I51. Chronic Bacterial and Fungal Arthritides

Abstract

The review will include risk factors, clinical features and management of musculoskeletal complications of tuberculosis, brucellosis and some fungal infections seen more commonly in the tropics. Because of the rarity of these chronic musculoskeletal infections, diagnosis can be challenging and is often overlooked unless the clinician has a high index of suspicion. The incidence of most of these conditions is declining, except for tuberculosis, which is the most common infective cause of death in tropical African countries and where it occurs commonly in association with underlying HIV infection. Immunocompromised individuals and lupus patients are at particular risk of developing extrapulmonary tuberculosis, of which osteoarticular tuberculosis is a rare form. The disease presents mainly as a spondylitis but occasionally as a peripheral joint monoarthritis. Spinal tuberculosis is a consequence of tuberculous granuloma causing progressive erosion and destruction of thoracolumbar vertebral bodies and adjacent intervertebral discs, and is often associated paraspinal muscle abscess formation. The clinical presentation varies from localized back pain in early disease to marked spinal deformity (gibbus spine) and paraplegia in late disease. Peripheral joint presents typically as a chronic monoarthritis. Brucellosis is a zoonosis that is seen mainly in people who consume unpasteurized milk and milk products, but also in livestock farmers, veterinarians and slaughterhouse, seen especially in the Middle East. Musculoskeletal manifestations are common and vary from arthralgia/arthritis, spondylitis and sacroiliitis (mostly unilateral). Fungal infections affecting the musculoskeletal system are extremely rare and occur mainly in the context of an immunocompromised host. The most common fungal infections are histoplasmosis, sporotrichosis and actinomycotic mycetoma (Madura foot). In all of these chronic infections, the causative organism is rarely isolated on culture of the synovial fluid or pus from an abscess. Histology of the affected tissue is more helpful. In the case of tuberculosis, the recent development of the GeneXpert MTB/RIF assay, a fully rapid automated molecular diagnostic test for the diagnosis of pulmonary tuberculosis, is of limited value in the diagnosis of extrapulmonary tuberculosis. Appropriate antimicrobial therapy is indicated in all chronic musculoskeletal infections cases. Surgical intervention is rarely indicated, mainly in patients with severe spinal disease.