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Objective: To investigate the clinical efficacy of one-stage total hip arthroplasty (THA) for treating the advanced hip tuberculosis., Methods: A retrospective study was conducted from July 2013 to June 2018, including 19 patients with advanced hip tuberculosis. All patients underwent total hip arthroplasty through posterior approach, and the surgical efficacy was evaluated., Results: Nineteen patients were followed up from 24 months to 48 months, the mean follow-up were 32.1 months. All the incisions healed in grade A. There were no aseptic loosening, dislocation or recurrence of hip tuberculosis after operation. At the last follow-up, the Harris score of the patients was (89.3 ± 6.7), which was significantly higher than (38.2 ± 10.5) of the patients before operation (P < 0.05); the flexion-extension range of motion was (93.6° ± 12.1°), which was significantly larger than (38.2° ± 10.5°) of the patients before operation (P < 0.05)., Conclusion: The one-stage total hip arthroplasty with regular antituberculosis treatment can attain satisfactory clinical efficacy in the treatment of advanced hip tuberculosis, which can relieve the joint pain and improve the joint function, without recurrence of hip tuberculosis.

Tuberculosis is an airborne multisystemic disease which primarily infects the lungs. Isolated tuberculous arthritis is rare. We present a case of a 41-year-old woman with a known case of lupus nephritis class IV who complained of pain and swelling over her left ankle joint for several months. She was treated for rheumatoid arthritis and was started with immunosuppressive agents. However, she did not improve with treatment and was later diagnosed with tuberculous arthritis based on a molecular study from joint aspiration. She was started on antituberculosis medication and showed improvement. We highlight the challenges in reaching the diagnosis and the importance of including tuberculous arthritis in differential diagnoses in cases with persistent ankle swelling., (© Royal College of Physicians 2021. All rights reserved.)

Background: Due to atypical clinical symptoms, it is difficult to diagnose joint tuberculosis infection, which often results in misdiagnosis and missed diagnosis. It is easy to cause joint disability. And there are few reports of using arthroscopy to diagnose and treat shoulder tuberculosis. This case series aims to introduce the clinical outcomes of arthroscopic treatment of shoulder tuberculosis., Methods: Twenty-nine patients with shoulder tuberculosis from September 2013 to February 2019 were included (10 males, 19 females; age range from 22 to 69; the average age is 37.6 years). All patients underwent arthroscopic lesion debridement, with preoperative and postoperative regular use of isoniazid, rifampicin, pyrazinamide, and streptomycin quadruple anti-tuberculosis drugs. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded before and at the last follow-up. The shoulder function was evaluated according to the visual analogue scoring method (visual analogue scale, VAS) pain score and Constant score., Results: Twenty-nine patients were followed up from 12 months to 2 years, and the average follow-up time was 15.7 months. The pathological diagnosis of all patients after surgery was shoulder tuberculosis. No serious complications were found at the last follow-up, and the incision healed well. VAS pain score, Constant score, ESR, and CRP at the last follow-up were significantly improved compared with those before treatment (P < 0.05)., Conclusion: On the basis of the standard use of anti-tuberculosis drugs before and after surgery, shoulder arthroscopy is used to treat early and mid-term shoulder tuberculosis, which can be diagnosed by direct observation under the arthroscope and postoperative pathological examination. It has the advantages of thorough lesion removal, minimal invasiveness, rapid recovery, and reliable clinical effect.

Competing Interests: Competing interests: None declared.

Tuberculosis is a topical issue in endemic countries. Foot involvement is rare and accounts for 5-10% of all osteoarticular tuberculosis. Pediatric cases of osteoarticular tuberculosis are uncommon especially in well vaccinated children. The clinical presentation is not specific and can be confused with common germ like staphylococcus. Biopsy is mandatory in endemic zone, and if the evolution is not good with antibiotherapy. Debridement can be indicated but must be gentle, because of the risk of navicular necrosis.

Introduction: Osteo-articular tuberculosis mainly affects the spine. Sternal localization is rare., Case Report: A 43-year-old man, HIV negative and with a history of tuberculous pleurisy, was seen in a pulmonology consultation for abscesses of the chest wall. The thoracic CT scan revealed multiple antesternal and retrosternal abscesses as well as bone lesions in the sternum, ribs and vertebrae. The diagnosis of sternal tuberculosis was made by microscopy and Xpert MTB/RIF test performed on pus from the abscesses. The progress under anti-tuberculous treatment was favourable., Conclusion: Sternal involvement with tuberculosis is uncommon and rarely detected. The problem is mainly diagnostic. Its therapy is based on anti-tuberculous treatment., (Copyright © 2020 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Long term multiple systemic antibiotics form the cornerstone in the treatment of bone and joint tuberculosis, often combined with local surgical eradication. Implanted carriers for local drug delivery have recently been introduced to overcome some of the limitations associated with conventional treatment strategies. In this study, we used a calcium sulphate hemihydrate (CSH)/nanohydroxyapatite (nHAP) based nanocement (NC) biomaterial as a void filler as well as a local delivery carrier of two standard of care tuberculosis drugs, Rifampicin (RFP) and Isoniazid (INH). We observed that the antibiotics showed different release patterns where INH showed a burst release of 67% and 100% release alone and in combination within one week, respectively whereas RFP showed sustained release of 42% and 49% release alone and in combination over a period of 12 weeks, respectively indicating different possible interactions of antibiotics with nHAP. The interactions were studied using computational methodology, which showed that the binding energy of nHAP with RFP was 148 kcal/mol and INH was 11 kcal/mol, thus varying substantially resulting in RFP being retained in the nHAP matrix. Our findings suggest that a biphasic ceramic based drug delivery system could be a promising treatment alternative to bone and joint TB.

Osteoarticular tuberculosis can occur in patients with rheumatoid arthritis (RA) receiving immunosuppressive therapy. Here, we describe a case of tubercular osteomyelitis in an old fused hip of a patient with RA who received prednisolone, salazosulfapyridine (SASP), and low-dose methotrexate (MTX). A 77-year-old man with a 4-year history of RA was admitted with a complaint of general fatigue. His symptoms of RA had been well controlled with a combination of prednisolone, SASP, and low-dose MTX. Because the laboratory data showed an increase in serum C-reactive protein levels, we suspected pneumonia. There was expansion of a pre-existing consolidation in the right lower lobe of his lung on chest computed tomography, and the sputum culture was positive for Klebsiella oxytoca . His family physician prescribed empiric antibiotics for pneumonia. Although the QuantiFERON ® test result was positive, the acid-fast bacillus staining result was negative in the sputum. He started complaining of pain in his left hip, where arthrodesis was performed for an unknown reason at the age of 20 years. Sonographic examination of his left thigh revealed fluid collection. The aspiration culture of the fluid was positive for Mycobacterium tuberculosis . He was initiated on rifampicin, isoniazid, pyrazinamide, and ethambutol. Surgical debridement of the fused left hip was performed twice along with a removal of previously implanted materials. Although infrequent, osteoarticular tuberculosis can occur during immunosuppressive therapy, especially in elderly patients. Physicians should be aware of a history of possible tuberculosis infection, such as hip arthrodesis, when prescribing MTX along with SASP and corticosteroid in the elderly.

Calvarial tuberculosis is very rare accounting for 0.2-1.3% of skeletal tuberculosis. Diagnosis is also challenging in these areas due to insidious onset of presentation, low bacterial loads in these sites and unapproachable locations for sample collection. Rarely these patients may presents with features of meningitis when the adjacent meninges are involved. Here we describe a case where tubercular involvement of sphenoid, clivus, and frontal bone, who presented as chronic meningitis and diagnosis was made on the basis of radiological and histopathological findings. All the lesions almost resolved following antitubercular treatment at 5 months follow up. A high index of suspicion is needed for early diagnosis and management of this condition., Competing Interests: Conflicts of interest The authors have none to declare., (Copyright © 2020 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Sri Lanka is a tuberculosis (TB) prevalent country with an incidence of 8886 cases in 2016 of which 30% were extra pulmonary tuberculosis (EPTB). These figures may be an underestimation, considering the diagnostic challenge of EPTB due to its diverse presentations and difficulty in microbiological confirmation. Here we describe a case of EPTB which was first diagnosed as granulomatosis with polyangitis when he presented with fever, anorexia, wasting, large joint pains, cervical pain, erythema nodosum, high inflammatory markers with strongly positive Mantoux reaction and, necrotizing granulomatous lymphadenitis in the cervical region. Immunosuppression with methotrexate 15 mg weekly and prednisolone 30 mg daily, achieved resolution of symptoms and the inflammatory markers. After about 4 months on tailing off prednisolone, he developed fever, anorexia, wasting and worsening occipital pain which evolved in to occipital condylar syndrome causing hypoglossal nerve palsy. With the aid of serial radiological, histopathological and bacteriological investigations, he was eventually diagnosed to have EPTB involving the left base of the skull with upper mediastinal lymphadenitis. This case highlights the importance to have a high index of suspicion to diagnose EPTB, especially in a country with a high prevalence of TB and to revise the diagnosis with a close follow up to avoid disastrous consequences associated with misdiagnosis., Competing Interests: Conflicts of interest The authors have none to declare., (Copyright © 2019 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Tuberculosis (TB) and its association with rheumatic diseases have been widely recognised. Occurrence of multifocal skeletal involvement constitutes <5% of all skeletal TB cases. We present a Malay patient with multifocal osteoarticular TB (OATB). A 35 year-old SLE woman with background usage of corticosteroid therapy and Azathioprine presented with lupus nephritis flare. Renal biopsy revealed diffuse proliferative lupus nephritis and intravenous (IV) Cyclophosphamide 0.5 g/m 2 (850 mg) was initiated. One week later, patient complained dorsum of left hand and right knee swelling. On physical examination, patient was afebrile and the left hand swelling was cystic in consistency while right knee was warm and tender. Erythrocyte Sedimentation Rate (ESR) was 50 mm/hr and C-Reactive Protein (CRP) was 9.4 mg/L. Her Mantoux test was positive with 20 mm induration. Wrist radiograph and chest radiograph was normal. Musculoskeletal ultrasound showed 4th extensor compartment tenosynovitis with Doppler signal and right knee effusion with synovial proliferation. Extensor tenosynovectomy and right knee aspiration was performed. Left hand excised tissue and right knee synovial fluid for acid-fast bacilli (AFB) stain, TB PCR, bacterial and fungal cultures were negative. Urgent histopathological examination of the excised tissue showed necrotising granulomatous inflammation. Patient was empirically started on TB treatment and subsequent mycobacterial culture confirmed the diagnosis of TB. The joints swelling resolved after one month of TB treatment. Multifocal OATB is an infrequent form of extrapulmonary TB and diagnosing OATB requires high index of suspicion particularly in SLE patient on immunosuppression. Prompt investigations are essential to the diagnosis of this rare condition for early initiation of anti-tuberculous therapy.

Tubercular osteomyelitis of zygomatic bone is extremely rare. Here we have reported a rarest case of primary tuberculosis (TB) of zygomatic bone in a 20 year male who presented with discharging sinus over right zygomatic region. Anti-tubercular chemotherapy given and patient improved well., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Sternoclavicular joint tuberculosis is rare and has been presented in literature with few sporadic case reports or small case series. Rarity of the condition, nonspecific symptoms, difficulty to visualise the area on X-rays, and minimal clinical signs make diagnosis of sternoclavicular tuberculosis extremely difficult. Delay in diagnosis is therefore the common feature of all presented reports in literature. We here present our experience of treating 19 cases of sternoclavicular tuberculosis at our centre., Materials and Method: This is an observational study from 2010 to 2017 in a tertiary care referral hospital. All patients with clinical tenderness of sternoclavicular joint and shoulder joint pain of over three week duration were subjected to MRI. Patients who showed radiological lesions (radiography/MRI) were subjected to core biopsy under image guidance. A total of 26 patients had biopsy confirmed sternoclavicular tuberculosis (TB) during this period., Results: All patients had improvement in shoulder function after treatment completion. Mean CSS pre-treatment was 29 which improved to mean of 8 after 18 months of ATT. Eight patients had excellent results, seven good, three fair, and one patient poor result. High initial ESR, late commencement of ATT from initial symptoms, and surgery of the involved joint were considered poor prognostic factors., Discussion: Sternoclavicular tuberculosis is a rare disease with controversial etiology. Both haematogenous spread through suprascapular artery and contiguous spread through latent disease in apical lungs has been postulated. Delay in diagnosis is common to most reports in literature. Early MRI is useful in diagnosis of the lesion. The treatment for sternoclavicular joint in literature is controversial with proponents of both surgery and conservative management., Conclusion: Primary sternoclavicular tuberculosis is rare condition and requires a high index of suspicion for an early diagnosis. A focused sternoclavicular MRI and early biopsy may help in timely diagnosis. Early commencement of ATT has overall good clinical and functional results.

This study aims to elucidate the strains and drug resistance of mycobacterium isolated from osteoarticular tuberculosis (OATB) patients and provide a reference for the diagnosis and treatment of OATB.Sixty-nine clinically diagnosed and surgically treated OATB patients were collected in time period of January 2017 to December 2018 at the First Affiliated Hospital of Xinjiang Medical University. The BACTEC MGIT 960 system was used for mycobacteria culturing, strain identification, and drug susceptibility testing, and the mycobacteria culture positive rate, species distribution, and drug resistance were analyzed.Within 4 weeks, 24 (34.78%) isolates of mycobacteria culture were positive; 40 (57.97%) isolates were positive, when culturing time was expanded to 8 weeks, and the difference was statistically significant (P < .05). Among the 40 isolates, 24 (60%) were identified as mycobacterium tuberculosis (MTB), 10 (25%) were Mycobacterium bovis, and 6 (15%) were non-tuberculous mycobacteria (NTM). Among total 69 isolates, 40 were enrolled in drug sensitivity test, and 15 (37.5%) isolates were confirmed drug resistant strains, in which 5 isolates were MTB, 4 isolates were M. bovis, and 6 isolates of NTM.The pathogen of clinically diagnosed OATB was mainly MTB. However, M. bovis and NTM also accounted for a considerable proportion, and their drug resistance rate was higher. Extending the culturing time appropriately could improve the culture positive rate. NTM was a drug resistant strain, and mycobacteria culturing, strain identification, and drug resistance analysis should be carried out to serve as a guide for individual treatment.

Background: This study aimed to develop and evaluate a sustained drug delivery system for the treatment of osteoarticular tuberculosis (TB) to address the issues surrounding low drug concentration in lesions and bone defects or nonunion after debridement., Methods: The effects of rifapentine on the proliferation and cell cycle of bone marrow mesenchymal stem cells (BMSCs) were evaluated by Cell Counting Kit-8 (CCK-8) and flow cytometry. Rifapentine polylactic acid (PLA) sustained-release microspheres (RPSMs) were prepared through the double emulsion solvent evaporation method and investigated the antibacterial activity in vitro. In this study, two sustained drug delivery systems were prepared by integrating RPSMs and BMSCs into hydroxyapatite/β-tricalcium phosphate (HA/β-TCP) or allogeneic bone. We evaluated these drug delivery systems for dynamics of drug release and osteogenic ability by in vitro release test, alkaline phosphatase (ALP) and alizarin red staining, and real-time PCR., Results: The results showed that rifapentine concentrations up to 45.0 μg/mL had no effect on cell proliferation and cell cycle. The encapsulation and drug loading efficiency of the fabricated RPSMs were 78.11%±1.16% and 35.57%±0.85%, respectively. The RPSMs had uniform particle size distribution and a long-term anti-bacterium effect. The HA/β-TCP-implanted drug delivery system was found to be more effective in reducing the burst release and having a longer duration of sustained release and retention compared to allogeneic bone. The ALP and alizarin red staining and real-time PCR results showed that it had excellent osteoconductive and osteoinductive properties., Conclusions: In conclusion, the sustained drug delivery system with HA/β-TCP as scaffold material represents a potential new strategy for TB infections and bone defects.

Competing Interests: Competing interests: None declared.

Osteoarticular tuberculosis (TB), despite being on the wane in the developed world, stays a problem of significance in the developing world. The issue is compounded by unusual presentations, inadequate diagnostic skills and limited understanding of its management. For foot infections, despite an increased awareness, many patients may be misdiagnosed, with associated treatment delays. A 19-year-old man presented with pain and swelling on lateral aspect of right ankle for 2 months. The patient had an undermined discharging sinus with surrounding induration and the skin adherent to the underlying bone. Patient was diagnosed as a case of ipsilateral TB lateral malleolus and calcaneus, managed with antitubercular drugs with complete resolution at 3 years of follow up. Foot and ankle TB can have atypical presentations causing delay in diagnosis. Contiguous spread of infection occurs through the synovium or the joint; however, extra-articular spread along the tendon sheaths or other soft tissues is possible, which is highlighted by the present case., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Increasing numbers of active tuberculosis in Germany were recorded in the last years. Thus, also extrapulmonary manifestations of tuberculosis gain clinical significance as differential diagnoses, especially when a metastatic tumor disease is suspected. We report the case of a 77-year-old male patient who presented with unilateral leg pain and B symptoms. Further investigations revealed an osteolytic mass in the sacrum as well as CT-morphological findings consistent with metastatic gastric cancer. However, transgastric biopsies showed necrotising granuloma with giant cells leading to molecular and cultural detection of Mycobacterium tuberculosis instead of suspected neoplastic tissue. A nine-month treatment regimen for suspected disseminated tuberculosis with bone involvement was initiated according to national guidelines. Clinical and radiological follow up examinations after treatment completion showed complete remission., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Brazil is one of the highest tuberculosis (TB) burden countries of the world. Cutaneous tuberculosis (CTB) is a rare form of extrapulmonary manifestation of tuberculosis. This study aimed to describe the clinico-evolutive, laboratory and therapeutic aspects of CTB cases among patients from a cohort with TB in Rio de Janeiro, Brazil., Methods: Cases of diagnosed CTB with microbiologic confirmation or clinical response to anti-tuberculous treatment associated with positive smear or histopathological findings between the years 2000 and 2016 were selected., Results: Seventy-five patients with CTB were included, most were women (58.7%) with a median age of 42 years. CTB diagnosis was based on culture in only 42.7% of the cases. Scrofuloderma represented 50.7% of the cases, followed by erythema induratum of Bazin (EIB) (18.7%), tuberculous gumma (13.3%), lupus vulgaris (8%), TB verrucosa cutis (4%), orificial TB (2.7%) and associated forms (2.7%). Other TB presentations were pulmonary (22.7%), mammary (6.6%) and osteoarticular (4%). All patients who completed the treatment (97.3%) had their lesions healed. Only two patients (2.6%) needed to change the therapy due to adverse reactions. Fifty percent of EIB patients presented recurrence., Conclusions: These data highlight the diversity of CTB presentations and the importance of the skin to assist in early identification and treatment of TB. More studies are necessary to improve the knowledge on EIB for a better approach towards these patients, mainly in cases of recurrence., (© 2019 The International Society of Dermatology.)

Primary rib cage tuberculosis (TB) is an infrequent form of presentation and represents 1% of all cases of osteoarticular TB. We report three cases of children who were previously healthy and who began with swelling of the anterior surface of the rib as initial manifestation of TB. The most important clinical presentations in this series were swelling and pain, with lytic lesions and a soft tissue mass in image studies simulating oncologic pathologies. Because none of the cases had positive epidemiological contact, TB was initially not considered, so the delay in diagnosis from the onset of symptoms was 4, 1, and 2 months, respectively. The diagnosis was made through histomorphological analyses. Treatment was administered during 12, 10, and 9 months. Posttreatment studies did not show any evidence of extrapulmonary TB and until date, the patients remained without relapse or active disease. The findings in our cases illustrate that the diagnosis of chest wall TB should be suspected in all patients from endemic areas who present rib injury.

Involvement of the thyroid gland with tuberculosis (TB) is unusual and is commonly associated with hypothyroidism. Involvement of the thyroid as a part of disseminated TB is even rarer. Dissemination is an indication of immunosuppression. We present a 16-year-old immunocompetent girl with disseminated TB involving the thyroid gland and the right radius bone with features of hyperthyroidism. The patient responded well to anti-TB treatment., Competing Interests: None

In an endemic zone of tuberculosis (TB), osseous involvement is a relatively common presentation. Spine and long bones are the the most common nidus of TB. Smaller bones and joints are relatively less involved. Thorough clinical examination and history of typical constitutional symptoms like weight loss, fever and loss of appetite are the diagnostic aids for initiating early treatment. Wrist and hand involvement is a rare occurrence and often presents atypically without any obvious symptoms or signs. This results in delayed diagnosis and worse outcome. TB of lunate without articular involvement is a very rare subset and we present such an isolated case of TB involving the lunate, without any typical symptoms, with the patient complaining of vague pain without any restriction of joint mobility. TB was diagnosed with the aid of radiology, haematology and histopathology. 18 months of multidrug antitubercular treatment was given, to which the patient responded well., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Bilateral Tubercular Dactylitis (TD) is an unusual presentation of tuberculosis and only handful numbers of cases are reported in the literature. Hence, very little is known about its clinical presentation, statistic, radiological features and its outcome., Methods: We have included seven male and two female patients of mean age 7.2 years, of the proven cases of bilateral TD by histopathological or microbiological or PCR analysis from core biopsy. Radiological features were recorded from plain radiograph. All patients were given Antitubercular drugs according to WHO 2010 recommendation (four drugs for 3-5 months, three drugs for next 3-5 months and finally two drugs for 6-8 months). Debridement was done whenever required., Results: Of total 26 lesions, the most common presentation was swelling with or without mild pain. Discharging sinus was present in four lesions. There were six phalanges, 18 metacarpal and two metatarsals. Radiographically, the most common type of lesion was soft tissue swelling followed by lytic lesion. Histopathologically tuberculosis was proven in 10 (55.6%) lesions, bacteria isolated in 5 (27.8%) lesions and PCR was done in 8 lesions and was positive in all. All lesions healed after giving ATT except one which developed psudo-arthrosis and one patient developed coronal plane deformity that was corrected by JESS., Conclusion: A clinician should always suspect tuberculosis while dealing with a pathology of hand and feet even if it is bilateral. Suspected case can be diagnosed by histopathological, microbiological or PCR analysis and it can be treated by ATT with a good functional outcome., (Copyright © 2017 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Primary Calvarial Tuberculosis, a rare entity of skull is even rarer after second decade of life in a healthy person without evidence of tuberculosis elsewhere in the body. Most of the cases are often misdiagnosed as osteomyelitis/syphilis/bony metastasis. We report a case of primary skull tuberculosis in 26-year-old male with complains of headache and swelling in the right frontal region with no history of previous tuberculosis. The patient was operated and the histopathological examination of excised tissue was suggestive of tubercular pathology. The patient is doing well after anti-tubercular therapy. Being a rare disease, tubercular osteomyelitis of skull bones is often missed and misdiagnosed due to lack of clinical suspicion and slow growth of mycobacterium cultures. Histopathological examination of biopsy material and demonstration of acid-fast bacilli in the pus are helpful for diagnosis and early management of the disease. Keywords: calvaria; Mycobacterium; osteomyelitis; tuberculosis.

A 30-year-old man, without previous medical record, was admitted to our centre due to persistent hacking cough for the previous 2 months, accompanied by nocturnal sweating, unquantified weight loss and low-grade fever. The patient was finally diagnosed of pulmonary tuberculosis (TB). During admission, a right forehead swelling was detected, painful to palpation, fluctuating and not attached to the skin, without cutaneous alterations or neurological impairment. Surgical debridement was performed and intraoperative cultures were positive for mycobacteria TB. The patient completed 9 months of antituberculous therapy and fully recovered., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Calvarial tuberculosis is rare presentation and has been reported in only about 0.01% of all patients with mycobacterial infections. Though rare, the incidence of Calvarial tuberculosis seems to be on the rise, especially in developing countries. We present three cases of Calvarial tuberculosis which were successfully managed at our Centre. All the cases occurred de novo in young, otherwise healthy individuals, hailing from good socio-economic backgrounds and without any past history or contact history with tuberculosis patients. We highlight the importance of keeping this diagnosis in mind in appropriate clinical situations as well as recommend the early commencement of optimal management to prevent serious neurologic complications & sequelae.

Isoniazid (INH) is a first-line therapy for bone tuberculosis (TB), but its clinic benefits are limited by severe side-effects after long-time administration. While nano-drug delivery systems present as promising strategies for INH delivery, the therapeutic efficacies are usually suboptimal due to ineffective drug accumulation at diseased sites. Local delivery system can achieve high drug concentration at focus sites with minimal systemic exposure, and herein we aimed to employ this strategy to develop a novel liposome-in-hydrogel system for localized treatment of bone TB. To achieve sustainable drug release, a derivative of INH called DINH was loaded because of its hydrophobicity, as well as its better activity and higher biosafety than INH. The hybrid system was demonstrated for thermo-responsive and self-healing properties via phase transition test and rheological studies, which were particularly useful for intra-articular administration. In vivo microdialysis studies revealed that the system can rapidly release drug into synovial fluid to reach effective inhibitory concentrations after localized injection, followed by a steady-state drug release. The optical image studies were performed to study its long-term behavior in vivo, which suggested a sustained drug release profile for several days. This work provides a promising drug delivery system for bone TB therapy., (Copyright © 2019. Published by Elsevier B.V.)

Background: Osteoarticular tuberculosis is a great masquerader presenting in varied forms and in atypical locations, and it is prone to misdiagnosis and missed diagnosis. Isolated acromioclavicular joint tuberculosis has been reported rarely., Case Presentation: A 19-year-old man presented with a chronic, mild pain, non-healing ulcer in right shoulder. Imaging of the shoulder revealed destruction of the acromioclavicular joint and histopathology confirmed the diagnosis of acromioclavicular tuberculosis. The patient underwent debridement, synovectomy and drainage of the abscess and recovered well with antitubercular therapy postoperatively., Conclusions: Awareness of this uncommon presentation of osteoarticular tuberculosis may assist in earlier diagnosis. Especially, in endemic countries, osteoarticular tuberculosis should be considered as a differential diagnosis in all atypical presentations to avoid residual problems.

Poor blood circulation makes it difficult for antitubercular drugs to achieve effective bactericidal concentration at tuberculose focus. The residual Mycobacterium tuberculosis around surgical wound would multiply, resulting in nonunion or sinus formation. Carbon nanotubes have strong tissue penetration and can cross many kinds of physiological barriers. Here, we constructed a chitosan/carbon nanotubes nanoparticles to control slow release of isoniazid. Transmission electron microscopy and nanoparticle tracking and analysis results showed that the diameter of chitosan/carbon nanotubes nanoparticles was between 150 and 250 nm. Chitosan/carbon nanotubes nanoparticles significantly prolonged the release time of isoniazid, and the release rate was more uniform, no sudden release was observed. In vitro experiments showed that chitosan/carbon nanotubes nanoparticles did not destroy biological function of isoniazid, but could reduce its cytotoxicity and inflammation. We further constructed animal model of tuberculous ulcer. The results showed that isoniazid/chitosan/carbon nanotubes nanoparticles promoted the healing of tuberculosis ulcer. Compared with isoniazid group and isoniazid/carbon nanotubes group, the area of wounds decreased by 94.6% and 89.8%, respectively. Immunohistochemistry showed that CD3+ and CD4+ T cell number decreased significantly in isoniazid/chitosan/carbon nanotubes group. In conclusion, we constructed a kind of isoniazid/chitosan/carbon nanotubes nanoparticles, which can significantly promote the healing of tuberculosis ulcer. Our study provided an effective way for the treatment of secondary wound healing of bone tuberculosis.

Background: Extra-pulmonary tuberculosis (EPTB) is defined as any bacteriologically confirmed or clinically diagnosed case of TB involving organs other than the lungs. It is frequently a diagnostic and therapeutic challenge with paucity of data available. The aim of this study was to assess the prevalence of bacteriologically confirmed EPTB; to determine the most affected organs and to evaluate the therapeutic outcome of EPTB patients treated under program conditions in the littoral region of Cameroon., Methods: A descriptive cross-sectional laboratory-based epidemiological survey was conducted from January 2016 to December 2017 and 109 specimens from 15 of the 39 diagnosis and treatment centers in the littoral region were obtained. Two diagnostic methods (Gene Xpert MTB and culture (LJ and MGIT) were used for EPTB diagnosis. Determine HIV1/2 and SD Biolinewere used for HIV diagnosis. Confirmed EPTB cases were treated following the national tuberculosis guide., Results: The prevalence of bacteriologically confirmed EPTB was 41.3% (45). All 45 cases were sensitive to rifampicin. Males were predominately more infected [26 (57.8%)] likewise the age group 31-45 years with 15 (33.3%) cases. The overall prevalence for HIV was 33.6% (36). HIV infection was present in 28.9% (13) of patients with EPTB. The most affected sites with EPTB were: Lymph nodes (66.5%), pleural cavity (15.6%), abdominal organs (11.1%), neuromeningeal (2.2%), joints (2.2%) and heart (2.2%). Overall, 84.4% of the study participants had a therapeutic success with males responding better 57.9% (p = 0.442). Therapeutic success was better (71.7%) in HIV negative EPTB patients (p = 0.787)., Conclusion: The prevalence of bacteriologically confirmed EPTB patients treated under program conditions in the littoral region of Cameroon is high with a therapeutic success of 84.4% and the lymph nodes is the most affected site.

Tuberculosis (TB) is a major health problem and a leading cause of illness and death from infectious disease. Tuberculosis in pregnancy has been associated with increased risks of prematurity and small for gestational age (SGA)infants.The present study is aimed to examine obstetrical and perinatal outcomes among women who had extra-pulmonary tuberculosis., Material and Methods: It was retrospective study involving patient who presented with extra pulmonary tuberculosis over a period of ten years (2008-2017)was reviewed. Diagnosed women were compared with controls in the ratio of six controls for each case. Data included age, parity and complications in the antenatal, intrapartum and postpartum periods. The mean birth weights of infant and the frequency of small for gestation age, neonatal depression and still births were used for perinatal outcome., Results: During the period of study 30 pregnant women were booked for extra -pulmonary TB. 22/30(73.3%) were diagnosed having extra pulmonary -TB prior to pregnancy and were taking ATT (anti-tubercular therapy) during the pregnancy, in 8/30(26.6%) it was diagnosed during pregnancy. Age, parity were similar in two groups. There was significantly increased incidence of oligoamnios and preterm rupture of membrane (P = 0.001). Mean gestation age of delivery in TB cases was 36.15 ± 1.8 weeks as compared to37.5 ± 0.5 weeks in low risk patients (P = 0.001). The mean birth weight of the infants of mother with extra pulmonary TB was 2324.26 ± 379.5 grams and 2712.3 ± 635.7 for control group(P = 0.001)., Conclusion: This study emphasize on the need for early diagnosis and treatment of tuberculosis preferably before pregnancy, regular medical follow up and good perinatal care., (Copyright © 2018. Published by Elsevier B.V.)

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.

A 23-year-old female on anti-tubercular therapy for tuberculous sacroiliitis presented with right sided gluteal and thigh abscess. Suspecting treatment failure, surgical evacuation of purulent material was done. The bacteriological isolation showed positivity for methicillin-resistant Staphylococcus aureus. Although the microbiological and histopathology examination of the specimen were negative for tubercular isolates, the cartridge based -nucleic acid amplification tests revealed positive genes for Mycobacterium tuberculosis and additional primers showed sensitivity for rifampicin and isoniazid. She was adequately treated with vancomycin for six weeks and anti-tubercular drugs for eight months and followed till the bony ankyloses at 18 months. This is a rare case based scenario wherein concomitant staphylococcal infection in tubercular sacroiliitis masqueraded as anti-tubercular drug resistance. The cartridge-based nucleic acid amplification test for tuberculosis is a rapid and sensitive modality in identifying mycobacteria even mixed infections and also determine drug resistance. There are fewer consensuses in the literature regarding the drugs and duration of anti-tubercular regime for tuberculous sacroiliitis with most regimes using four drugs between six to eighteen months., (Copyright © 2018 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests: None declared.

Anti-tuberculosis chemotherapy with a long duration and adequate dosing is the mainstay for treatment of osteoarticular tuberculosis (TB). However, it is difficult for systemic administration to reach adequate local drug concentrations and achieve effective treatment. Herein, a hydroxyapatite (HA) scaffold implant combined with a drug-releasing system was designed to achieve in situ and long-term anti-TB drug release and highly efficient therapeutic activity in vitro and in vivo. The clinical anti-TB drugs hydrophilic isoniazid (INH) and hydrophobic rifampicin (RFP) were molecularly dispersed into polyvinyl alcohol (PVA) through immersion-curing techniques and were steadily adhered onto the surfaces of HA scaffolds (HA-drug@PVA). The HA-drug@PVA scaffolds showed a long-term, sustained drug release profile and killed proliferating Mycobacterium in vitro. In vivo experimental results revealed that the HA-drug@PVA scaffolds provided over 10- and 100-fold higher concentrations in muscles and bones, respectively, as well as a much lower concentration (<0.025) in blood. Furthermore, the HA-drug@PVA scaffold implanted in an osteoarticular TB rabbit model showed obvious bone regeneration and fusion due to the inhibition of TB-associated inflammatory changes. The excellent therapeutic effects indicate that in situ implant materials combined with a long-term drug release system are promising for the treatment of osteoarticular TB and other osteoarticular infections., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

A 71-year-old man presented with septic arthritis of the hip with an initial culture growth of methicillin-sensitive Staphylococcus aureus (MSSA) masking the diagnosis of tuberculosis (TB). Based on joint aspirate culture and sensitivity results, the patient was first diagnosed with MSSA arthritis. He was started on intravenous antibiotics and underwent washout and debridement of hip. During the procedure, the surgeons observed characteristic tubercular changes and samples were sent for tubercular testing. The reports of cultures for acid-fast bacilli and synovial biopsies confirmed our intraoperative suspicion of TB. Antitubercular medication was started and it helped patient to improve quickly. He completed 9 months of tubercular treatment regimen and at completion total hip replacement was offered. At 8-year follow-up, the patient was doing fine with no recurrence of infection in his hip. High index of suspicion for skeletal TB was raised based on clinical and radiological signs especially if there was a delay or absence of response to appropriate therapy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Despite the high prevalence of pulmonary tuberculosis worldwide, extrapulmonary tuberculosis especially cutaneous and osteoarticular tuberculosis occurs rarely, both of which are often difficult to be recognized since their symptoms mimic those of many other cutaneous and osteoarticular diseases. Here, we present a rare case of cutaneous tuberculosis potentially accompanied by osteroarticular tuberculosis in a 36-year-old Chinese man who presented with multiple persistent skin ulcers for one year and were nonresponsive to multiple therapeutic approaches. A single anti-tuberculous regimen with rifampicin resulted in healing of all skin lesions and excellent recovery of the general condition., (© 2018 Wiley Periodicals, Inc.)

Diaphyseal tuberculosis (TB) is a rare case of the skeletal TB. The following report documents the case of a 52-year-old Moroccan woman with a swelling over the right forearm followed by pulmonary TB under treatment for 3 months. The radiographs of the forearm show a lytic image located at the radius mid-diaphysis. The histopathology confirmed the diagnosis. The patient received surgical drainage with trepanation of the bone. The antibacillary chemotherapy was administered for 6 months. It is, therefore, indispensable to bear in mind the possibility of such atypical presentations of TB when making a rapid and pertinent diagnosis and prescribing the appropriate treatment., Competing Interests: There are no conflicts of interest

A 50-year-old woman presented with pain, swelling, and reduced range of motion of right knee joint since one year. Radiograph of knee joint revealed eccentric, expansile, geographic lytic lesion on the medial epiphyseal region of tibia mimicking giant cell tumor (GCT). She underwent minimally invasive biopsy, which was positive for acid-fast bacilli and revealed necrotizing chronic granulomatous lesion, diagnostic of tuberculosis (TB). This case emphasizes to consider tuberculosis arthritis as differential diagnosis when a case of destructive giant cell tumor is encountered., (Copyright © 2016 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Systemic lupus erythematosus (SLE) patients are at higher risk of developing opportunistic infections such as tuberculosis (TB), especially extrapulmonary forms like osteoarticular TB, compared to the general population. However, tuberculous sacroiliitis has been scarcely reported in these patients. We present a 34-year-old woman with SLE who developed articular tuberculosis simultaneously affecting the right sacroiliac joint and the left knee. The patient was successfully treated with antituberculosis therapy for nine months. In this case, in addition to the immunological abnormalities of lupus, the long-term glucocorticoid therapy at high dosages was the main risk factor for the development of osteoarticular tuberculosis.

We present a case of a 31-year-old man of Indian origin with no previous medical history who presented with an inflamed knee. Treatment for bacterial infection was unsuccessful, and needle aspiration of the left knee effusion/collection was smear and culture positive for tuberculosis (TB), despite Xpert MTB/RIF being falsely negative. The patient was commenced on quadruple therapy for TB and within 2 months had improved significantly with no clinical evidence of ongoing inflammation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Tuberculosis of the shoulder is rare. It encompasses all articular and periarticular tuberculouses of the shoulder. Its insidious evolution, mimicking inflammatory and degenerative diseases, reflects the frequency of its diagnostic delay. We report a rare case of tuberculous bursitis of the shoulder in a woman living in rural areas, with renal insufficiency and treated for peritoneal TB and psoas. The anamnesis revealed signs of tuberculous impregnation. Clinical examination showed painful swelling of the shoulder associated with stiffness. MRI of the shoulder objectified infectious bursal disease. Its tuberculous origin was confirmed by the histological examination of ultrasound-guided synovial biopsy. The patient underwent TB treatment with good outcome. At 9-year follow-up, the patient had satisfactory articular function with no recurrence of infectious disease.