016/j.arth.2012.05.009
arthroplasty, who developed large tuberculous abscesses on the thigh eight years after surgery.
Case Report A 62-year-old man presented to our hospital with palpable masses around the previous surgical incision site on the right thigh. Ten years earlier, the patient suffered a fracture of the right femur neck and underwent internal fixation with screws. Two years after surgery, he was converted to a metal- on- metal total hip replacement (THA) due to nonunion of the femoral neck fracture. Eight years postoperatively, he complained of mild discomfort in the thigh and exhibited a gradual enlargement of non-tender cystic masses throughout the previous 1-year. Upon physical examination, two movable masses (11 cm × 10 cm and 10 cm × 10 cm, respectively) were located on the anterlolateral aspect of the thigh (Fig. 1). There were no external signs of infection, including pain, local heating sense, or erythematous alterations. The levels of inflammatory biomarkers were slightly elevated. The inflammatory biomarkers included;, a blood leukocyte count (8.12 × 10 9/L; normal range, 4.8 to 10.8 × 10 9/L), the erythrocyte sedimentation rate (24 mm/Hr; normal range, 0 to 9 mm/Hr) and the highly sensitive C-reactive protein
374.e1
374.e2 The Journal of Arthroplasty Vol. 28 No. 2 February 2013
Fig. 1. 8 years after total hip arthroplasty, the patient presented with large cystic mass located slightly distal from a previous wound.
(1.32 mg/dl; normal range, 0 to 0.5 mg/dl). Due to the presence of the lesions, we suspected an initial diagnosis of metallosis secondary to the metal-on-metal THA. Radiographs of the right hip revealed a well-seated total hip prosthesis without evidence of loosening or implant failure (Fig. 2). Preoperative ultrasonographic findings revealed that the plate-like homo-echotexure lesions corresponded with the old hematoma. The radiologist
recommended an MRI for a more accurate diagnosis. However, a computed tomography scan was conducted due to the expense, which detected soft-tissue swelling without abnormalities within the hip joint and the periarticular region. During the surgical procedure, a whitish-grey pus poured out of the masses (Fig. 3). The infection was limited to the soft tissue layer, which corresponded with the findings of the computed tomography scan. Microscopic analysis of the adjacent soft tissue demonstrated necrosis and exhibited chronic active inflammation, with the presence of numerous neutrophils. The acid-fast bacilli staining test was positive, which was consistent with tuberculosis. Approximately two months later, M. tuberculi was grown in special media. The chest radiographs and abdomen computed tomography scan were used to detect any other primary lesions from tuberculosis. However, there were no active lesions. The patient was treated with a six month regimen of anti-tuberculosis medication following the confirmation of the solitary soft tissue tuberculosis infection. At the 24 month follow-up, the patient was totally asymptomatic with a healed wound.
Discussion Primary musculoskeletal tuberculosis is generally considered to be caused by the hematogenous spread or direct introduction of Mycobacterium tuberculosis via the skin [2]. Although Mycobacterium cannot penetrate
Fig. 2. A-B. (A) Anteroposterior radiograph obtained at admission shows a mass shadow at right thigh but the implants showed no significant abnormal findings except radiolucent lesions in greater trochanter area (B) Anteroposterior radiograph obtained at postoperative 2-years shows dissolution of the mass and no progression of the radiolucent lesions.
Musculoskeletal Mycobacterium Infection With Cystic Mass After THA Lee et al
Fig. 3. An incision and drainage of the mass. Intraoperative findings were whitish-grey pus through the mass. The infection was limited to only a soft tissue layer.
intact skin, a breach in the normal barrier function of the skin from a minor abrasion or injury could lead to the potential penetration of the tubercle bacilli [5]. Primary tuberculosis with a direct infection has been reported after an intralesional steroid injection, needle stick injury and blepharoplasty [6]. A recent case report described an incision infection with mycobacterium after THA, which occurred four months after surgery with inflammatory signs [7]. These findings contrast with the results from our study. This patient did not present with signs of infection or inflammation. Specifically, there was no erythema, induration or rubor. He did have cystic masses which we attributed to metal debris from the bearing surface. Initially, he was assumed to suffer from metallosis associated with metalon-metal THA. However, the simple radiographs and computed tomography scans demonstrated no radioopaque lesions or bubble signs, which are pathognomonic of metallosis [8] (Fig. 2). Iliopsoas pseudobursa or obscuring phenomenon of the actual joint capsule by a metal artifact was also not observed. Two stage revision is a well-established technique for the treatment of late onset infection after THA. However, in this case, there were several contradictions because the infection was located on the soft tissue with cystic formation and no definite signs of inflammation. The intraoperative frozen pathologic findings exhibited cassation necrosis corresponding with the tuberculosis infection. We decided to retain a well fixed prosthesis
374.e3
and resect infected soft tissue along with the two cystic masses. Several studies had demonstrated the possibility of retaining the total hip prosthesis thorough debridement of the infected tissues and postoperative antituberculosis therapy [9,10]. Yoon et al [9] reported an excellent outcome after a primary THA in 7 patients with active tuberculous arthritis of the hip. They found that there was no reactivation of the infection at the average time of 4.8 years after operation. In conclusion, we experienced successful treatment of primary musculoskeletal tuberculous abscesses after THA using surgical debridement and anti-tuberculosis agents with retention of the prosthesis. Although there may be debate, thorough debridement and treatment with anti-tuberculosis agents could be a reasonable alternative option for musculoskeletal tuberculous abscesses that are limited to the soft tissue level.
References 1. Farina MC, Gegundez MI, Pique E, et al. Cutaneous tuberculosis: a clinical, histopathologic, and bacteriologic study. J Am Acad Dermatol 1995;3:433. 2. Ho CK, Ho MH, Chong LY. Cutaneous tuberculosis in Hong Kong: an update. Hong Kong Med J 2006;4:272. 3. Zouhair K, Akhdari N, Nejjam F, et al. Cutaneous tuberculosis in Morocco. Int J Infect Dis 2007;3:209. 4. Heycock JB, Noble TC. Four cases of syringe-transmitted tuberculosis. Tubercle 1961;25. 5. Wong HW, Tay YK, Sim CS. Papular eruption on a tattoo: a case of primary inoculation tuberculosis. Australas J Dermatol 2005;2:84. 6. Kim JK, Kim TY, Kim DH, et al. Three cases of primary inoculation tuberculosis as a result of illegal acupuncture. Ann Dermatol 2010;3:341. 7. Cansu E, Erdogan F, Ulusam AO. Incision infection with Mycobacterium tuberculosis after total hip arthroplasty without any primary tuberculosis focus. J Arthroplasty 2011;3:505 e1. 8. Heffernan EJ, Alkubaidan FO, Nielsen TO, et al. The imaging appearances of metallosis. Skeletal Radiol 2008;1: 59. 9. Yoon TR, Rowe SM, Santosa SB, et al. Immediate cementless total hip arthroplasty for the treatment of active tuberculosis. J Arthroplasty 2005;7:923. 10. Wang Y, Wang J, Xu Z, et al. Total hip arthroplasty for active tuberculosis of the hip. Int Orthop 2010;8:1111.