Imaging of musculoskeletal and spinal tuberculosis

Imaging of musculoskeletal tuberculosis

Tuberculosis (TB) represents a major public health problem worldwide. Any tissue may be infected. Involvement of the musculoskeletal (MSK) system account for 1-3% of all tuberculous infections. MSK TB may manifest as tuberculous spondylitis, arthritis, osteomyelitis, and soft tissue infections. Although TB spondylitis may present with distinctive imaging features compared to pyogenic infections of the spine, the imaging semiology of extra-spinal TB infections is mostly nonspecific and may mimic other lesions. TB infections should therefore always be considered in the differential diagnosis, particularly in immunocompromised patients. The aim of this article is to review the imaging features of spinal and extra-spinal MSK TB. Magnetic resonance imaging is considered the modality of choice to make the diagnosis and to evaluate the extent of the disease.

Imaging recommendations and algorithms for pediatric tuberculosis: part 2-extrathoracic tuberculosis

Despite advances in diagnosis and treatment in recent years, tuberculosis (TB) remains a global health concern. Children are amongst the most vulnerable groups affected by this disease. Although TB primarily involves the lungs and mediastinal lymph nodes, it can affect virtually any organ system of the body. Along with clinical history combined with physical examination and laboratory tests, various medical imaging tools help establish the diagnosis. Medical imaging tests are also helpful for follow-up during therapy, to assess complications and exclude other underlying pathologies. This article aims to discuss the utility, strengths and limitations of medical imaging tools in the evaluation of suspected extrathoracic TB in the pediatric population. Imaging recommendations for the diagnosis will be presented along with practical and evidence-based imaging algorithms to serve as a guide for both radiologists and clinicians.

Necrotizing granulomatous inflammation mimicking skeletal metastasis: a possible differential diagnosis

Tuberculosis is an endemic disease in India for decades, and its coexistence in the patients with malignancy cannot be ignored. The non-specific uptake of 2-deoxy-2-[fluorine-18] fluoro-d-glucose in active infection and malignancy can affect the diagnosis and management of patients. However, characteristic anatomical features of the lesion aid not only in its localization but also in diagnosis. We share an interesting case of necrotizing granulomatous inflammation of dorsal spine mimicking skeletal metastases in a treated case of carcinoma cervix.

Tuberculosis of ischial tuberosity as a rare cause of gluteal pain: A case series of 9 patients with review of literature

BACKGROUND

Osteo-articular Mycobacterium tuberculosis infection of the ischial tuberosity is a rare cause of gluteal pain.

METHODS

A retrospective clinico-radiological review of nine patients with Mycobacterium tuberculosis infection of the ischial tuberosity was undertaken. The spectrum of presenting features, diagnostic challenges, radiological findings with particular emphasis on Magnetic resonance imaging (MRI) and clinical course was reviewed.

RESULTS

All the 9 patients (5 male: 4 female) aged between 8 and 50 years of age (mean 15.3 years) developed insidious onset of buttock pain over a period of weeks to months with difficulty in walking. Microbiological and/or histopathological confirmation of Mycobacterium tuberculosis infection was undertaken in all cases. Complementary MRI revealed diffuse bone marrow signal hypointense or isointense on T1-weighted and hyperintense on T2-weighted and STIR images. MRI was able to provide anatomic details of soft tissue lesions and extensions. MRI illustrated the sinus tract in one patient. Ultrasound imaging allowed diagnostic and therapeutic management of in 3 patients.

CONCLUSION

Tuberculosis of ischial tuberosity can be a rare cause of gluteal pain. Delay in diagnosis could be due to an indolent natural history, unusual presentation and clinical features. A high index of suspicion especially in endemic areas with complementary imaging and microbiological or histopathological confirmation of Mycobacterium tuberculosis infection is necessary for definitive diagnosis. Targeted treatment under the umbrella of Anti-Tubercular Therapy is crucial in achieving successful clinical outcome.

Computed Tomographic Evaluation of Mediastinal Masses - An Experience at a Tertiary Care Centre in Bareilly, India

BACKGROUND Mediastinal lesions are one of the most common lesions of the chest in children and adults. Multidetector computed tomography (MDCT) is the most common investigation done in patients with suspected abnormalities on X-ray. Crosssectional imaging visualises complex anatomy, helps in predicting the tissue of origin, characterises lesions and depicts the extent of involvement of adjacent structures. Complications of mediastinal lesions and emergent conditions, for example, sealed pneumo-mediastinum, tracheoesophageal / pulmonary fistula, a peri-lesional abscess can be well assessed on CECT. The possibility of the lesion as benign or malignant and can be well predicted. Vascular lesions like aneurysms, dissections, and embolism can be evaluated and stable lesions requiring to follow up and unstable lesions requiring emergent treatment are differentiated using MDCT. The objectives of the study were to characterize and identify features pathognomic of specific mediastinal masses on computed tomography and find out diagnostic accuracy of MDCT in mediastinal masses and compare them with pathological results wherever possible. METHODS A prospective study was done in the Department of Radiodiagnosis, Rohilkhand Medical College and hospital, Bareilly for a span of 1 year from November 2018 to October 2019. Our study included 51 patients. Mediastinal lesions were assessed based on size, compartmental localisation, and attenuation and enhancement patterns. RESULTS In our study with 51 patients, 16 lesions were non-neoplastic and 35 were neoplastic lesions. Anterior mediastinal lesions constituted maximum lesions followed by middle and posterior mediastinal lesions. Lymph nodal masses were the commonest lesions out of which 4 cases were tubercular in origin, 4 were lymphomatous and 4 were metastatic. Neurogenic tumours were most common in the posterior mediastinum consisting of 6 cases. 2 vascular lesions were seen, 1 of aortic aneurysm and 1 aortic dissection. The diagnostic accuracy of MDCT was 93 % compared to histopathological results. Computed tomography (CT) plays a major role in evaluating mediastinal masses by virtue of its excellent multiplanar reconstruction capabilities and demonstration of exact anatomic relationships. However, in many situations, histopathological examination is needed to know the exact tissue of origin and for further management. CONCLUSIONS We conclude that CT has a major role in evaluating mediastinal masses regarding location, extent and tissue characterization. It can display certain features pathognomic for particular masses thus obviates the need for invasive procedures. KEY WORDS Mediastinal Lesions, MDCT, Imaging Modality, Histopathology

Disseminated Tuberculosis Mimicking Lung Cancer with Multiple Bone Metastasis: A Case Report

Tuberculosis (TB) is a contagious infectious disease caused by Mycobacterium tuberculosis (Mtb) of which attacking various organs particularly the lungs. Tuberculosis can occur together with malignancy or manifest as malignancy. Lung tuberculosis may appear in a variety of clinical and radiological manifestations caused by other diseases including tumors. These tumors are called pseudo-tumors. TB pseudo-tumor is a rare manifestation that can occur in immunocompetent patients in both primary and post-primary TB. The clinical presentation of TB pseudo-tumor is nonspecific and the clinical suspicion must be increased to diagnose related diseases. Radiological features can also be challenging to be distinguished from actual tumors. The classic manifestations of pulmonary TB are generally easy to diagnose due to the distinctive clinical and radiological characteristics nonetheless some pulmonary TB symptoms are also often found in patients with lung cancer. Infection patients resemble malignancies most were asymptomatic (> 27%) and the remaining 27% showed symptoms that varied with the average symptoms experienced about 1 month earlier. Clinical presentations that require a lot of misdiagnosis result in delayed treatment and unnecessary procedures. Establishing a diagnosis in cases of tuberculosis that causes malignancy is very important since the management and outcomes of the infection and malignancy process are quite different. Consequently we report a 24-year-old man with tuberculosis possible lung cancer with multiple bone metastase. Extrapulmonary tuberculosis which attacks bones and joints constitutes 10% to 20% of all TB cases. The location of bone and joint TB generally develops in the lumbar or thoracic vertebrae

Spinal Tuberculosis Treatment: An Enduring Bone of Contention

Spinal tuberculosis is the most common form of extrapulmonary tuberculosis. It is of great importance to neurologists because of the potentially devastating complication of paraplegia, which may set in during active disease or the healed phase. Due to the deep-seated nature of the disease, definitive diagnosis is often challenging. There is no clear consensus on the appropriate duration of therapy for spinal tuberculosis, with various guidelines recommending treatment from as short as 6 months to up to 18 months. In this article, we present a critical appraisal of the evidence on the same. In our opinion, the duration of antitubercular therapy needs to be individualized and the decision to terminate therapy should be multifactorial (clinical, radiological, pathological/microbiological where possible) rather than being enmeshed within any particular guideline.

Spinal Tuberculosis Mimicking as Prostate Cancer Metastases in Ga-68 Prostate-specific Membrane Antigen Positron-emission Tomography/Computed Tomography

Prostate-specific membrane antigen (PSMA) is a type II transmembrane glycoprotein which is overexpressed in prostate cancer. However, the widespread use of PSMA positron-emission tomography (PET) scan revealed various nonprostatic PSMA-avid diseases. Here we present a report of a known case of carcinoma prostate, post orchidectomy, radiotherapy, on hormonal therapy with complain of back pain, referred for Ga68 PSMA PET/CT scan. The scan revealed PSMA-avid lesion of contiguous D6 and D7 vertebrae with associated soft-tissue component. The biopsy of the lesion was suggestive of tuberculosis.

Multimodal imaging of Spina Ventosa (TB Dactylitis) of the foot

We present the case of a 29-year-old male healthcare worker with a 6 month history of progressive left foot pain resulting in presentation to the emergency department on 3 occasions. He denied systemic symptoms. Multimodal imaging demonstrated an expansile erosive inflammatory lesion centered on the neck of the second metatarsal with aggressive features. CT of the thorax, abdomen, and pelvis demonstrated calcified mediastinal lymph nodes and left inguinal adenopathy. The lesion was biopsied under ultrasound guidance demonstrating a necrotizing granulomatous osteomyelitis with acid fact bacilli. This is consistent with TB dactylitis (spina ventosa). Treatment with antimycobacterial drugs was commenced.

Radiographic/MR Imaging Correlation of Spinal Bony Outlines

The human spine is a highly specialized structure that protects the neuraxis and supports the body during movement, but its complex structure is a challenge for imaging. Radiographs can provide fine bony detail, but lack soft tissue definition and can be complicated by overlying structures. MR imaging allow(s) excellent soft tissue contrast, but some bony abnormalities can be difficult to discern. This makes the 2 modalities highly complementary. In this article, the authors discuss the correlation between radiographic and MR imaging appearances focusing first on disease affecting the vertebral body itself, its surrounding structures, and finally global spinal alignment.

[Modern radiological diagnostics in spine surgery]

BACKGROUND

Radiological imaging is important in the preoperative diagnosis of many forms of spinal pathology and plays a fundamental role in the assessment of p.o. effects, which can be verified on the spinal column as well as on the surrounding soft tissues, depending on the imaging method used.

AIM

The article provides an overview of the current status and possibilities of radiological diagnostic methods for the verification of possibly recommended spine surgery in the context of degenerative, inflammatory-infectious, post-traumatic or p.o. pathologies and changes in the spine: X‑rays, computed tomography (CT), magnetic resonance imaging (MRI). The supplementary nuclear medicine procedures (scintigraphy, PET[-CT], SPECT, etc.) which may be required for special questions are not discussed.

MATERIAL AND METHODS

The merits and limitations of the techniques used in the investigation of advanced degenerative spinal pathologies and post-traumatic conditions are discussed, with multidetector CT being the focus of attention in spinal clearance for traumatic injuries. In most cases of spinal infection, MRI images, as a central diagnostic tool, show typical findings such as destruction of adjacent endplates, bone marrow and intervertebral disc abnormalities, and paravertebral or epidural abscesses. However, it is not always easy to diagnose a spinal infection, especially if atypical MR patterns of infectious spondylitis are present. Knowledge of them means misdiagnosis and improper treatment can be avoided.

RESULTS

It is shown that high-quality modern radiological examinations are essential for diagnosis and p.o. management, as these provide answers to the main questions in the treatment: Is the entity/injury stable or unstable, acute or old, benign or malign; is there a myelopathy or p.o. complication?

DISCUSSION

The main indications for p.o. diagnostic imaging, difficulties such as metal artefact formation, and potential pitfalls are analyzed. Entity-specific radiological image patterns, imaging algorithms and differential diagnostic peculiarities are presented and discussed based on current literature and selected case studies.

Spontaneous spondylodiscitis: review, incidence, management, and clinical outcome in 44 patients

OBJECTIVESpontaneous spondylodiscitis remains uncommon but is a serious complication of the vertebral column. Risk factors include diabetes, hemodialysis, intravenous drug abuse, and chronic steroid use, and pain is the most common presenting symptom. This study aims to review the literature and report on the incidence, management, and clinical outcome of spontaneous spondylodiscitis in 44 patients.METHODSThis is a prospective study including 44 patients with spontaneous spondylodiscitis managed in the neurosurgery department of Cairo University Hospitals during the period between January 2012 and October 2017. All patients had a full clinical assessment, laboratory tests, radiological studies in the form of MRI with and without contrast, and a postoperative follow-up of up to 12 months.RESULTSTwelve cases underwent conservative treatment in the form of complete bed rest, intravenous antibiotics, and a spinal brace. Ten cases underwent surgical intervention in the form of laminectomy, debridement, and open biopsy. Twenty-two cases underwent laminectomy and surgical stabilization with fusion. There were 15 cases of tuberculous spondylodiscitis, 6 cases of brucellosis, 6 cases of pyogenic infection, and 17 cases in which no organism could be detected.CONCLUSIONSOnce the primary diagnosis is confirmed, early and adequately prolonged antibiotic therapy is recommended for spontaneous spondylodiscitis. Some cases can be successfully treated with conservative treatment alone, whereas surgery may be needed in other cases such as severe destruction of endplates, spinal abscess formation, mechanical instability, neurological deficits, and severe pain that have failed to respond to conservative treatment.

Tuberculous coxitis with trochanteric bursitis manifesting a year after immigration to Germany: a case report

Background

Osteoarticular tuberculosis is rare in Germany. In particular, trochanteric bursitis is an extremely rare manifestation of osteoarticular tuberculosis. We describe a case of tuberculous coxitis with trochanteric bursitis, successfully treated with a fourfold tuberculostatic therapy.

Case presentation

We report the case of a 43-year-old human immunodeficiency virus-negative Sudanese man with osteoarticular tuberculosis, who was originally admitted with the suspected diagnosis of ankylosing spondylitis. Low grade fever together with the positive result of an interferon-gamma release assay test as well as findings from magnetic resonance imaging provided clues to the diagnosis. A definitive diagnosis could be set after a computed tomography-guided biopsy.

Conclusions

Apart from a rare involvement pattern of osteoarticular tuberculosis, including trochanteric bursitis, this case highlights the increasing importance of osteoarticular tuberculosis as a differential diagnosis of rheumatic disorders. With the growing migration flows from tuberculosis-endemic African countries, clinicians in central and northern Europe may be more frequently confronted with atypical involvement patterns of osteoarticular tuberculosis.

The spectrum of tuberculosis of the spine in pediatric age group: a review

INTRODUCTION

Pediatric spinal tuberculosis is characterized by rapid bone destruction and carries the risk of rapid onset neurological deficits and severe deformity of the spine. Behavior of spinal deformity over time is affected by growth of spine. Owing to this dynamic behavior of pediatric spinal tuberculosis both in active phase and in healed phase, it presents with challenges which are quite different from adults with caries spine. A clinician must have high index of suspicion for accurate and early diagnosis of spinal tuberculosis in the pediatric population and should also have a thorough knowledge of differences in natural history between adult and pediatric spinal tuberculosis.

DISCUSSION

This is based on the senior author's experience of dealing with tuberculosis of the spine in children over the last two decades. Recent advances in field of rapid diagnosis of tuberculosis based on nuclear material-related diagnostic tests have further improved the management of tuberculosis. At the same time, the basic treatment principles remain the same. However, the threshold for surgical vs conservative treatment have subtle differences when compared to adult population. The importance of long-term follow-up after treatment must be appreciated.

CONCLUSION

Tuberculosis in the spine in children needs early attention. Prompting to diagnostic and medical therapy measures can avoid neurological sequellae and delayed deformity.

The Use of Imaging in Management of Patients with Low Back Pain

Lower back pain (LBP) is one of the most common chief complaints encountered in primary care. Advanced imaging studies, including computerized tomography (CT) and magnetic resonance imaging (MRI), are frequently ordered in the setting of LBP. Structural abnormalities are commonly identified by CT and MRI in patients complaining of low back pain, however, these findings are also found in asymptomatic patients. In the past decade, multiple guidelines have been published to help providers identify patients in whom the use of advanced imaging is appropriate. In this article, we review common conditions associated with LBP that require advanced imaging along with their clinical and associated imaging findings.

Posterior surgical treatment of ankylosing spondylitis with spinal tuberculosis: A case series and long-term follow-up

This retrospective cohort study aimed to evaluate the clinical outcomes of posterior surgical treatment of ankylosing spondylitis (AS) with spinal tuberculosis (STB). This was a retrospective study including 12 patients treated between January 2004 and April 2014 for AS with STB at our department. All patients underwent 1-stage posterior internal fixation, debridement, and bone fusion. The patients were evaluated based on the American Spinal Injury Association (ASIA), kyphotic Cobb angle, and the visual analog score (VAS). All patients were followed up for an average of 42.7 ± 13.2 months after surgery and bone fusion was achieved 6.8 ± 1.3 months. According to ASIA, 2 cases were rated as Grade D, 10 cases were Grade E at last follow-up. The average preoperative Cobb angle was 26.7 ± 7.6° (range 15-36) and the average postoperative Cobb angle was 7.8 ± 1.2° (range 6-9). The mean latest follow-up Cobb angle was 9.1 ± 1.0° (range 6-10). Compared with the average preoperative Cobb angle, there were significant differences regarding the kyphotic Cobb angle measured postoperatively and at final follow-up (P < .05). The VAS significantly was considerably improved between the preoperative and the last clinical visits. These positive results demonstrate that 1-stage surgical treatment for AS with STB by posterior debridement, fusion, and instrumentation can be an effective and feasible treatment method for this specific condition. It should be noted that it is necessary to carry out antiosteoporosis treatment and perform long-segmental instrumentation in order to obtain spinal stabilization.

The clinical outcomes and surgical strategy for cervical spine tuberculosis: A retrospective study in 78 cases

Literature on the treatment of cervical spinal tuberculosis (CSTB) is uncommon, the surgical approaches to cervical spinal tuberculosis were controversial. The aim of the study was to evaluate the clinical outcomes of 3 surgical techniques in CSTB patients, and to determine the most appropriate approach for CSTB patients. Between April 2006 and June 2012, we performed a retrospective review of clinical and radiographic data that were collected from 850 consecutive spinal tubercular patients, including 87 patients who were diagnosed and treated for CSTB in our hospital. Apart from 9 patients being treated conservatively, the remainder (78 cases) underwent surgery by anterior debridement, interbody fusion and instrumentation (A group), posterior instrumentation and anterior debridement, fusion and instrumentation in a single or two-stage operation (AP group), or posterior debridement, fusion and posterior instrumentation (P group). The patients were evaluated preoperatively and postoperatively on the basis of hematologic, radiographic examinations, and neurologic function. The 78 patients were followed up for a mean duration of 41.2 ± 7.2 months (range, 24-65 months). Postoperatively, the preoperative erythrocyte sedimentation rate (ESR) value returned to normal within 3 to 6 months in all patients, and solid bone fusion was achieved in 3 to 8 months. The patients exhibited significant improvement in deformity and neurological deficit postoperatively, while the visual analog scale for pain showed significant improvement in all patients at the last follow up visit. The follow-up outcomes demonstrated that all 3 surgical methods were viable management options for CSTB. Individualized therapeutic strategies should be selected according to the patient's general condition, focal characteristics, and the surgeon's experience.

Neuroimaging in Central Nervous System Infections

Radiologic imaging is often employed to supplement clinical evaluation in cases of suspected central nervous system (CNS) infection. While computed tomography (CT) is superior for evaluating osseous integrity, demineralization, and erosive changes and may be more readily available at many institutions, magnetic resonance imaging (MRI) has significantly greater sensitivity for evaluating the cerebral parenchyma, cord, and marrow for early changes that have not yet reached the threshold for CT detection. For these reasons, MRI is generally superior to CT for characterizing bacterial, viral, fungal, and parasitic infections of the CNS. The typical imaging features of common and uncommon CNS infectious processes are reviewed.

An uncommon cause of sciatic pain: tuberculous osteomyelitis of the ischial tuberosity

A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagnosis of tuberculous osteomyelitis with unknown portal entry. The patient did not report a history of a previous tuberculosis (TB) infection and her chest X-ray was negative for TB. Considering TB in the differential diagnosis of a 'bone abscess', it is of paramount importance to come to a correct diagnosis. Conventional radiographs still remain the first-line imaging modality for evaluation of skeletal symptomatology. However, biopsies or aspirates are often needed to yield the definitive diagnosis. The lack of awareness of the potential extrapulmonary involvement of TB leads to an important delay in diagnosis and treatment. Antituberculous drugs should be started at the time of biopsy and continued during 12-18 months, due to poor drug penetration into osseous and fibrous tissues.

Osteoraticular Tuberculosis-Brief Review of Clinical Morphological and Therapeutic Profiles

Osteoarticular tuberculosis (OATB) is a rare form of tuberculosis (TB) whose incidence rose significantly nowadays especially in the underdeveloped countries. The main risk factors predisposing to this new challenge for the medical system are the Human Immunodeficiency Virus (HIV) epidemic, the migration from TB endemic areas and the development of drug and multidrug-resistant strains of Mycobacterium tuberculosis (Mt). The disease affects both genders and any age group although the distribution depending on gender is controversial and that depending on age has a bimodal pattern. In most cases the initial focus is elsewhere in the organism and the most frequent pathway of dissemination is lympho-haematogenous. The clinical picture includes local symptoms as pain, tenderness and limitation of motion, with some particularities depending on the segment of the osteoarticular system involved, sometimes accompanying systemic symptoms specific for TB and other specific clinical signs as cold abscesses and sinuses. The radiographic features are not specific, CT demonstrates abnormalities earlier than plain radiography and MRI is superior to plain radiographs in showing the extent of extraskeletal involvement. Both CT and MRI can be used in patient follow-up to evaluate responses to therapy. TBhas been reported in all bones of the body, the various sites including the spine (most often involved) and extraspinal sites (arthritis, osteomyelitis and tenosynovitis and bursitis). Two basic types of disease patterns could be present: the granular type (most often in adults) and the caseous exudative type (most often in children) one of which being predominant. The algorithm of diagnosis includes several steps of which detection of Mt is the gold standard. The actual treatment is primarily medical, consisting of antituberculosis chemotherapy (ATT), surgical interventions being warranted only for selected cases. It is essential that clinicians know and refresh their knowledge about manifestations of OATB.

Musculoskeletal Tuberculosis

Musculoskeletal tuberculosis (TB) accounts for approximately 10% of all extrapulmonary TB cases in the United States and is the third most common site of extrapulmonary TB after pleural and lymphatic disease. Vertebral involvement (tuberculous spondylitis, or Pott's disease) is the most common type of skeletal TB, accounting for about half of all cases of musculoskeletal TB. The presentation of musculoskeletal TB may be insidious over a long period and the diagnosis may be elusive and delayed, as TB may not be the initial consideration in the differential diagnosis. Concomitant pulmonary involvement may not be present, thus confusing the diagnosis even further. Early diagnosis of bone and joint disease is important to minimize the risk of deformity and enhance outcome. The introduction of newer imaging modalities, including MRI (imaging procedure of choice) and CT, has enhanced the diagnostic evaluation of patients with musculoskeletal TB and for directed biopsies of affected areas of the musculoskeletal system. Obtaining appropriate specimens for culture and other diagnostic tests is essential to establish a definitive diagnosis and recover M. tuberculosis for susceptibility testing. A total of 6 to 9 months of a rifampin-based regimen, like treatment of pulmonary TB, is recommended for the treatment of drug susceptible musculoskeletal disease. Randomized trials of tuberculous spondylitis have demonstrated that such regimens are efficacious. These data and those from the treatment of pulmonary TB have been extrapolated to form the basis of treatment regimen recommendations for other forms of musculoskeletal TB.

Magnetic Resonance Imaging in Differentatial Diagnosis of Pyogenic Spondylodiscitis and Tuberculous Spondylodiscitis

BACKGROUND

Infectious spondylodiscitis is characterized by the involvement of two adjacent vertebrae and the intervening disc. Incidence rate of the disease is estimated at 0.4-2 cases per 100000 per year. Staphylococcus aureus is the most common infectious agent causing pyogenic spondylodiscitis. Non-pyogenic infections of the spine are most frequently caused by Mycobacterium tuberculosis, and fungi. Clinical symptoms are nonspecific. Early diagnosis and appropriate treatment can prevent unfavorable irreversible sequela for the patient. Significant developments in techniques of imaging of pathological tissues raised expectations among the clinicians regarding possibility to distinguish between tuberculous spondylodiscitis and pyogenic spondylodiscitis on MR images. The aim of this study was to identify and differentiate between features of tuberculous and pyogenic spondylodiscitis on MR images.

MATERIAL/METHODS

We performed retrospective analysis of MR images obtained from 34 patients with confirmed spondylodiscitis (18 with pyogenic spondylodiscitis, and 16 with tuberculous spondylodiscitis). Data acquisition was performed using 1.5 T MRI scanners where images were obtained using similar protocols. T2 TIRM and T1-weighted images with and without contrast enhancement were subject to assessment in coronal, axial and sagittal planes.

RESULTS

Characteristic features of pyogenic spondylodiscitis include: involvement of the lumbar spine, ill-defined paraspinal abnormal contrast enhancement, diffuse/homogeneous contrast enhancement of vertebral bodies, low-grade destruction of vertebral bodies, hyperintense/homogeneous signal from the vertebral bodies on T2 TIRM images. Prevailing features of tuberculous spondylodiscitis included: involvement of the thoracic spine, involvement of 2 or more adjacent vertebral bodies, severe destruction of the vertebral body, focal/heterogeneous contrast enhancement of vertebral bodies, heterogeneous signal from the vertebral bodies on T2 TIRM images, well-defined paraspinal abnormal contrast enhancement, paraspinal and epidural abscesses, meningeal enhancement at the affected spine level.

CONCLUSIONS

Comparison of MR images of patients diagnosed with pyogenic spondylodiscitis and tuberculous spondylodiscitis allowed identification of individual characteristics for preliminary differentiation between TB and infectious spondylodiscitis and thereby enabling proper treatment.

Role of alpha-crystallin, early-secreted antigenic target 6-kDa protein and culture filtrate protein 10 as novel diagnostic markers in osteoarticular tuberculosis

Osteoarticular tuberculosis constitutes about 3% of all tuberculosis cases. Early and accurate diagnosis of tuberculosis is a challenging problem especially in the case of osteoarticular tuberculosis owing to the lower number of bacilli. However, an accurate and timely diagnosis of the disease results in an improved efficacy of the given treatment. Besides the limitations of conventional methods, nowadays molecular diagnostic techniques have emerged as a major breakthrough for the early diagnosis of tuberculosis with high sensitivity and specificity. Alpha-crystallin is a dominantly expressed protein responsible for the long viability of the pathogen during the latent phase under certain stress conditions such as hypoxia and nitric oxide stress. Two other proteins-early secreted antigenic target-6 and culture filtrate protein-10-show high expression in the active infective phase of Mycobacterium tuberculosis. In this article, we focus on the different proteins expressed dominantly in latent/active tuberculosis, and which may be further used as prognostic biomarkers for diagnosing tuberculosis, both in latent and active phases.

Multiple Bony Metastatic Lesions and Evaluation of Primary: Case Records of a Cancer Research Centre

During 2012-13, we diagnosed 4 patients with extensive skeletal tuberculosis (TB) who were referred to us as cases of bony metastasis with unknown primary. Radiological investigations done outside favoured a diagnosis of disseminated malignancy. Positron emission tomography/computed tomography (PET/CT) scan performed in our institute for localization of primary lesion also suggested metastatic disease. There was no evidence of malignancy on histo-pathological examination (HPE) of the involved sites. The diagnosis of TB was established on characteristics HPE. This article highlights the diagnostic dilemma of PET/CT in cases of TB versus malignancy and the importance of HPE for reaching an accurate diagnosis.

Multifocal skeletal tuberculosis: A case report

Tuberculosis (TB) of the musculoskeletal system is a rare clinical condition. Multifocal bone involvement is extremely rare and difficult to recognize. Thus, due to the diverse and atypical clinical manifestations of multifocal skeletal TB, the disease is easy to misdiagnose. In the present study, a rare case of atypical disseminated multifocal skeletal TB was reported, which exhibited uncommon findings in radiological images that were more suggestive of a hematological malignancy or metastatic disease. In conclusion, the diagnosis of this condition by conventional diagnostic methods is challenging. The importance of CT-guided needle biopsy and open biopsy in the diagnosis of skeletal TB was emphasized.

Clinicoradiologic Profile of Involvement and Healing in Tuberculosis of the Spine

BACKGROUND

There is no much information about how tuberculous lesions of the spine progress/heal; what clinical and radiological features suggest progression/healing; what is the optimal duration of antitubercular treatment; and what clinical, laboratory, and radiological investigations and their frequency should be done to monitor the disease course.

AIMS

The present study aimed to evaluate what specific clinicoradiologic features suggest involvement and healing in tuberculosis of the spine.

SUBJECTS AND METHODS

Fifty spinal tuberculosis patients (30 males and 20 females) diagnosed clinicoradiologically were enrolled in the study. Patients were evaluated clinically, radiographically, and by magnetic resonance imaging (MRI) at regular intervals to monitor the disease course till 24 months of the initial presentation.

RESULTS

Wedge/collapse (23/50 cases), soft tissue mass (29/50 cases), disc narrowing (45/54 discs), and endplate erosions (89/107 endplates) were the plain radiological findings of tubercular spinal involvement. Earliest sign of healing on plain radiography was decrease in fuzziness of endplate, ultimately leading to either sclerosis of endplate or fusion of adjacent vertebrae. Initial MRI findings included bone marrow edema (50/50 cases), discitis (53/62 discs), endplate erosions (105/123 endplates), pre- and para-vertebral collections (45/50 cases), epidural involvement (26/50 cases), epidural spread (77/109 vertebrae), and subligamentous spread (42/50 cases). Earliest feature of healing on magnetic resonance (MR) examination was decrease in inflammatory soft-tissue masses and reduction in marrow edema.

CONCLUSIONS

Salient features of spinal involvement in tuberculosis on plain radiograph were paradiscal involvement, endplate destruction, and soft tissue masses. Marrow edema, paravertebral collections, subligamentous spread, extradural component, endplate erosion, and discitis suggested tubercular involvement of the spine on MRI. A decrease in these was observed to have prognostic value both in monitoring disease course and response to chemotherapy. Based on the clinicoradiologic findings of the present study, we propose decision-making algorithm, follow-up algorithm, and MR examination protocol for spinal tuberculosis.

LEVEL OF EVIDENCE

This was a Level II study.

Spinal Tuberculosis Resembling Neoplastic Lesions on MRI

BACKGROUND

Tuberculous spondylitis is one of the commonest forms of skeletal tuberculosis in developing countries like India causing significant morbidity due to compression of spinal cord and adjacent nerve roots. Diagnosis and intervention at early stage can prevent permanent damage such as spinal deformity and neurological deficits.

AIM

The purpose of this study was to demonstrate atypical MRI features in cases of tubercular spondylitis resembling neoplastic lesions and to stress that tuberculous spondylitis should be one of the differential diagnoses in any spinal pathology especially in developing countries.

MATERIALS AND METHODS

This was a prospective study done in the patients diagnosed as tuberculous spondylitis on 0.2 T Siemens MRI between June 2011 and December 2014 in a tertiary care hospital in India. Total 529 cases of tubercular spinal lesions were diagnosed. Out of which only 59 patients showed atypical features on MR imaging which resembled neoplastic lesions were included in the study. The diagnosis was confirmed by cytology, histopathology, serology and corroborative findings.

RESULTS

Lumbo-sacral region involvement (30.5%) is the commonest in our study followed by dorsal and cervical region. Multiple level lesions are seen in 14 cases (23.7%). All the 59 (100%) cases show no involvement of intervetebral disc. Posterior appendage involvement seen in 32 cases (54.2%). Soft tissue component seen in Intraspinal (37.2%) and paraspinal (45.7%) compartments. Cord compression seen in 19 cases (32.2%), out which only 7 cases (11.8%) shows cord oedema.

CONCLUSION

On MRI, tubercular spondylitis may have variable pictures on imaging. For any spinal and paraspinal lesions, we should also consider the possibility of tubercular aetiology along with other. Since early diagnosis avoids unnecessary delay in the treatment thereby reducing morbidity and possible complications.

Spinal tuberculosis: Our experience and a review of imaging methods

We share our experience of 2000 spinal tuberculosis (TB) cases, including both typical and atypical presentations. The aim of the study is to estimate the incidence and types of spinal TB referred to our department for diagnosis. 2000 patients were selected by convenience sampling from January 2006 to September 2010. Study design was descriptive and among 2000 mostly unknown cases without evidence of symptoms of systemic TB (1080 males and 920 females). MRI without and with IV contrast, CECT with MPR, and in some cases not fit for MRI, CT myelography, were performed. Out of 2000 cases of tuberculous spine, 1080 (54%) were male and 920 (46%) were female. Their age ranged from 8-60 years. About 90% of patients were below the age of 40 years. Peak age among the males and females was 20-29 years and 14-35 years, respectively. The most common site of involvement was dorsal spine (45%) followed by lumbo-sacral spine (33%), cervical spine (10%) and at multiple levels (12%). Biopsies were done in 240 (12%) cases. Spinal TB should always be suspected when radiographs demonstrate a destructive spinal process. Awareness and prompt management of TB spine will help in reducing the continuing morbidity of this disease.

Computed tomography detection of clinically unsuspected skeletal tuberculosis

OBJECTIVE

To report the frequency of clinically unsuspected axial skeletal tuberculosis (STB) and findings on computed tomography (CT).

MATERIALS AND METHODS

An evaluation of CT chest, abdomen, and pelvis of patients with tuberculosis was done. Bone window images were evaluated for skeletal involvement.

RESULTS

Of the 726 CT studies, 34 (4.7%) patients had skeletal involvement. Thoracic spine was the most commonly affected site with involvement of body in 58% cases. Intervertebral disc involvement, soft tissue abscess, and epidural extension were identified in 83%, 53%, and 39% of cases, respectively.

CONCLUSION

Evaluation of bone window on CT can detect axial STB.

Utility of magnetic resonance imaging in the differential diagnosis of tubercular and pyogenic spondylodiscitis

AIM

We evaluated the potential of magnetic resonance imaging (MRI) in the diagnosis of spinal infections and specifically its accuracy in differentiating tubercular and pyogenic spondylodiscitis.

MATERIALS AND METHODS

Totally, 50 patients referred for MRI scans with the clinical diagnosis of spinal infections were included in our study. The patients were classified as tubercular (TS), pyogenic (PS), and indeterminate spondylodiscitis on the basis of imaging findings and were correlated with the final diagnosis made by histopathology/cytology/culture/biochemistry or with successful therapeutic outcome. Imaging findings were subsequently analyzed for differentiating tubercular and pyogenic spondylodiscitis using the Chi-square test.

RESULTS

The most common pattern of spinal infection was spondylodiscitis (78% incidence rate) with epidural extension (86%) and cord compression (64%) being most common complications observed. Imaging (postcontrast study) and final diagnosis correlated in 93.7% tubercular (sensitivity of 75% and specificity of 90%) and 75% pyogenic (sensitivity of 90% and specificity of 83.3%) spondylodiscitis. The patients with tubercular spondylitis had a significantly (P < 0.05) higher incidence of following MRI findings: A well-defined paraspinal abnormal signal (80% in TS vs. 40% in PS), a thin and smooth abscess wall (84.2% in TS vs. 10% in PS), presence of intraosseous abscess (35% in TS vs. 0% in PS), focal and heterogenous enhancement of the vertebral body (75% in TS vs. 20% in PS), vertebral destruction more than or equal to grade 3 (71.8% in TS vs. 0% in PS), loss of cortical definition (75% in TS vs. 20% in PS), and spinal deformity (50% in TS vs. 5% in PS).

CONCLUSION

Contrast-enhanced images improve the sensitivity and specificity of detection and differentiation of tubercular and PS.

Multifocal osteoarticular tuberculosis of the extremities in an immunocompetent young man without pulmonary disease: A case report

Osteoarticular tuberculosis (TB), an uncommon form of extrapulmonary TB, is a universal mimicker and thus represents a potential differential diagnosis of any osteolytic lesion. The present study describes a case of multifocal osteoarticular TB in an immunocompetent young man who presented with swelling and extremity pain. The patient underwent plain radiography, bone scan and magnetic resonance imaging. A diagnosis was ultimately made based on the pathology results from his second left toe. The patient responded well to anti-TB medication. The radiological findings of multifocal osteoarticular TB are described in this report. To the best of our knowledge, this is the first reported case of multifocal osteoarticular TB symmetrically affecting all the extremities.

Surgical management for thoracic spinal tuberculosis posterior only versus anterior video-assisted thoracoscopic surgery

STUDY DESIGN

A comparable retrospective study.

OBJECT

To compare the clinical outcomes of surgical treatment by posterior only and anterior video-assisted thoracoscopic surgery for thoracic spinal tuberculosis (TSTB).

METHOD

145 patients with TSTB treated by two different surgical procedures in our institution from June 2001 to June 2014 were studied. All cases were retrospectively analyzed and divided into two groups according to the given treatments: 75 cases (32F/43M) in group A performed single-stage posterior debridement, transforaminal thoracic interbody fusion and instrumentation, and 70 cases (30F/40M) in group B underwent anterior video-assisted thoracoscopic surgery (VATS). Clinical and radiographic results in the two groups were analyzed and compared.

RESULTS

Patients in group A and B were followed up for an average of 4.6±1.8, 4.4±1.2 years, respectively. There was no statistically significant difference between groups in terms of the operation time, blood loss, bony fusion, neurological recovery and the correction angle of kyphotic deformity (P>0.05). Fewer pulmonary complications were observed in group A. Good clinical outcomes were achieved in both groups.

CONCLUSIONS

Both the anterior VATS and posterior approaches can effectively treat thoracic tuberculosis. Nevertheless, the posterior approach procedure obtained less morbidity and complications than the other.

Case report on the recurrence of tuberculosis of hip after 40 years

Tuberculosis of joints is relatively rare condition and is associated with varied degree of immobility as well as other limitations. Tuberculosis of hip joint results in a remarkable decline in the living standard of the patients since hip joint has a wide range of function in daily movements apart from being the pivotal weight bearing joint in human body. The degeneration of hip joint culminates into long term morbidity for the patient. In this case report we present a patient who had suffered from the tuberculosis of hip joint 40 years before and had received the standard anti-tuberculosis chemotherapeutic regimen with isoniazid, rifampicin, pyrazinamide and ethambutol. After treatment, the patient had some degree of relief from the pain however the movement of the hip joint was restricted; the restriction increasing progressively since. On diagnostic testing he was found to have a recurrence of tuberculosis along with the old scar tissue left by the primary condition. The patient was assessed thoroughly after which total hip replacement surgery was performed along with the adhesiolysis. The patient made a remarkable recovery after the surgery with a considerable increased range of movement in his hip joint.

Comparison of pyogenic spondylitis and tuberculous spondylitis

Pyogenic spondylitis and tuberculous spondylitis are common causes of spinal infection. It is difficult to differentiate tuberculous spondylitis and pyogenic spondylitis clinically and radiologically. Recently magnetic resonance imaging has been reported to be beneficial for early diagnosis and differential diagnosis of the spondylitis, and is being used extensively for diagnosis. However, the diagnosis must be considered in combination with corresponding changes in clinical manifestations, radiological findings, blood and tissue cultures and histopathological findings. Conservative treatments, including antimicrobial medications, are started initially. Surgical treatments, which include anterior or posterior approach, single-stage or two-stage surgery, with or without instrumentation, may be performed as indicated.

Pott's Spine: Diagnostic Imaging Modalities and Technology Advancements

Spinal tuberculosis (TB) or Pott's spine is the commonest extrapulmonary manifestation of TB. It spreads through hematogenous route. Clinically, it presents with constitutional symptoms, back pain, tenderness, paraplegia or paraparesis, and kyphotic or scoliotic deformities. Pott's spine accounts for 2% of all cases of TB, 15% of extrapulmonary, and 50% of skeletal TB. The paradiscal, central, anterior subligamentous, and neural arch are the common vertebral lesions. Thoracic vertebrae are commonly affected followed by lumbar and cervical vertebrae. Plain radiographs are usually the initial investigation in spinal TB. For a radiolucent lesion to be apparent on a plain radiograph there should be 30% of bone mineral loss. Computed tomographic scanning provides much better bony detail of irregular lytic lesions, sclerosis, disc collapse, and disruption of bone circumference than plain radiograph. Magnetic resonance imaging (MRI) is the best diagnostic modality for Pott's spine and is more sensitive than other modalities. MRI frequently demonstrates disc collapse/destruction, cold abscess, vertebral wedging/collapse, marrow edema, and spinal deformities. Ultrasound and computed tomographic guided needle aspiration or biopsy is the technique for early histopathological diagnosis. Recently, the coexistence of human immunodeficiency virus infections and TB has been increased globally. In recent years, diffusion-weighted MRI (DW-MRI) and apparent diffusion coefficient values in combination with MRI are used to some extent in the diagnosis of spinal TB. We have reviewed related literature through internet. The terms searched on Google scholar and PubMed are TB, extrapulmonary TB, skeletal TB, spinal TB, Pott's spine, Pott's paraplegia, MRI, and computed tomography (CT).

Various Spectrum of MRI Findings in Articular and Para-articular Tuberculosis: Pictorial Assay

Tuberculosis continues to be a health-related issue in India. Musculoskeletal tuberculosis is noted to occur dramatically as isolates, primarily accounting for large numbers of extra-pulmonary tuberculosis since early diagnosis is always a priority; with good prognosis, it is a curable disease. Delayed treatment is associated with severe morbidity. Musculoskeletal tuberculosis accounts for a large number of extra-pulmonary tuberculosis. In this article, we describe various articular and para-articular MRI spectrum findings that are seen in patients with tuberculosis. MRI is the perfect modality to study the extent of involvement and its related complications.

Integration of PET/CT in Current Diagnostic and Response Evaluation Methods in Patients with Tuberculosis

Tuberculosis is a systemic disease that still affects many people. While pleural involvement is frequently observed in extrapulmonary tuberculosis, multiple skeletal system and articular involvements are quite rare. FDG PET imaging could be a promising diagnostic and treatment monitoring method, especially in complicated cases and if the other methods are inadequate. In this case study, we report a patient who was admitted with suspected malignancy and then diagnosed with tuberculosis pleuritis, lymphadenitis, spondylodiscitis, and sacroiliitis with specific symptoms; the response to anti-tuberculosis therapy was shown using FDG PET/CT.

Imaging findings of Pott's disease

Tuberculosis (TB) continues to be an important public health problem in developed countries especially in deprived socioeconomic groups, older people, immunocompromised patients, drug-therapy resistant cases and the immigrant population. The spine is the most frequent location of musculoskeletal TB. The wide range of clinical presentations results in difficulties and delays in diagnosis. Advanced disease mimics other infections and malignancy. The diagnosis of spinal infections relies on three main factors: clinical symptoms, imaging and bacteriological culture. Advanced imaging such as Magnetic Resonance Imaging (MRI), Multidetector Computed Tomography (MDCT) and Fluor18-Deoxiglucose Positron Emission Tomography combined with CT (F-18 FDG PET-CT) demonstrate lesion extent, serve as guide for biopsy with aspiration for culture, assist surgery planning and contribute to follow-up. Diagnosis of TB cannot be established solely on the basis of clinical tests or imaging findings and biopsy may be required. Differential diagnosis between tuberculous and pyogenic spondylitis is of clinical importance, but may be difficult on the basis of radiological findings alone. Findings not pathognomonic but favoring tuberculous etiology include: slow progression of lesions with late preservation of disk space, involvement of several contiguous segments, large intraosseous and paraspinal abscesses containing calcifications, and body collapse with kyphotic deformity. In this essay the highlights of TB imaging are reviewed through published literature. In addition, we review retrospectively the radiological findings of 48 patients with tuberculous spondylitis treated from 1993 to 2010. There were 23 male and 25 female patients with a mean age of 53 years.

A large tuberculosis abscess causing spinal cord compression of the cervico-thoracic region in a young child

INTRODUCTION

Despite numerous descriptive publications, the guidelines for treatment of cervical spinal tuberculosis (TB) are not very clear. The authors report a case of a young girl with cervico-thoracic spinal TB extending from C5 to T3 vertebrae presenting with weakness of the right hand and unsteady gait.

CASE REPORT

An 11-year-old female who is an immigrant to the UK from Afghanistan, presented to our clinic with a 10-day history of difficulty in walking with an unsteady gait and 3-month history of progressive weakness in both her arms, the right side more affected than the left. Her immunisation history was unclear. Examination of the arms showed bilateral thenar and hypothenar wasting, more so on the right than the left. An MRI scan revealed a large para-spinal abscess extending from C3/4 to T4/5 with a significant anterior epidural cord compression from C5/6 to T2/3. Therapeutic/diagnostic aspiration was performed under ultrasound guidance and the aspirate was sent for microbiology. She was started empirically on multidrug anti-tubercular treatment and steroids. Although Ziehl-Neelsen stain was negative for acid-fast bacilli, microbiological confirmation of TB was obtained by positive TB culture sensitive to all first-line anti-TB drugs. She made a dramatic improvement within 3 weeks of anti-tubercular treatment. A follow-up MRI scan at 8 months showed complete resolution of the abscess. At 2 years of follow-up, she was a healthy looking child, back to her school with no residual clinical signs/symptoms of the disease.

CONCLUSION

Our case of cervico-thoracic tuberculous abscess in a young child suggests that even with incomplete neurological deficit caused by epidural cord compression, ultrasound (or CT)-guided aspiration and anti-tubercular medication provide acceptable results at 2 years of follow-up.

Multifocal tuberculosis: Many faces of an old menace

Tuberculosis continues to be a major health problem, and is among the leading causes of morbidity and mortality worldwide. Pulmonary tuberculosis is the commonest and epidemiologically the most important type of tuberculosis as the source of spread in the community. Some patients presenting with pulmonary tuberculosis also have associated multifocal extra-pulmonary tuberculosis and vice versa. Among these patients, some have predisposing factors for the development of disseminated tuberculosis, such as a heavy Mycobacterial load, weak or impaired innate or acquired immunity owing to diabetes, immune therapies, substance abuse or AIDS. Multifocal tuberculosis is characterized by the presence of large multifocal tuberculosis areas in the same or different adjacent or distant organs. This study presents a series of 20 patients with multifocal tuberculosis.

MATERIALS AND METHODS

The patients' records were reviewed to locate those with multifocal tuberculosis as well as pulmonary tuberculosis during the period between 4/2003 and 12/2010. A total of 1,388 patients with confirmed open pulmonary tuberculosis were admitted at the tuberculosis center within the Dammam Medical Complex. Out of this group of patients, 20 cases (1.5%) were found to have multifocal tuberculosis.

CONCLUSION

Multifocal tuberculosis is observed both in immunocompetent as well as in those with weak or compromised immune systems. A thorough physical examination is required even in those confirmed pulmonary cases of tuberculosis to suspect and find extra-pulmonary involvement, because it is important from the management and prognostic perspective. The ultimate outcome under DOTS (directly observed treatment short course) was good in the majority of these cases, and only a few of them required surgical intervention.