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Spectrum of imaging findings in osteoarticular tuberculosis
Egyptian Journal of Radiology and Nuclear Medicine volume 55, Article number: 23 (2024)
Abstract
Background
Tuberculosis (TB) is still a major public health problem. It is endemic in most of the developing countries. Osteoarticular tuberculosis is an uncommon infection, and its diagnosis is often missed due to non-specific clinical and imaging findings.
Main body of abstract
The diagnosis of osteoarticular TB is often delayed due to non-specific clinical presentation and often mimics with other infectious/inflammatory disorders. However, as the disease is curable, prompt diagnosis and early initiation of treatment remain critical to prevent the development of deformity and bone destruction. MRI is sensitive in early detection of articular and marrow abnormalities, detecting complications and assessing response to treatment.
In this review, we describe the spectrum of various MR imaging findings of osteoarticular TB, which helps in early diagnosis and differentiating these from other pathologies with similar imaging appearances. These are described through case-based illustrations of different anatomical locations of osteoarticular TB.
Short conclusion
MR imaging is the emerging modality of choice for early diagnosis of osteoarticular tuberculosis and helps to differentiate it from other infective/inflammatory diseases.
Background
Tuberculosis (TB) can involve pulmonary as well as extra pulmonary sites. Osteoarticular TB accounts for 1–3% cases of all tuberculous infections [1]. Tubercular spondylitis constitutes almost 50% of cases, followed by tubercular arthritis mainly involving peripheral joints in 30% of cases, tubercular osteomyelitis in 19% and remaining 1% which includes tenosynovitis, bursitis and Poncet’s disease. [2, 3]
Osteoarticular tuberculosis is increasing in incidence especially in developing countries due to the AIDS epidemic, emergence of multi-drug-resistant strains of Mycobacterium tuberculosis and growing number of immunocompromised patients [4, 5]. Osteoarticular TB results from hematogenous dissemination of mycobacteria from primary/reactivated focus of infection [6]. Among the various imaging modalities including conventional radiography, ultrasonography, computed tomography and bone scan, MRI is the modality of choice because of its multiplanar capability and excellent soft tissue contrast, which helps in early detection of changes in bones and joints including bone marrow oedema, synovial proliferation, bone and cartilage destruction and soft tissue abnormalities. [7]
In this article, we have described the various patterns of osteoarticular TB and their imaging features on MRI through case-based illustrations. Certain imaging features which point to the diagnosis of TB have been described, and key imaging features which aid in diagnosis and choosing the correct differentials have been highlighted.
Main text
Classification of osteoarticular TB based on anatomical location
Tubercular spondylitis
Spinal TB or Pott’s spine is the most common type of osteoarticular TB. It can occur secondary to pulmonary or abdominal TB and rarely occur as the primary manifestation.
Presentation: Clinical presentation is usually non-specific, but the patients my present with constitutional symptoms, backache, spinal deformity and tenderness among others.
Location: Most common sites of spinal TB are lower thoracic spine followed by lumbar and cervical spine. Involvement of cervical vertebrae (3–5%) and atlantoaxial joint (1%) are less common. Tubercular spondylitis commonly affects two or more contiguous vertebrae; however, skip lesions (4–10%) and single vertebral involvement may occur.
Patterns of vertebral TB: According to anatomical location, vertebral TB is subclassified as paradiscal, anterior, central and posterior arch lesions [8] (Fig. 1).
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Paradiscal involvement of vertebral end plates adjacent to intervertebral disc and with later disc involvement (Fig. 2).
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Anterior-anterior subperiosteal lesion under anterior longitudinal ligament, involved multiple contiguous vertebrae (Fig. 3).
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Central-single vertebral involvement with preservation of adjacent disc spaces (Fig. 4).
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Posterior/appendiceal-isolated involvement of posterior elements of vertebrae (Fig. 5).
There is no single test available for diagnosis of TB. Combined approach using clinical and demographic history, radiological imaging and microbiological and histopathological investigations are required to reach the final diagnosis. Microbiological culture remains the gold standard test for diagnosis of TB. However, culture results are only available after 6–8 weeks which results in delay in the initiation of treatment.
Radiological imaging
Plane radiography Radiographs are usually the first investigation obtained in patients with suspected TB, but in early stage of disease, radiographs may appear normal. For any radiolucent lesion to be apparent on radiograph, there should be at least 30% loss of bone minerals. [9]
Ultrasonography Ultrasonography although non-specific helps in the assessment of soft tissue abscesses and guidance for drainage.
Computed tomography (CT) scan CT scan is particularly useful for the assessment of degree of bone destruction and presence of sequestrum. Some skeletal location of osteoarticular TB including craniovertebral junction, posterior element of vertebra, ribs, sternum and sacroiliac joints that are not clearly visible on radiographs can be better evaluated by CT scan. [11]
A CT-guided biopsy of lesion in bone/joint is most commonly used method for microbiological and histopathological diagnostic work-up. [12]
MRI characteristics of tubercular spondylodiscitis
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Bone marrow oedema shows high signal intensity on T2 WI and STIR images.
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Vertebral lesions appear hypointense on T1WI and hyperintense on T2WI and shows heterogenous post-contrast enhancement (Figs. 2, 3, 4, and 5)
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Intervertebral disc involvement appears hypointense on T1WI and hyperintense on T2WI and will show heterogeneous post-contrast enhancement (Fig. 6).
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Pre, paravertebral and psoas abscess appear as heterogenous collections with peripheral enhancement on post-contrast images with central non-enhancing hypointense area. The location and extent of these abscesses can be best demonstrated on post-contrast T1WI images (Figs. 2, 3, and 4).
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These granulation tissues and epidural abscesses cause narrowing of the thecal sac and compression of the spinal cord resulting in neurological complications [13] (Figs. 3, 4, 5, 6)
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Tubercular granulomas and meningeal thickening and enhancement the better appreciated on post-contrast T1WI (Fig. 6).
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Rare sites including craniovertebral junction lesions and skip lesion are also better evaluated with MRI (Fig. 7).
Key imaging features suggestive of TB versus other infectious aetiologies include.
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More than one vertebra involved
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Relative sparing of intervertebral disc
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Large paravertebral abscesses
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Subligamentous spread
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Heterogenous signal intensity on MRI
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Rim enhancement pattern of MRI. [14]
Tubercular arthritis
Tubercular arthritis is most common site for extra-axial osteoarticular TB.
Presentation Slowly progressive joint pain and boggy swelling are the most common presentation. In advanced stage of disease, ankylosis may occur. Clinically, tubercular arthritis mimics gout or juvenile arthritis, resulting in delay and confusion in diagnosis. [15]
Location Tuberculous arthritis is usually monoarticular (90%).
Common- Large weight bearing joints, such as knee, hip joint and sacroiliac joint.
Less common-. Shoulder, ankle, elbow and wrist joints (1% each).
Rare- Small joints of hands, feet, acromioclavicular and sternoclavicular joints.
Radiological imaging
Plain radiograph Juxta-articular osteopenia, bone erosions and gradual narrowing of joint space are typical. Phemister triad is characteristic feature of tubercular arthritis, described by Phemister (Figs. 10, 11, 12, 13, 14).
Ultrasonography Ultrasonography can be useful in the detection of joint effusion in cases of tubercular arthritis and soft tissue abscess, psoas abscess associated with other forms of osteoarticular TB; however, it is non-specific.
Computed tomography CT scan is much better in the detection and characterization of lytic and sclerotic bone lesions and destruction of bony circumference compared to plane radiographs. It provides better delineation of shape and calcification of the soft tissue abscesses.
MRI findings in tubercular arthritis:
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1.
Bone and cartilage changes:
Bone marrow oedema or osteomyelitis associated with tubercular arthritis is the characteristic appearance of marrow oedema on T2/STIR images with variable amount of enhancement on post-contrast images (Figs. 8, 9, 10, 11, 12, 13, 14, 15).
Necrotic areas of bone will appear low signal intensity areas on both T1- and T2-weighted images (Figs. 8, 9).
Destruction of articular cartilage and cortical bone can be visualized as defect in the hypointense cortical rim [16] (Figs. 8, 9, 10, 11, 12).
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2.
Synovial changes Synovial inflammation can present as articular synovitis, bursal synovitis and tendon sheath synovitis.
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Synovitis usually results in joint effusion, which is often the earliest imaging feature and appears as high signal intensity on T2WI (Figs. 8, 9, 10).
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Synovial proliferation associated with TB arthritis is typically hypointense to intermediate signal intensity on T2WI and shows enhancement on post-contrast T1WI (Figs. 8, 9 and 12,13).
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Granulation tissue, synovial and capsular thickening and cartilage destruction are also seen in tubercular arthritis. Articular lesions appear with low or intermediate signal intensity on T2WI [17] (Fig. 11).
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Low signal intensity areas on T2WI correspond to fibrosis, sclerosis, new bone formation and intra-articular loose bodies [18] (Fig. 8, 9 and 11).
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Involvement of tendons, tendon sheaths and bursae adjacent to joint result in tubercular synovitis and bursitis which appear as high signal intensity synovial effusion on T2WI with tendon sheath thickening [19] (Fig. 10 and 12).
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3.
Juxta-articular soft tissue changes
Inflammation of soft tissue adjacent to joint results in cellulitis, which can be visualize as high signal intensity on T2WI with post-contrast enhancement (Figs. 8, 9, 10, 11, 12, 13, 14).
Myositis usually shows enlargement of muscles with high signal intensity on STIR and T2WI and variable post-contrast enhancement.
Granulation tissues within soft tissues show homogenous enhancement (Fig. 9) while abscesses demonstrate intermediate/high signal on T2WI with peripheral rim enhancement on post-contrast images [20] (Figs. 8 and 12).
Key imaging features
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Unilateral joint involvement with large soft tissue abscess/collection favour tubercular ?y.
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Late joint space reduction with end stage fibrous ankylosis are typical features of joint TB.
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Tubercular abscesses show a smooth and thin enhancing rim at periphery while pyogenic abscesses usually show a thick and irregular peripheral rim enhancement [21].
Tubercular osteomyelitis
Presentation Pain and swelling adjacent to affected bone is commonly seen. Abscess, discharging sinus tracts may be seen in later course of disease.
Tubercular osteomyelitis of rib usually presents with chest wall cold abscess.
Location TB can affect any bone. Metaphysis is most commonly involved location for TB osteomyelitis Lesions can be solitary or multifocal.
Commonly involved sites- small bones of hands and feet and long bones of extremities.
A subtype of TB osteomyelitis is cystic tuberculosis, commonly seen in children and young adults. It usually affects the metaphysis of long bones and often skull and flat bones may be involved [22, 23].
Radiological imaging
Plain radiograph Osteomyelitis appears as diffuse osteoporosis, lytic lesion, sclerosis and periostitis. Bone sequestrum can be seen as radio-dense spicules within area of bone destruction. Osteomyelitis is often confused with malignancy on plane radiographs [10] (Figs. 15, 16).
MR imaging features of TB osteomyelitis
Magnetic resonance imaging in tubercular osteomyelitis include T1-weighted images for better anatomical detail and delineation of medulla, cortex, periosteum and soft tissue.
Fat-suppressed and STIR sequences are better for visualization of inflammatory changes and fluid collections.
Post-contrast T1W images are obtained after administration of gadolinium-based contrast agent in suspected cases of osteomyelitis, for better characterization of abscesses and sinus tracts (Table 1).
MR imaging features of tubercular osteomyelitis are non-specific and unfortunately not useful in differentiation from pyogenic osteomyelitis.
Tubercular dactylitis affects short tubular bones of hands and feet (metacarpal, metatarsal and phalanges). Infective foci first lodge in centre and interior of short tubular bone, forming tubercular granuloma. This leads to spindle-shaped expansion of the bone (spina ventosa). Abscesses and sinus tract formation can occur secondarily leading to secondary infection and thickening of bone [25] (Fig. 16).
Tubercular tenosynovitis and bursitis
Primary tubercular tenosynovitis is rarest manifestation of osteoarticular tuberculosis. Tubercular tenosynovitis may either occur as a result of hematogenous dissemination or due to periarticular extension of tubercular arthritis (Table 2).
Clinical presentation
Common presenting feature of tubercular synovitis is carpal tunnel syndrome. This is secondary to compression of median nerve under flexor retinaculum by thick and inflamed tendon sheath. Symptoms include wrist pain, numbness and tingling sensation in fingers with decreased range of motion.
Location
Tenosynovitis- Flexor tendon sheaths of the dominant hand.
Bursitis- Trochanteric, subacromial, subgluteal and radioulnar bursae.
Tubercular synovitis can present with various forms including-
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1.
Hygromatous stage-characterized by the presence of fluid within the tendon sheath without associated synovial thickening.
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2.
Serofibrinous stage-characterized by thickening of flexor tendons and synovium with multiple tiny debris (rice bodies) within the synovial fluid.
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3.
Fungoid stage-characterized by soft tissue mass involving the tendon and tendon sheath [26].
Radiological Imaging
Ultrasonography: Ultrasound is usually the primary investigation for diagnosis of tenosynovitis. It can delineate the extent and degree of involvement of the tendon and tendon sheath. Tendon and synovial thickening are predominant features seen on ultrasound with minimal effusion [27].
MR imaging features of tenosynovitis and bursitis
Tenosynovitis
Tubercular tenosynovitis mimics various non-infective inflammatory disorders such as rheumatoid arthritis, seronegative arthritis, pigmented villonodular synovitis among others (Table 3).
The characteristic MR imaging features favouring the diagnosis of tubercular aetiology include presence of low signal intensity synovial thickening on T2 WI around the flexor and extensor tendons and synovial fluid collection with low signal intensity non-enhancing foci within the tendon sheath (Fig. 11).
Additional changes such as bone erosions, osteomyelitis and median nerve encasement in wrist are also frequently seen [28].
Bursitis
Tuberculosis of bursa usually occurs in association with tubercular arthritis and osteomyelitis. It may exhibit two patterns—distension of bursa with fluid collection and multiple small abscesses [29].
On MR imaging, T2 WI images show intermediate signal intensity in area of caseous necrosis, high signal intensity correlates with effusion and low signal intensity in areas of fibrosis, sclerosis, new bone formation and intra-articular loose bodies. On T1 WI involving bursa sometimes can appear as a hyperintense lining (Fig. 8).
Conclusions
Radiologists should be aware of imaging features suggestive of osteoarticular tuberculosis and its potential mimics as MR is the emerging modality of choice for evaluation of suspected cases even in early stages of disease. This is imperative to early diagnosis and management at early-stage disease and thereby reducing complications.
Availability of data and materials
Not applicable.
Abbreviations
- TB:
-
Tuberculosis
- MRI:
-
Magnetic resonance imaging
- OATB:
-
Osteoarticular tuberculosis
- HIV/AIDS:
-
Human immunodeficiency virus/acquired immunodeficiency syndrome
- OM:
-
Osteomyelitis
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Dr. A.S. performed clinical evaluation and management part of all cases. Dr. R.J. analysed and interpretated all radiological imaging investigations under supervision of Dr. R.S.S. and Dr. V.C., and these are the major contributor in writing manuscript. Dr. R.K. provide data related to microbiological testing. All authors have read and approved the manuscript.
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Jangid, R., Solanki, R.S., Chaudhary, V. et al. Spectrum of imaging findings in osteoarticular tuberculosis. Egypt J Radiol Nucl Med 55, 23 (2024). https://doi.org/10.1186/s43055-024-01191-5
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DOI: https://doi.org/10.1186/s43055-024-01191-5