Tubercular involvement of the lateral malleolus and adjacent calcaneus: presentation of a rare case and review of the literature

Abstract

Osteoarticular tuberculosis (TB), despite being on the wane in the developed world, stays a problem of significance in the developing world. The issue is compounded by unusual presentations, inadequate diagnostic skills and limited understanding of its management. For foot infections, despite an increased awareness, many patients may be misdiagnosed, with associated treatment delays. A 19-year-old man presented with pain and swelling on lateral aspect of right ankle for 2 months. The patient had an undermined discharging sinus with surrounding induration and the skin adherent to the underlying bone. Patient was diagnosed as a case of ipsilateral TB lateral malleolus and calcaneus, managed with antitubercular drugs with complete resolution at 3 years of follow up. Foot and ankle TB can have atypical presentations causing delay in diagnosis. Contiguous spread of infection occurs through the synovium or the joint; however, extra-articular spread along the tendon sheaths or other soft tissues is possible, which is highlighted by the present case.

Foot and ankle tuberculosis, A Case Report & Review of The Literature

“…Before beginning protracted multimodal medical therapy, prompt cross-sectional imaging and tissue diagnosis are essential; an incomplete diagnosis could result in worse outcomes; rarely is surgical intervention necessary, and it is only done to make a diagnosis (12) . Not very much different to this case, Kumar P et al reported a case of a 19-year-old man came with lateral right ankle pain and edema for two months; the skin was attacked to the underlying bone and had an undermined discharge sinus with surrounding induration; diagnosed as lateral malleolar and calcaneal TB; after receiving treatment with antitubercular medications, the patient's condition completely resolved after three years of follow-up (13) .…”

“…Two weeks postoperatively, the surgical wound heal with no complication. Four weeks post-operatively ESR returned to (13). Six weeks post-operatively, she was weaned from the long walker boot and advised to start physiotherapy for the right ankle.…”

Tuberculosis presenting as arthritis of the ankle: A case report

“… 18 Of foot and ankle involvement with M. tuberculosis , the calcaneum has the highest reported incidence, probably because it is the most vascular bone of the foot, while it is continuously subjected to the stresses as it contacts the ground. 19 Once the bone or the synovium is seeded, the bacilli may progressively infect the tissues or remain dormant to be reactivated when the patient’s immunity is suppressed. 20 If the synovium is seeded first, the lesion gradually evolves to become a pannus and spreads through the articular cartilage to reach the subchondral region.…”

“…5 , 6 The duration of anti-tuberculous treatment for ankle tuberculosis in the previous reports are highly variable ranging from 6 to 18 months. 19 , 31 Prolonged chemotherapy is often justified since osteoarticular tuberculosis, predominantly being paucibacillary with dormant bacilli, hence resistant to anti-tuberculous treatment. 19 , 32 Early diagnosis is a major prognostic determinant of ankle tuberculosis.…”

“… 19 , 31 Prolonged chemotherapy is often justified since osteoarticular tuberculosis, predominantly being paucibacillary with dormant bacilli, hence resistant to anti-tuberculous treatment. 19 , 32 Early diagnosis is a major prognostic determinant of ankle tuberculosis. 33 , 34 The combination of physiotherapy and occupational therapy with the pharmacological management may improve clinical outcomes.…”