TUBERCULOSIS OF PERIPHERAL JOINTS - A DILEMMA IN DIAGNOSIS

15 cases of peripheral joint tuberculosis presenting to a tertiary ref erral hospital are reviewed. The presentation is characterized by an i nsidious onset with a slowly progressive, painful, ankylosed or swolle n monarthropathy with a mean length of history of 6.5 +/- 7 years. The knee joint was involved in 7 patients, hip in 6, elbow and shoulder 1 each. Significant systemic toxicity was absent, the white count was n ormal (mean 7.3 +/- 2.4 x 10(9)/1) and the erythrocyte sedimentation r ate (ESR) was only slightly elevated (mean 31 +/- 23 mm/first h). Feat ures of extra-articular pulmonary tuberculosis mere present in 7 patie nts and periarticular findings were present (abscesses in 7 and sinuse s in 4 patients). Despite a characteristic presentation, the diagnosis was initially missed in 10, leading to delay in instituting correct t reatment. One patient presented with osteoarthritis and a Baker's cyst . Definitive joint arthropathy was present in all patients. The highes t diagnostic yield was with a combination of synovial histology, synov ial fluid culture and direct smear examination for acid fast bacilli ( 14 patients) and lowest if direct smear examination was used alone (2 patients). Chemotherapy with rifampicin and isoniazid alone (3 patient s) or with at least 1 other drug was given for a mean of 15 +/- 5 mont hs. Apart from debridement/drainage surgery, fusion/excision arthropla sty was performed in 6 cases and one had a total knee replacement. A h eightened diagnostic acumen is needed in such cases.