20-41: Tuberculous Arthritis

Infection of peripheral joints by M tuberculosis usually presents as a monoarticular arthritis lasting for weeks to months (or longer), but less often, it can have an acute presentation that mimics septic arthritis. Any joint can be involved (eFigure 20-40); the hip and knee are most commonly affected. Constitutional symptoms and fever are present in only a small number of cases. Tuberculosis also can cause a chronic tenosynovitis of the hand and wrist. Joint destruction occurs far more slowly than in septic arthritis due to pyogenic organisms. Synovial fluid is inflammatory but not to the degree seen in pyogenic infections, with synovial white cell counts in the range of 10,000–20,000 cells/mcL (10–20 × 10⁹/L). Smears of synovial fluid are positive for acid-fast bacilli in a minority of cases; synovial fluid cultures, however, are positive in 80% of cases. Because culture results may take weeks, the diagnostic procedure of choice usually is synovial biopsy, which yields characteristic pathologic findings and positive cultures in greater than 90%. Antimicrobial therapy is the mainstay of treatment. Rarely, a reactive, sterile polyarthritis associated with erythema nodosum (Poncet disease) develops in patients with active pulmonary or extrapulmonary tuberculosis.