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CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 50-53

Tubercular arthritis of elbow joint leading to radial nerve palsy: a rare presentation of a common disease


Department of Neurology, VMMC & Safdarjung Hospital, New Delhi, India

Date of Submission19-Jun-2019
Date of Decision10-Dec-2019
Date of Acceptance02-Feb-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Dr. Neera Chaudhry
DM (Neurology), Professor and Head, Room No 814, SSB Building, 8th floor, Department of Neurology, VMMC & Safdarjung Hospital, New Delhi-110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_48_19

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  Abstract 


Tuberculosis of the elbow is a rare manifestation of musculoskeletal tuberculosis, accounting for only 2–5% of total number of cases. Peripheral neuropathy associated with tuberculosis is an even rarer phenomenon with very few cases described in literature, mainly involving either the ulnar nerve or the posterior interosseous nerve. This rarity of occurrence often leads to missed diagnoses. Here we present the case of a gentleman who had presented with tubercular arthritis of the elbow joint leading to radial nerve palsy. The diagnosis was established on the basis of elbow radiographs and Magnetic Resonance Imaging (MRI), nerve conduction studies and tru-cut biopsy of the synovium. The patient showed significant improvement with anti-tuberculous drug therapy.

Keywords: Elbow, neuropathy, tuberculosis


How to cite this article:
Sengupta A, Chaudhry N, Choudhury C, Gyanchandani K. Tubercular arthritis of elbow joint leading to radial nerve palsy: a rare presentation of a common disease. MAMC J Med Sci 2020;6:50-3

How to cite this URL:
Sengupta A, Chaudhry N, Choudhury C, Gyanchandani K. Tubercular arthritis of elbow joint leading to radial nerve palsy: a rare presentation of a common disease. MAMC J Med Sci [serial online] 2020 [cited 2020 May 28];6:50-3. Available from: http://www.mamcjms.in/text.asp?2020/6/1/50/283505




  Introduction Top


Tuberculosis is a worldwide pandemic affecting 200 million people with India accounting for 25% of those cases, skeletal tuberculosis accounting for 1–3% of them and for 10–30% of extrapulmonary tuberculosis cases.[1] Elbow tuberculosis accounts for 2–5% of all skeletal TB.[2] Peripheral neuropathy associated with TB is even rarer. Few cases are reported in literature. We present a case of tubercular arthritis of the elbow joint leading to radial nerve palsy, an extremely uncommon presentation of musculoskeletal tuberculosis.


  Case Report Top


A 74-year old gentleman, known hypertensive, diabetic with coronary artery disease, presented with pain and swelling of the left elbow for 2.5 months and sudden onset wrist and finger drop with difficulty in elbow extension for 1.5 months. There was no history of proximal left upper limb weakness or weakness of hand grip, weakness of any other limb, cranial nerve or bladder bowel involvement, any sensory diminution trauma, fever, rash, pain in other joints, photosensitivity, anorexia or weight loss. His general physical examination as well as general systemic examination was normal. He had left elbow swelling with tenderness around radial head. His range of motion at the elbow was 10–90 degrees with power of 1/5 of wrist and finger extensors [Figure 1]. Deep tendon reflexes were normal except triceps jerk absent on left side. His plantar response was bilaterally flexor with normal sensory examination. He was clinically diagnosed as a case of radial nerve palsy.
Figure 1 Swelling of left elbow with wrist and finger drop.

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Investigations revealed normal leucocyte count with erythrocyte sedimentation rate (ESR) of 16 mm/hour. Rheumatoid factor was negative. Serum uric acid was within normal limits. Chest X-Ray was also normal. Nerve conduction studies showed non-recordable left radial motor response with normal radial sensory response [Figure 2]. X-Ray films of the left elbow showed normal joint space with normal bony alignment with increased soft tissue shadow with osteolytic lesion on medial aspect of radial neck with cortical involvement of ulna, suggestive of infective etiology [Figure 3]. Magnetic Resonance Imaging (MRI) Scan of left elbow joint showed destructive changes and bone marrow edema in capitulum and medial condyle of humerus which was hyperintense on T2 weighted images, along with bone marrow edema in proximal radius and ulna, fluid collection and thickening of synovium, suggestive of tuberculosis [Figure 4]. A tru-cut synovial biopsy showed multiple epithelioid cell granulomas along with Langhans giant cells and foci of caseation necrosis which tested negative on acid fast bacilli smear or Ziehl Neelson staining. The patient was started on anti-tubercular therapy. He showed improvement in elbow swelling and pain with improvement of power at wrist joint to 3/5 after 1.5 months of follow up.
Figure 2 Nerve conduction studies showing non recordable left radial motor response with normal radial sensory response.

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Figure 3 X ray films of the left elbow showing normal joint space with normal bony alignment with increased soft tissue shadow with osteolytic lesion on medial aspect of radial neck with cortical involvement of ulna, suggestive of infective etiology.

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Figure 4 Magnetic Resonance Imaging (MRI) Scan of left elbow joint showing destructive changes and bone marrow edema in capitulum and medial condyle of humerus, which was hyperintense on T2 weighted images, along with bone marrow edema in proximal radius and ulna, fluid collection and thickening of synovium, suggestive of tuberculosis.

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  Discussion Top


Osteoarticular tuberculosis accounts for up to 35% of extrapulmonary cases,[1] often occurring at weight-bearing joints, most commonly the spine, followed by hip and knee.[3] The elbow is the most common joint affected in the upper extremity.

Tuberculosis of the joints is characteristically monoarticular, infrequently multifocal. In the elbow, tuberculosis usually starts in the olecranon and lower end of humerus. The primary disease is rarely limited to the synovium only. The onset is usually insidious, with primary complaint of pain, along with joint swelling, restriction of movements, lymphadenopathy or discharging sinuses.[4] In approximately 50% of patients there is no radiographic evidence of pulmonary involvement. Because of its infrequent occurrence and random symptoms, misdiagnosis and delayed diagnosis often lead to joint deformity, which further affects the limb function.

Musculoskeletal involvement is caused by haematogenous, lymphatic or direct local spread of tubercle bacilli from other lesions from a quiescent pulmonary primary or other extraosseous focus. [2]

Tuberculoma occurs as a solitary space-occupying lesion caused by hematogenous spread of the tuberculosis bacillus. The most common central nervous system (CNS) site for tuberculoma is the cerebellum. Tuberculoma involving a peripheral nerve is extremely rare.[5]

The pathogenesis of tuberculoma involving a peripheral nerve is unclear. Involvement of a peripheral nerve usually occurs secondary to direct infiltration from a tubercular lesion affecting adjacent structures such as a joint, bone, and lymph nodes. Other proposed theories include immune mediated neuropathy, vasculitic neuropathy, compressive neuropathy, a meningitic reaction (radiculopathy as a result of tuberculous meningitis) or secondary to toxic effects of anti-tuberculous drug therapy.[6] In the present case, there appears to be a direct infiltration of the radial nerve from a tubercular lesion affecting adjacent elbow joint as demonstrated radiologically as well as histologically.

The radiological findings are non-specific in the early stages. Harwood-Nash et al described radiographic characteristics of tuberculous arthritis as the “Phemister triad” of juxta-articular osteoporosis, marginal bone erosion and gradual narrowing of joint spaces.[1] MRI features include bone marrow changes indicating either osteomyelitis or bone marrow oedema, chondral and sub-chondral bone erosions, synovial thickening, joint effusions and loss of joint space.[1] T1- and T2-weighted MRI images demonstrate marrow changes as areas of low and high signal intensity, respectively, which are enhanced with administration of intravenous gadolinium contrast De Backer et al. (2006).[7]

Sonography is an alternative to MRI allowing both dynamic studies and bilateral comparisons. Sonographically guided musculoskeletal aspiration and biopsy provide effective diagnosis. The diagnosis is confirmed in all cases by fine needle aspiration cytology from the joint or draining lymph node and by microscopic examination of tissue obtained from sinus track, synovium, or bone.The treatment of tubercular arthritis involves continuous treatment for at least 6 to 9 months with oral antituberculosis medications. With early diagnosis and treatment, approximately 90% to 95% of patients can achieve healing with near normal function.[1] A poor prognosis may be expected when symptoms are long standing or a greater osteoarticular area is involved.

Differential diagnoses of elbow pain include lateral epicondylitis, tuberculous arthritis, pyogenic arthritis, gout, pigmented villonodular synovitis, hemophilic arthropathy, rheumatoid arthritis, and tumors. Tuberculosis arthritis must be considered in case of unexplained swelling of the soft tissue, joint pain, or a poor response to treatment.

In summary, disabilities due to tuberculous arthritis are closely related to the timeliness of diagnosis and treatment. Therefore, early diagnosis is important. Sonographic examination and sonographically guided joint fluid aspiration provide accessible, inexpensive, and radiation-free methods to help with early diagnosis and to allow better recovery of joint functions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ding Y, Wei T, Liu S, Ho S, Liang W, Yang C. Early‐stage tuberculous arthritis of the elbow presenting as lateral epicondylitis. J Ultrasound Med 2008;27:293-297  Back to cited text no. 1
    
2.
Chen WS, Wang CJ, Eng HL. Tuberculous arthritis of the elbow. Int Orthop 1997;21:367-70  Back to cited text no. 2
    
3.
Moore SL, Rafii M. Imaging of musculoskeletal and spinal tuberculosis. Radiol Clin North Am 2001;39:329-42  Back to cited text no. 3
    
4.
Tuli SM. Tuberculosis of the skeletal system, 2nd ed, Jaypee Brothers Medical Publishers, Delhi, 1997, pp 132-40.  Back to cited text no. 4
    
5.
Hasan SA, Prakash VED. Tuberculoma of the ulnar nerve. A new clinical entity. J Int Coll Surg 1964;42:30-4.  Back to cited text no. 5
    
6.
Orrell RW, King RH, Bowler JV, Ginsberg L. Peripheral nerve granuloma in a patient with tuberculosis. J Neurol Neurosurg Psychiatry 2002;73:769-71.  Back to cited text no. 6
    
7.
De Backer AI, Mortelé KJ, Vanhoenacker FM, Parizel PM. Imaging of extraspinal musculoskeletal tuberculosis. Eur J Radiol 2006;57:119-30.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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