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Arthritis, Tuberculous

For further information, see CMDT Part 20-41: Tuberculous Arthritis

Key Features

  • Infection of peripheral joints by M tuberculosis usually presents as a monoarticular arthritis lasting for weeks to months (or longer)

  • Less often, it can have an acute presentation that mimics septic arthritis

  • Any joint can be involved; the hip and knee are most commonly affected

Clinical Findings

  • Constitutional symptoms and fever are present in only a small number of cases

  • Can cause a chronic tenosynovitis of the hand and wrist

  • Joint destruction occurs far more slowly than in septic arthritis due to pyogenic organisms

  • Rarely, patients with active pulmonary or extrapulmonary tuberculous develop a reactive, sterile polyarthritis associated with erythema nodosum (Poncet disease)

Diagnosis

  • Synovial fluid is inflammatory, 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

  • Synovial biopsy is diagnostic procedure of choice; it yields characteristic pathologic findings and positive cultures in > 90%

Treatment

Table 9–14.Characteristics of antituberculous medications.
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Table 9–14. Characteristics of antituberculous medications.
Medication Most Common Side Effects Tests for Side Effects Drug Interactions Remarks
Isoniazid Peripheral neuropathy, hepatitis, rash, mild CNS effects. AST and ALT; neurologic examination. Phenytoin (synergistic); disulfiram. Bactericidal to both extracellular and intracellular organisms. Pyridoxine, 25–50 mg orally daily, is given as prophylaxis for neuropathy; 50–100 mg orally daily as treatment for it.
Rifampin Hepatitis, fever, rash, flu-like illness, GI upset, bleeding problems, kidney failure. CBC, platelets, AST and ALT. Rifampin inhibits the effect of oral contraceptives, quinidine, corticosteroids, warfarin, methadone, digoxin, oral hypoglycemics; aminosalicylic acid may interfere with absorption of rifampin. Significant interactions with protease inhibitors and nonnucleoside reverse transcriptase inhibitors. Bactericidal to all populations of organisms. Colors urine and other body secretions orange. May discolor contact lenses.
Rifapentine Bone marrow suppression, hematuria/pyuria, hepatitis, GI upset, flu-like illness. CBC, platelets, AST and ALT. Strong cytochrome P450 inducer with multiple drug interactions. Use in HIV patients receiving antiretroviral therapy should be limited to experts in antiretroviral therapy. Bactericidal to both extracellular and intracellular organisms. Colors urine and other body secretions orange. Long half-life, can be administered weekly in LTBI prophylaxis. Not for use in induction phase of therapy.
Pyrazinamide Hyperuricemia, hepatotoxicity, rash, GI upset, joint aches. Uric acid, AST, ALT. Rare. Bactericidal to intracellular organisms.
Ethambutol Optic neuritis (reversible with discontinuance of drug; rare at 15 mg/kg); rash. Red-green color discrimination and visual acuity. Rare. Bacteriostatic to both intracellular and extracellular organisms. Mainly used to inhibit development of resistant mutants. Use with caution in kidney disease or when ophthalmologic ...

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