- Email: [email protected]
Visceral complications in tuberculosis of bones and joints
VISCERAL
COMPLICATIONS IN TUBERCULOSIS BONES AND JOINTS*
OF
HEINZR. LANDMANN, M.D. NEW
T
YORK
UBERCULOSIS of the skeIeta1 apparatus remains one of the most difI&It problems in surgery, difGcuIt because of the surgica1 technicaIities invoIved and because of the chronicity of the Iesion. Consequent to this chronicity is the ever present threat of viscera1 compIication, a threat which, unfortunateIy, we are apt to await rather than to anticipate. The present study is designed to investigate the nature of viscera1 invoIvement in tubercuiosis of the bones and joints, and to determine to what extent it foIIows a predictabIe path. Is it possibIe to estabIish any ruIes enabIing us to anticipate compIications? At the outset of this investigation it was decided not to incIude cases presenting a termina1 miIiary dissemination since its pathway from the bIood stream is rather diffuse and the sequence of viscera1 invoIvement speculative. Furthermore, it is not the intention of the author to enter into any discussion of theoretica concepts or to restate any of the physioIogic or pathoIogic materia1 easiIy avaiIabIe in current Iiterature. The materia1 from which the present concIusions were derived consists of unseIected cases of tubercuIosis of bones and joints admitted to the HospitaI for Joint Diseases and Mount Sinai HospitaI for the five year period 1932-1936 incIusive. Out of a Iarger series, 139 cases were seIected for study, these being a11 the cases deliniteIy proved as tubercuIous and presenting sufficient data to warrant interpretation. TabIe I shows the distribution of the Iesion in a11 159 cases. TabIe II shows the distribution of the cases as to age, and TabIes III and IV the distribution as to sex and age. * From
the SurgicaI Service,
HospitaI
for Joint
CITY
These data require no further discussion here since their pertinence to the present subject is incidenta1. Briefly, seventy-two cases invoIved the spine, thirty-five maIe and thirty-seven femaIe; 44 cases invoIved
the knee, evenIy divided between the sexes, and eighteen cases occurred in the hip joints, ten maIe and eight femaIe.
Of these cases, ten showed evidence of viscera1 compIications : I. A 59 year oId maIe had tubercuIosis of the right hip and deveIoped biIatera1 tubercuIosis of the kidney. 2. A 39 year oId maIe with tuberculosis of the spine deveIoped perinephritic abscess. 3. A 40 year oId femaIe with tubercuIosis of the spine deveIoped Addison’s disease.
Diseases, and the Orthopedic New York City.
569
Service,
Mount
Sinai Hospital,
570
American Journal of Surgery
Landmann-Bone
4. A 25 year oId maIe with tubercuIosis of the spine deveIoped hydronephrosis. No tubercIe baciIIi found in urine. 5. A 26 year old maIe with tubercuIosis of the spine deveIoped epididymitis. 6. A 5 year oId femaIe with tubercuIosis of the right knee deveIoped tubercuIous peritonitis. 7. A 3 year oId maIe with tubercuIosis of the spine deveIoped Ieft renaI tubercuIosis. 8. A 35 year old male with tubercuIosis of the spine deveIoped toxic hepatitis. g. A 2 year oId maIe with tubercuIosis of the right mandibuIa deveIoped Ieft renaI tubercuIosis. IO. A 20 year oId femaIe with tubercuIosis of the spine deveIoped Ieft renaI tubercuIosis.
TubercuIosis
renaI tubercuIosis and five tubercuIous epididymitis. Harris, who systematicaIIy examined the urine of forty-three aduIts and sixty-seven children for tubercuIous baciIIuria, found tubercIe baciIIi in the urine in sixteen cases of the former and nine of the Iatter. Of his sixteen cases he reported five as certain tubercuIosis of the kidney (I I .6 per cent) and six as uncertain. He had no case of proved tubercuIosis of the kidney in his juveniIe cases.
+r3
20 15 10 5 Ii!_ to 3
I IO 15 40NUYd)LUY
Looking over these cases it immediateIy becomes apparent that most of the compIications were secondary tubercuIous infections, or possibIy foci present without symptoms before the onset of perceptibIe bone and joint manifestations. Whichever it was, foIIowing or antedating the skeIeta1 manifestations, insofar as the existing status was concerned, they presented a complication of the presenting Iesion. PredominantIy the compIicating infection invoIved the genitourinary system (eight cases, 5 per cent). There were four cases (2.5 per cent) of proved renaI tubercuIosis and one case of proved epididymitis tubercuIosa. These figures are higher than the findings of Duncan who reported genitourinary complications in 2.5 per cent. Snyder reported a stiI1 higher percentage. Of his IOO cases, eight were found to have
JUNE, 1939
I
40 25 48 svrrt 4rO3M
In the present series, the hydronephrosis of Case IV was caused by pressure of a coId abscess on the ureter. The kidney was shown not to be invoIved by tubercuIosis. The occurrence of adrena invoIvement in Case III with the symptoms of Addison’s disease is exceptionaIIy interesting because of its rarity in the presence of other easiIy recognized gross tubercuIous Iesions. As for the hepatitis in Case VIII, it is hard to say whether it was of tubercuIous origin or not. The hepatitis cIeared up compIeteIy after a few weeks. The repeated demonstration of secondary genitourinary invoIvement in skeIeta1 tubercuIosis shouId suggest the advisabiIity of examining the urine of a11 patients suffering from tubercuIosis of bone and joints at reguIar intervaIs for tubercIe baciIIi, so that Iesions might be discovered earIy. Since earIy renaI tubercuIosis gives no Iead to the examiner because of Iack of symptoms, repeated examination of the urine shouId be done as a routine. The observation that tubercIe baciIIi may appear intermittentIy minimizes the significance of negative findings. Many progressive cases of kidney tubercuIosis or tubercuIosis of the ureter and bIadder
NEWSERIESVOL.XLIV. No. 3
couId be thereby anticipated measures instituted.
Landmann-Bone and
proper
SUMMARY I. One hundred fifty-nine cases of proved tubercuIosis of bones and joints were examined, ten of which showed visceral compIications. 2. Four cases of renal tubercuIosis were found and one case of epididymitis. 3. AI1 cases except one have secondary tubercuIous Iesions as compIications. 4. The most frequent is the invoIvement of the genitourinary tract.
Tuberculosis
American Journal of Surgery
57I
5. Routine examination of the urine for tubercIe baciIIi at repeated definite intervaIs shouId be incIuded in the genera1 supervision of cases of tubercuiosis of the skeIeta1 system. REFERENCES
DUNCAN. SkeIetaI and extra-skeletal tuberculous lesions associated with joint tuberculosis. J. Bone ti Joint Surg., 19: 64, 1937. SNYDER. The association of putmonary and other tubercuIous Iesions in cases of proven bone and joint tubercuIosis. J. Bone 0 Joint Surg., 15: 924, ‘933.
HARRIS. Observations on the pathoIogy of surgical tubercuIosis. Am. J. Surg., IO: 314, 1930.
THE inflammatory reaction . . . is just as physioIogica1 as the healing process, since it is a response of nature which prepares the ground for the repair of lost, divided or dead tissue.
COMPLICATIONS IN TUBERCULOSIS BONES AND JOINTS*
OF
HEINZR. LANDMANN, M.D. NEW
T
YORK
UBERCULOSIS of the skeIeta1 apparatus remains one of the most difI&It problems in surgery, difGcuIt because of the surgica1 technicaIities invoIved and because of the chronicity of the Iesion. Consequent to this chronicity is the ever present threat of viscera1 compIication, a threat which, unfortunateIy, we are apt to await rather than to anticipate. The present study is designed to investigate the nature of viscera1 invoIvement in tubercuiosis of the bones and joints, and to determine to what extent it foIIows a predictabIe path. Is it possibIe to estabIish any ruIes enabIing us to anticipate compIications? At the outset of this investigation it was decided not to incIude cases presenting a termina1 miIiary dissemination since its pathway from the bIood stream is rather diffuse and the sequence of viscera1 invoIvement speculative. Furthermore, it is not the intention of the author to enter into any discussion of theoretica concepts or to restate any of the physioIogic or pathoIogic materia1 easiIy avaiIabIe in current Iiterature. The materia1 from which the present concIusions were derived consists of unseIected cases of tubercuIosis of bones and joints admitted to the HospitaI for Joint Diseases and Mount Sinai HospitaI for the five year period 1932-1936 incIusive. Out of a Iarger series, 139 cases were seIected for study, these being a11 the cases deliniteIy proved as tubercuIous and presenting sufficient data to warrant interpretation. TabIe I shows the distribution of the Iesion in a11 159 cases. TabIe II shows the distribution of the cases as to age, and TabIes III and IV the distribution as to sex and age. * From
the SurgicaI Service,
HospitaI
for Joint
CITY
These data require no further discussion here since their pertinence to the present subject is incidenta1. Briefly, seventy-two cases invoIved the spine, thirty-five maIe and thirty-seven femaIe; 44 cases invoIved
the knee, evenIy divided between the sexes, and eighteen cases occurred in the hip joints, ten maIe and eight femaIe.
Of these cases, ten showed evidence of viscera1 compIications : I. A 59 year oId maIe had tubercuIosis of the right hip and deveIoped biIatera1 tubercuIosis of the kidney. 2. A 39 year oId maIe with tuberculosis of the spine deveIoped perinephritic abscess. 3. A 40 year oId femaIe with tubercuIosis of the spine deveIoped Addison’s disease.
Diseases, and the Orthopedic New York City.
569
Service,
Mount
Sinai Hospital,
570
American Journal of Surgery
Landmann-Bone
4. A 25 year oId maIe with tubercuIosis of the spine deveIoped hydronephrosis. No tubercIe baciIIi found in urine. 5. A 26 year old maIe with tubercuIosis of the spine deveIoped epididymitis. 6. A 5 year oId femaIe with tubercuIosis of the right knee deveIoped tubercuIous peritonitis. 7. A 3 year oId maIe with tubercuIosis of the spine deveIoped Ieft renaI tubercuIosis. 8. A 35 year old male with tubercuIosis of the spine deveIoped toxic hepatitis. g. A 2 year oId maIe with tubercuIosis of the right mandibuIa deveIoped Ieft renaI tubercuIosis. IO. A 20 year oId femaIe with tubercuIosis of the spine deveIoped Ieft renaI tubercuIosis.
TubercuIosis
renaI tubercuIosis and five tubercuIous epididymitis. Harris, who systematicaIIy examined the urine of forty-three aduIts and sixty-seven children for tubercuIous baciIIuria, found tubercIe baciIIi in the urine in sixteen cases of the former and nine of the Iatter. Of his sixteen cases he reported five as certain tubercuIosis of the kidney (I I .6 per cent) and six as uncertain. He had no case of proved tubercuIosis of the kidney in his juveniIe cases.
+r3
20 15 10 5 Ii!_ to 3
I IO 15 40NUYd)LUY
Looking over these cases it immediateIy becomes apparent that most of the compIications were secondary tubercuIous infections, or possibIy foci present without symptoms before the onset of perceptibIe bone and joint manifestations. Whichever it was, foIIowing or antedating the skeIeta1 manifestations, insofar as the existing status was concerned, they presented a complication of the presenting Iesion. PredominantIy the compIicating infection invoIved the genitourinary system (eight cases, 5 per cent). There were four cases (2.5 per cent) of proved renaI tubercuIosis and one case of proved epididymitis tubercuIosa. These figures are higher than the findings of Duncan who reported genitourinary complications in 2.5 per cent. Snyder reported a stiI1 higher percentage. Of his IOO cases, eight were found to have
JUNE, 1939
I
40 25 48 svrrt 4rO3M
In the present series, the hydronephrosis of Case IV was caused by pressure of a coId abscess on the ureter. The kidney was shown not to be invoIved by tubercuIosis. The occurrence of adrena invoIvement in Case III with the symptoms of Addison’s disease is exceptionaIIy interesting because of its rarity in the presence of other easiIy recognized gross tubercuIous Iesions. As for the hepatitis in Case VIII, it is hard to say whether it was of tubercuIous origin or not. The hepatitis cIeared up compIeteIy after a few weeks. The repeated demonstration of secondary genitourinary invoIvement in skeIeta1 tubercuIosis shouId suggest the advisabiIity of examining the urine of a11 patients suffering from tubercuIosis of bone and joints at reguIar intervaIs for tubercIe baciIIi, so that Iesions might be discovered earIy. Since earIy renaI tubercuIosis gives no Iead to the examiner because of Iack of symptoms, repeated examination of the urine shouId be done as a routine. The observation that tubercIe baciIIi may appear intermittentIy minimizes the significance of negative findings. Many progressive cases of kidney tubercuIosis or tubercuIosis of the ureter and bIadder
NEWSERIESVOL.XLIV. No. 3
couId be thereby anticipated measures instituted.
Landmann-Bone and
proper
SUMMARY I. One hundred fifty-nine cases of proved tubercuIosis of bones and joints were examined, ten of which showed visceral compIications. 2. Four cases of renal tubercuIosis were found and one case of epididymitis. 3. AI1 cases except one have secondary tubercuIous Iesions as compIications. 4. The most frequent is the invoIvement of the genitourinary tract.
Tuberculosis
American Journal of Surgery
57I
5. Routine examination of the urine for tubercIe baciIIi at repeated definite intervaIs shouId be incIuded in the genera1 supervision of cases of tubercuiosis of the skeIeta1 system. REFERENCES
DUNCAN. SkeIetaI and extra-skeletal tuberculous lesions associated with joint tuberculosis. J. Bone ti Joint Surg., 19: 64, 1937. SNYDER. The association of putmonary and other tubercuIous Iesions in cases of proven bone and joint tubercuIosis. J. Bone 0 Joint Surg., 15: 924, ‘933.
HARRIS. Observations on the pathoIogy of surgical tubercuIosis. Am. J. Surg., IO: 314, 1930.
THE inflammatory reaction . . . is just as physioIogica1 as the healing process, since it is a response of nature which prepares the ground for the repair of lost, divided or dead tissue.