Tuberculous arthropathy

Last revised by Dr Tamsir Rongpipi on 04 Jun 2022

Tuberculous arthropathy is a type of musculoskeletal manifestation of tuberculosis (TB) and a common cause of infectious arthritis in developing countries. Any pathological joint lesion where the exact diagnosis is equivocal should be considered tubercular in origin unless proven otherwise.

Please refer to the main article on tuberculosis for a general and broad discussion of this condition.

Although rare in western countries, tuberculous arthropathy is still a common problem in developing countries. The tubercular arthropathy is never a primary lesion, it is always a sequela of pulmonary or lymph node tuberculosis. It can occur at any age. There is no sex predilection for the disease.

The primary causative organism is mycobacterium tuberculosis; however, atypical mycobacteria i.e. Mycobacterium kansasii,  M. xenopi and M. avium intracellulare are also isolated in immunocompromised individuals.

The organism reaches the bone and remains dormant until recrudescence occurs. Any factor which modifies the state of local resistance and resultant activation of dormant tubercle bacilli, microtrauma has been proposed as a mechanism; however, no case could establish trauma as an etiological factor.

The most common form of articular tuberculosis is spondylitis followed by arthritis of weight bearing joints (especially knee and hip 6). The spine is the most common site, followed by the hip joint, which constitutes approximately 15% of all cases.

Tubercular arthropathy can affect any joint but is frequently reported in the knee, ankle, sacroiliac joint, sternoclavicular joint, shoulder, elbow, and wrist. Tubercular arthropathy is usually monoarticular.

Several types of tuberculosis in the shoulder have been described and are discussed separately in the article shoulder tubercular arthropathy.

Initial acid-fast bacilli smears are often negative. Synovial culture is positive in ~80% of cases 6.

Plain films are reliable for detecting tubercular arthropathy and for follow up of treatment. A triad of radiologic abnormalities (Phemister's triad) includes:

  • peri-articular osteoporosis
  • peripherally located osseous erosion
  • gradual joint space narrowing

Tubercular arthropathy can be divided by radiological features into early and late stages:

  • early stages (stage of synovitis and arthritis) - radiographic features include
  • late stages (stage of erosion and destruction)
    • gradual narrowing of joint space (there is involvement of articular cartilage)
    • severe subchondral erosion and destruction
    • pathological subluxation and dislocation
    • fibrous ankylosis - in contrast to pyogenic arthritis, the development of bone ankylosis is uncommon in tuberculous arthritis and, when present, is more likely to be secondary to prior surgical intervention
    • atrophic changes in bones may occur and lead to atrophic arthropathy (seen in shoulder joint as carries sicca)             

Joint effusion may be the only finding but is non-specific.

CT can establish the degree of bone destruction or, rarely, sequestrum. Extension of infection into surroundings or any sinus tract formation can also be demonstrated on the post-contrast scan.

The lesions are typically: 

  • T1: hyperintense
  • T2: hypointense
  • T1 C+ (Gd): brilliant enhancement

This may be as a result of presence of blood degradation products, inflammation, necrosis and fibrosis, which is seldom seen in other proliferative arthropathies.

MRI can assess associated abnormalities (e.g. osteomyelitis, myositis, cellulitis, periarticular abscess, tenosynovitis, bursitis, skin ulceration or sinus tract formation):

  • sinus tracts appear as a linear T2 hyperintensity with a marginal 'tram track' enhancement
  • periarticular abscesses have a thin, smooth, enhancing wall

A complete course of chemotherapy is the most important therapeutic approach. In advanced cases, surgical treatment is indicated if the deformity is limiting.

Differential diagnosis of tubercular arthropathy may include causes of erosive arthritis, monoarticular arthropathy and arthropathies resulting in ankylosis and joint destruction, such as:

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Cases and figures

  • Case 1: tuberculous arthritis with Phemister triad
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  • Case 2: tuberculosis - sacro-iliac joint
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  • Case 3: tuberculosis affecting the left sternoclavicular joint
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  • Case 4: tuberculosis - sacro-iliac joint
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  • Case 5: tuberculosis - sacro-iliac joint
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  • Case 6: right hip
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  • Case 7: caries sicca
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  • Case 8
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  • Case 9
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  • Case 10
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  • Case 11
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  • Case 12
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  • Case 13: MRI
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