1. Outline Epidemiology Presentation Investigations Optimal management

2. Tuberculosis notifications by site of disease (pulmonary/non-pulmonary), England and Wales, 1982- 2009

3. TB - Epidemiology Rising prevalence nationally and locally Traditionally mostly pulmonary TB – 60% –40% extra-pulmonary TB Increasing proportion of EPTB (50%) 10% of EPTB are joint TB

4. Joint TB - presentation Presentation is often insidious and atypical Can be sub-acute and therefore there can be a delay in diagnosis Painful joints may precede systemic symptoms by several weeks Sometimes is the tip of the iceberg of a multi-focal TB

5. Joint TB - presentation Early –Usually a single joint –Painful –No swelling or deformity Later joints may become warm and swollen Sometimes they have a fever Look for other symptoms eg cough

6. Coventry TB rate by year 1999-2006 Rate per 100,000 population 0 5 10 15 20 25 30 35 19992000200120022003200420052006 rate Coventry PCT West Midlands England & Wales Linear (Coventry PCT) Coventry 2007 Courtesy Dr Gee

7. Figure 4. Tuberculosis case reports and rates by age group and place of birth, UK, 2008

8. Tuberculosis case reports and rates by place of birth and ethnic group, UK, 2008

9. World health organisation

10. Three-year average tuberculosis case rates by primary care organisation, UK, 2006-2008

11. Joint TB -presentation Ask about previous TB/contact history –But absence does not rule out TB or make it unlikely Ethnicity is important Think osteo-articular TB … Have a high index of suspicion.. –In a young patient with a single chronic painful joint and from an area of high background incidence of TB

12. TB Beware of the young patient (from an area of high incidence) with backache that doesn’t go away Must also consider the diagnosis in pregnant ladies

13. Joint TB - Investigations Plain x-rays often normal MRI can be helpful in diagnosis 1 –But there needs to be a high index of suspicion to request this Aspiration of synovial fluid for TB culture Synovial biopsy –ie tissue for TB culture should sent in saline or water –Higher yield 2 1.Desai.J Bone Joint surg Br.1994 2. osteoarticular TB in a general hospital in the last decade.ruiz.clin microbiol infect.2003

14. Joint TB - Management Standard quadruple therapy* Rifampicin Isoniazid Pyrazinamide Ethambutol *short course chemotherapy for spinal Tb.parthasarathy. journal of bone and joint surgery.1999

15. How long for?

16. Joint TB - management Usually 6 months is standard No controlled trials for peripheral joint TB 6 months? 12 months? Do they require surgery?

17. Joint TB - management 1 A multicentre MRC study of spinal tuberculosis suggests good results can be achieved with 6-9 months of treatment and this is currently the recommendation of The British Thoracic Society Guidelines/NICE 1.Fourteenth report of the Medical Research Council Working Party on Tuberculosis of the Spine. Int Orthop. 1999; 23(2): 73-81

18. Outcome at 5 years OutcomeHong Kong Surgery+6HRs No % Hong Kong Surgery+9HRs No % Madras Surgery+6HR No % Madras 6HR No % Madras 9HR No % Favourable 23 9625 9672 8875 9184 98 Unfavourable 1 4 10 97 82 Total242682 86

19. Joint TB - management Even quite extensive joint disease with severe radiographic changes can resolve with medical treatment alone

20. Joint TB - management However, if treatment is delayed, there can be considerable loss of function and a requirement for extensive surgical intervention.

21. Key messages Peripheral joint tuberculosis should be considered in any patient with chronic joint pain and particularly if there is swelling present and especially if the patient is from an ethnic group with a high background incidence of tuberculosis. Biopsy and culture is important to identify MDR- TB Chemotherapy is sufficient in many cases and surgery is helpful in selected cases

22. Supplementary slides

23. Short course chemotherapy MRC working party on TB of spine 3 countries: Hong Kong, India and Korea 3 randomised trials 5 year assessment International Orthopaedics 1999 23 : 73-81

24. Short course chemotherapy Comparison of …. –Hong Kong radical resection +6HRS –Ambulant therapy 6HR (medical) –Ambulant therapy 9HR (medical)

25. International Orthopaedics 1999 23 : 73-81 Short course chemotherapy Outcomes –Unfavourable outcome –Favourable outcome (full functional activity, radiologically quiescent, no myelopathy with functional impairment, modification of therapy)

26. Therapy Medical therapy usually sufficient Surgery in selected cases (cord compression, progressive neurology, marked kyphosis) 6(-9) months therapy –2HRZE+ 4HR

27. Indications for surgery patients aged less than 15 years, in whom the initial angle of kyphosis is more than 30º patients started on ambulant chemotherapy who develop progressive kyphosis

28. Indications for surgery children aged less than ten years with destruction of vertebral bodies who have partial or no fusion even during programme patients with compression of the spinal cord in whom the neurological status deteriorates in spite of chemotherapy