Reactivation of ancient trochanteric tuberculosis 60 years after surgical drainage

S. Sastre, S. García and À. Soriano1

Hospital Clinic Universitari de Barcelona, 1Institut Clínic de l’Aparell Locomotor, 2Institut Clínic d’Infeccions I Inmunologia, Barcelona, Spain.

Correspondence to: S. S. Sastre. E-mail: ssastre{at}clinic.ub.es

SIR, Tuberculous bursitis with associated osteitis of the greater trochanter is a rare cause of lateral hip pain and most cases were diagnosed in the early part of the twentieth century [1]. However, in those countries such as Spain where tuberculosis infection has had a higher incidence in the past, elderly people are susceptible to reactivate an ancient tuberculosis owing to the impairment of their immune system. With the re-emergence of tuberculosis more atypical osteoarticular cases have been reported [24]. Nowadays, the latest modalities in diagnosis and the specific antituberculous drug therapies allow us to make an earlier diagnosis and to find a definitive cure. However, it is necessary to keep in mind that tuberculosis is one of the causes of severe hip pain in elderly people.

We describe an 80-yr-old woman who had a surgical drainage of the trochanter area owing to tuberculous osteitis when she was 20. The patient was admitted to our hospital in 1995 complaining of lateral right hip pain, limping gait, tenderness over the greater trochanter and a skin fistula with a white supurative fluid. Radiographs of the hip showed a partial destruction of the margin of the greater trochanter, lytic foci in the underlying bone and a small focus of calcification in the adjacent soft tissues (Fig. 1). Magnetic resonance imaging showed fluid around the greater trochanter in the subgluteus medium and maximum bursae, revealing the extent of the inflammation within the adjacent marrow and delineating the extent of abscess formation in the gluteal region and subcutaneous tissues (Fig. 2). The bone scan with technetium-99m-labelled leucocytes showed an important uptake of the trochanteric area and tender tissues around it. Blood tests revealed an erythrocyte sedimentation rate of 35 mm/h, C-reactive protein of 4.5 mg/dl and leucocytes at 10.90 x 109/l (85% neutrophils, 5.4% lymphocytes). A wide excision and curettage of the bone was done and microbiological and pathological studies were performed. No acid-fast bacilli were detected in the sample, but DNA of Mycobacterium tuberculosis was amplified using the polymerase chain reaction (PCR). Löwenstein culture was positive for M. tuberculosis susceptible to first-line antituberculous drugs. Typical granulomas containing caseum were observed in the pathological studies. The patient completed a treatment with rifampicin, isoniazid and pyrazinamide for 2 months followed by 7 months of rifampicin and isoniazid. Six years later the patient is asymptomatic and the range of movement of the hip is normal.



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FIG. 1. Radiograph of the left hip revealing destruction of the cortical margin of the greater trochanter, lytic foci within the greater trochanter and a fleck of calcification within the soft tissues.

 


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FIG. 2. Coronal T1-weighted MRI image with partial destruction of left greater trochanter, with oedema in the neighbouring soft tissues and the bursae overlying the trochanter.

 
Tuberculous trochanteric bursitis with osteitis is a rare cause of hip pain. It accounts for 1–2% of all musculoskeletal tuberculosis [3]. There are few cases reported in the recent English medical literature [5, 6] and no reported cases of trochanteric tuberculosis reactivation after surgical drainage have been found.

Trochanteric tuberculosis used to present as a chronic pain and local tenderness over the lateral aspect of the hip that can be intermittent and may be undiagnosed for many years [5]. However, the most frequent causes of trochanteric pain are idiopatic trochanteric bursitis, septic bursitis, osteochondritis and tumours. The use of ultrasound or computed tomography in order to direct aspiration of bursal fluid for culture may be useful in the early diagnosis of tuberculous bursitis. In the absence of cold abscesses, fistula formation or evidence of tuberculosis elsewhere, this condition may be confused with other aetiologies. In the presence of a cutaneous fistula an over-infection could occur and prevent the diagnosis of tuberculosis if specific tests are not requested. Currently, modern tests to detect tuberculosis (genetic detection by means of PCR) allow us to obtain an early diagnosis.

Osteoarticular tuberculosis can reappear in those elderly people who were exposed to tuberculosis in their youth. Therefore, it is necessary to bear this fact in mind when making the differential diagnosis of the cause for hip pain in the elderly.

References

  1. Harisinghani MG, McLoud TC, Shepard JA, Ko JP, Shroff MM, Mueller PR. Tuberculosis from head to toe. Radiographics 200;20:449–70
  2. Tuli SM. General principles of osteoarticular tuberculosis. Clin Orthop 2002;398:11–9[Medline]
  3. García S, Combalía A, Serra A, Segur JM, Ramón R. Unusual locations of osteoarticular tuberculosis. Arch Orthop Trauma Surg 1977;116:321–3[CrossRef]
  4. Dhillon MS, Nagi ON. Tuberculosis of the foot and ankle. Clin Orthop 2002;398:107–13[Medline]
  5. Rehm-Graves S, Weinstein AJ, Calabrese LH, Cook SA, Boumphrey FR. Tuberculosis of the greater trochanteric bursa. Arthritis Rheum 1983;26:77–81[ISI][Medline]
  6. King AD, Griffith J, Rushton A, Metreweli C. Tuberculosis of the greater trochanter and the trochanteric bursa. J Rheumatol 1998; 25:391–3[ISI][Medline]
Accepted 12 February 2003





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