Painful swelling of the left elbow in a uraemic patient

Cheng-Hung Huang1, Jinn-Yang Chen1, An-Hang Yang2 and Wu-Chang Yang1

1 Division of Nephrology, Department of Medicine and 2 Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taiwan

Correspondence and offprint requests to: Jinn-Yang Chen, MD, Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. Email: jychen{at}vghtpe.gov.tw

Keywords: haemodialysis; tuberculous arthritis

Case

A 76-year-old woman presented in 1998 with end-stage renal failure due to chronic interstitial nephritis. Haemodialysis treatment was proposed but the patient refused. She had been on a low-protein diet and calcium carbonate treatment thereafter. Her renal function deteriorated further, and she suffered from general weakness, weight loss 10 kg over 2 months, and painful swelling of the left elbow in May 2001. She visited several local hospitals, and renal osteodystrophy was diagnosed. Due to the absence of symptomatic improvement, she was referred to our hospital for further management.

On admission, physical examination was normal apart from pale conjunctivae and painful swelling of the left elbow. Laboratory investigation revealed white cell count of 8800/mm3 with normal differential count; haemoglobin 6.5 g/dl; blood urea nitrogen 77 mg/dl; creatinine 9.4 mg/dl; serum albumin 3.3 g/dl; calcium 11.3 mg/dl; phosphate 5.4 mg/dl; iPTH 44 pg/ml; total alkaline phosphatases 61 IU/l; aluminium 8.9 µg/l; 25-hydroxyvitamin D2 (25(OH)D2) 14 ng/ml (normal 25.7 ± 15.8 ng/ml); 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) 22 pg/ml (normal 16.4–42.4 pg/ml) and rheumatoid factor <20 IU/ml. A chest roentgenogram showed clear lung fields. Haemodialysis was initiated. Due to the persistent elevation of serum calcium, calcium carbonate was withheld and a low-calcium dialysate (Ca 2.5 mEq/l) was prescribed. However, hypercalcaemia persisted. X-ray of the left elbow disclosed osteolytic bone destruction at the left proximal ulna without cystic lesions (Figure 1). Magnetic resonance imaging (MRI) of the left elbow showed synovitis with marked joint effusion and bursitis (Figure 2). Gallium scan revealed active inflammation in the left elbow joint. The differential diagnosis of monoarthritis included rheumatoid arthritis, gouty arthritis, infectious arthritis, amyloid arthropathy and malignancy. Sonography-guided aspiration of the left elbow was performed. Cytology and bacterial culture of the aspirated specimen disclosed negative findings. Due to scanty specimen, crystal examination was not performed. However, there was no evidence of rheumatoid arthritis, gouty arthritis or amyloid arthropathy on the basis of clinical features, imaging studies and laboratory investigations. Infectious arthritis, such as granulomatous arthritis, was therefore suspected. Debridement and open biopsy of the left elbow were performed. Light microscopy examination revealed numerous granulomata composed of epithelioid cells, occasional Langhans giant cells and caseous necrosis (Figure 3). Acid-fast bacilli were also demonstrated. Several weeks later, cultures of the biopsy specimen grew Mycobacterium tuberculosis. Anti-tuberculous therapy with rifampicin, isoniazid and pyrazinamide was started on 5 September 2001. The patient’s left elbow discomfort improved gradually. Serum calcium eventually returned to normal values.



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Fig. 1. Radiography of left elbow showing osteolytic bone lesion over left proximal ulna (arrow) with soft-tissue swelling.

 


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Fig. 2. (A) T1- and (B) T2-weighted MR images showing ulnar cortical bone destruction (arrows), synovitis, bursitis and marked joint effusion.

 


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Fig. 3. Numerous granulomata composed of epithelioid cells and Langhans giant cells. (H & E x 200.)

 
Discussion

The incidence of tuberculosis in uraemic patients is 10 times greater than in the general population [1]. Moreover, tuberculous infection in uraemic patients is characterized by frequent extrapulmonary involvement [2,3]. However, bone and joint tuberculosis is rare, and only four cases have been reported in haemodialysis patients [47]. Generally, the diagnosis of tuberculosis in end-stage renal failure is difficult because the presentation of this disease mimics features associated with the uraemic syndrome. Systemic manifestations such as fever, night sweating and weight loss may occur, but they are uncommon in the absence of lung involvement. Early diagnosis and immediate treatment improve the prognosis of uraemia-related tuberculosis.

Tuberculous arthritis is typically a monoarthritis. The most common site is the vertebral column, followed by the large weight-bearing joints such as the hip and knee. Tuberculous monoarthritis presents insidiously with joint pain and joint swelling. X-ray changes in tuberculous arthritis are usually non-specific and depend upon the stage of the disease. Changes seen classically include joint-space narrowing, metaphyseal and subchondral erosions and subchondral cysts. In our case, the X-ray finding was typically non-specific, which prompted us to perform invasive procedures.

Articular complications are common among patients receiving renal replacement therapy. They include complications of renal osteodystrophy, osteonecrosis, septic arthritis, malignancy and various crystal-induced arthropathies due to sodium urate, calcium pyrophosphate or hydroxyapatite. Soft-tissue syndrome such as tendinitis, tendon rupture and bursitis are seen in dialysis patients as well. In our patient, the diagnosis of malignancy was excluded because no malignant cells could be demonstrated in the aspirated specimen. On the other hand, renal osteodystrophy was not suspected based on the clinical features, imaging studies and laboratory investigations. Infectious arthritis was suspected initially. Since the hypercalcaemia persisted despite discontinuation of calcium carbonate and the use of low-calcium dialysate, and since there was no evidence of secondary hyperparathyroidism, granulomatous arthritis was suspected, in particular tuberculous arthritis. A sonography-guided biopsy pointed to a diagnosis of tuberculosis 1 month after the start of haemodialysis treatment.

Our case demonstrates that tuberculous arthritis may present with only joint pain and swelling, in the absence of fever. In a uraemic patient without a specific aetiological agent for a suspected septic monoarthritis, we suggest early synovial biopsy for culture and histology to detect M. tuberculosis. This allows early diagnosis and treatment.

Teaching points

  1. In TB endemic areas, a careful evaluation of end-stage renal failure patients with monoarthritis for evidence of mycobacterial infection is essential, and close follow-up is needed to facilitate early detection.
  2. In uraemic patients with refractory hypercalcaemia and monoarthritis, tuberculous arthritis should always be borne in mind.
  3. This case is instructive in that tuberculous arthritis should be considered early in face of an acute or chronic monoarthritis in a uraemic patient with refractory hypercalcaemia.

Conflict of interest statement. None declared.

References

  1. Andrew PL, Andrew IA, Geoffrey MB et al. Tuberculosis in patients undergoing maintenance hemodialysis. Am J Med 1979; 67: 597–602[ISI][Medline]
  2. Papadimitriow M, Memmos D, Metaxas P. Tuberculosis in patients on regular hemodialysis. Nephron 1979; 24: 53–57[ISI][Medline]
  3. Mitwalli A. Tuberculosis in patients on maintenance dialysis. Am J Kidney Dis 1991; 18: 579–582[ISI][Medline]
  4. Nik-Akhtar B. Tuberculous osteoarthritis in hemodialysis patients [letter]. Nephron 1980; 26: 56[ISI]
  5. Haskell LP, Tannenberg AM. Tuberculous arthritis in a hemodialysis patient. Am J Nephrol 1987; 7: 404–407[ISI][Medline]
  6. Fang JT, Huang CC, Liu HP. Apparent neoplasm of the clavicle of a dialysis patient, ultimately revealed as tuberculosis. Nephrol Dial Transplant 1996; 11: 1380–1382[ISI][Medline]
  7. Hirotaka F, Hiroyuki S, Akihiko K et al. Tuberculous arthritis mimicking neoplasm in a hemodialysis patient. Am J Med Sci 2001; 322: 373–375[CrossRef][ISI][Medline]




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