Orthopaedic Department of M.K.C.G. Medical. College and Hospital, Berhampur, with chief complaints of fever for preceding 1 month with loss of appetite and a ...
Ind, J, Tub. 2001, 48, 209
Case Report
TUBERCULOSIS OF CALCANEUM: A CASE REPORT B. Swain,S. Mishra, K. Pattnaik, D. Pattnaikand P. Dutta* (Received on 29.5.2001; Accepted on 4..7.2001) Summary : We report a case of calcaneal tuberculosis by a Multi- Drug Resistant (MDR) strain of M tuberculosis in an HIV scronegative male which is a rare occurrence.
INTRODUCTION
The increased incidence of tuberculosis has been accompanied by HIV infection and multi-drug resistance1. Mycobacterium tuberculosis is a leading cause of mo rb id ity and mortality worldwide. Tuberculosis is the leading cause of death due to a single infectious agent. The emergence of multi-drug resistant strains is a major public threat, particularly in vulnerable populations 2 . Extra-pulmonary tuberculosis is more common in HIV seropositive patients 3 . Among extra-pulmonary skeletal tuberculosis cases, tuberculosis of spine is one of the most common forms of the disease. According to sites of predilection, involvement of foot comes after spine, hip and knee, sequentially4. In foot, the lesion involves calcaneum, talus, 1st metatarsal and navicular bones in order of decreasing frequency5. D e v e l o p me n t of p r i m a r y d r u g resistance in tuberculosis is a result of spontaneous mutation of mycobacteria by the action of a single drug or inadequate treatment6.
treatment with first line drugs, there was recurrence of pleural effusion after 10 months. He was febrile, anaemic (mild) without lymphadenopathy. Except for raised ESR of 112 mm in l st hr. (Westerngren), the routine haemogram showed no abnormality. Mantoux test showed 14 mm induration with 5 T.U. Sickling test was negative. ELISA test for HIV antibody was also negative. X-ray of right foot showed an osteolytic lesion in the calcaneum (Fig. 1). FNAC of the swelling revealed tuberculous lesion of right calcaneum. Curetted material from the lesion was sent to the Department of Microbiology for culture and sensitivity, both for M. tuberculosis and for other non-tubercular bacteria. There was growth of M tuberculosis on L.J. medium after 4 weeks. The growth was confirmed by Z-N staining and other
CASE REPORT
A 26 year old male was hospitalized in Orthopaedic Department of M.K.C.G. Medical College and Hospital, Berhampur, with chief complaints of fever for preceding 1 month with loss of appetite and a painful swelling over right heel for the last 2 months. About 3 years back, he had pyrexia of unknown origin (PUO) for three months followed by pleural effusion on left side. In spite of Fig. 1: X-ray of right foot showing an csteolytic lesion in the calcaneum thoracocentesis and adequate anti-tuberculosis Departments of Microbiology and TB & Chest Diseases*, M K C G Medical College, Berhampur Correspondence : Dr .B. Swam, Department of Microbiology, M K C G Medical College, Behrampur- 760 004
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standard biochemical tests7. The strain was found essential for prevention of dissemination and to be resistant to INH, Rifampicin, Streptomycin, emergence of multi-drug resistance. Cycloserine, Thioacetazone and sensitive to Amikacin, Kanamycin, Ethionamide, PAS and REFERENCES Sparfloxacin. The patient was treated with reserve drugs. There was excellent improvement both symptomatically and radiologically.
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DISCUSSION 3.
Tuberculosis is a systemic disease with single or multiple local manifestations. The primary focus may be active or quiescent. In most countries, the primary drug resistance in patients without prior chemotherapy is generally low. This particular case, most probably, was harbouring the MDR strain of M. tuberculosis to start with. Usually, pulmonary tuberculosis patients being treated irregularly and inadequately may develop drug resistant tuberculosis but extra-pulmonary osseous involvement with an MDR strain of M. tuberculosis is extremely rare. Adequate, sustained therapy with sensitive drugs is
4.
Morrissy RT. In : Lovell and Winters . Paediatric Orthopaedics. 4th Ed. Morrissy Raymond T and Weinstein S.LEds. (Lippincott-Raven, Philadephia) 1996 ; Vol. 1. 579. WHO Manual on Antimicrobial Resistance and susceptibility testing (World Health Organisation, Geneva). 1997 : 55 Gilliam Dean, Peter Alderman. An unusual presentation of tuberculosis, Tropical Doctor 1997 ; 27 : 185 Rao KM. In Text Book of Tuberculosis. 2nd Edn. (Revised), (Vikas Publishing House Pvt. Ltd. New Delhi, 1981, 408
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Tuli SM. In: Tuberculosis of the Skeletal system (Bones, Joints, Spine and Bursal Sheaths). 2nd Edn, Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, 1997 ; 115
6.
Paramasivan CN. An overview of drug resistant TB in India. Lung India 1998 ; 16 : 21 Watt B, Rayner A, Harris G. In: Mackie and Me Cartney Practical Medical Mocrobiology. 14th Edn. Collee JG, Andrew OF, Marmion BP, Simmons A. Eds. (Churchill Livingstone, New York). 1996 ; 329
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