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Surg Technol Int. Author manuscript; available in PMC 2019 March 01.
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Published in final edited form as:

Surg Technol Int. 2017 December 22; 31: 273–275.

Primary Septic Arthritis of The Knee due to Mycobacterium

Tuberculosis in a Previously Healthy Child
Samuel Rosas, MD [Resident Physician Scientist],
Department of Orthopedics, Wake Forest School of Medicine, Winston-Salem, North Carolina

Daniel Rosas, BS [Senior Medical Student],

Universidad CES Medical School, Universidad CES, Medellín, Antioquia, Colombia
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Valentina Múnera Orozco, MD [Attending Physician],

Emergency Room Department, Universidad CES, Medellín, Antioquia, Colombia

Manuela Parra Cardona, MD [Attending Physician],

Emergency Room Department, Universidad UPB, Medellín, Antioquia, Colombia

Chukwuweike Gwam, MD [Research Fellow], and

Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinal
Hospital of Baltimore, Baltimore, Maryland

Simon Pedro Aristizabal, MD [Attending Orthopaedic Surgeon]

Department of Orthopedics, Universidad CES, Medellín, Antioquia, Colombia
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Abstract
Pediatric septic arthritis can be a devastating disease. Often, the diagnosis can be challenging as
autoimmune and infectious causes may present in a similar fashion. Thus, we present the case of a
five-year-old male patient, from the Pacific coast of Colombia, with chronic morning knee pain
and stiffness thought to be caused by an autoimmune disease. He presented with a mild effusion of
the left knee, a flexed posture, and limited extension to 25°. Inflammatory markers demonstrated
an infectious pattern. Autoimmune markers were negative. A diagnostic arthrotomy and lavage
was conducted followed by microbial cultures, cell count, and gram staining. Polymerase chain
reaction (PCR) of the joint fluid demonstrated mycobacterium tuberculosis. The patient was
treated according to the national protocols and continued on to complete resolution.

Infectious arthritis with m. tuberculosis may present in a chronic indwelling fashion with mildly
elevated reactants in immunocompetent, previously healthy children even without any risk factors.
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INFORMED CONSENT STATEMENT

The patients mother/legal guardian agreed to the sharing of the patient’s case for educational purposes. This consent was obtained in
the native language of the mother by two of the attending physicians (VM and MC). Imaging and test results were de-identified
through the EMR system prior to submission of this article.
AUTHORS’ DISCLOSURES
The authors have no conflicts of interest to disclose.
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INTRODUCTION
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New onset arthritis of the knee in a pediatric patient warrants great attention as it may lead
to potential life-long consequences.1-3 Possible etiologies include infections, trauma,
rheumathoid, and oncologic among others.3-6 The patients history in concordance with the
physical exam and laboratory and imaging tests may aid to diagnose the patient in a timely
manner, but often overlap between the test results and an unspecific history prevent the
diagnosis from being made in a timely fashion.5, 7-10 The incidence of this entity has been
reported to range from 1 in 100,000 in well-developed nations compared to 1 in 5000 for
developing countries.1, 11

CASE PRESENTATION
A 16-month old male child was referred to a tertiary care center in Medellin, Colombia due
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to chronic loss of left knee extension and occasional fevers. The orthopedic department was
consulted as the child presented with a clinical scenario of morning fevers, left knee edema,
and loss of knee extension. The patient also experienced limping that improved throughout
the day which had been present for a month. The patient had been previously healthy,
completed the national vaccination plan, and denied a family history of diseases, personal
history of trauma, surgery, and or any sick contacts. The child had a normal birth weight and
length and had achieved all pediatric milestones for his age.

Upon physical examination, the patient presented with a normal cardiovascular, respiratory,
and neurologic exam except for moderate swelling of the left knee, with a tendency to
maintain it in flexion, with extension limited to 25°, and slight warmth, but no pain, upon
palpation was noted. The distal neurovascular exam had normal pulses and sensation.
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Laboratory examinations revealed hemoglobin of 11.3 mg/dl, hematocrit of 34%,

rheumatoid factor of 8.6, 14,100 leukocytes/mm2 with 30% neutrophils, and 60%
lymphocytes. The erythrocyte sedimentation rate (ESR) was 43 mm/hour with a C-reactive
protein of 0.8 mg/dl. Given the increased morning gait disturbance, which improved
throughout the day, a decision to further investigate for possible rheumatologic causes was
made. Complement levels and antinuclear antibodies (ANAs) were normal and an
ophthalmologic consult revealed no uveitis.

Anterior to posterior and lateral x-rays of both knees revealed no signs of infection, trauma,
or other complications (Fig. 1). A knee ultrasound revealed slight knee effusion observed at
the peri-articular bursas, without a clear inflammatory process or tumor. The soft tissues
were deemed as normal.
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The decision was made for an arthrotomy with incision and lavage with cultures, gram
stains, biopsy, and PCR for mycobacteria. During the arthrotomy, no pus was seen and only
5cc of yellowish fluid could be extracted. The synovial tissues appeared normal and no other
findings were apparent. The purulent discharge was sent for culture for aerobes, anaerobes,
mycobacteria, and PCR for tuberculosis.

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The mycobacterial PCR revealed a positive m. tuberculosis infection with a negative rpoB
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gen. At that time, a chest x-ray (CXR) and a Mantoux test (also known as purified protein
derivative [PPD]) were obtained to rule out extra-skeletal TB. The CXR was read as negative
for active or past tuberculosis, and the PPD was read as positive 48 hours after application.

The patient was treated according to the national protocolos from the Colombian Ministry of
Health for extrapulmonary tuberculosis with isoniazid (9.8mg/Kg/day), rifampin (13mg/Kg/
day), ethambutol (24mg/Kg/day), pyrazinamide (35mg/Kg/day), and pyridoxine (10mg/day)
for six months.

At the six-week follow up, the patient had improved gait with near normal extension limited
to 10°. He continued therapy and follow-up was completed at three months and six months.
At the latest six month follow-up, the patient had complete restoration of function, with
normal gait, no clinical leg length discrepancy, complete range of motion, and normal 5/5
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strength.

DISCUSSION
Tuberculosis infections are a common cause of morbidity and mortality—mostly in
developing countries.2,312 Tuberculosis (TB) may mimic other diseases, making diagnosis
difficult, especially in children, as it often presents as extra-pulmonary TB compared to
adults, which most commonly presents as pulmonary TB.3,4,12-14

Skeletal TB is most commonly seen in older pediatric patients, including teenagers.8 This
form of presentation is not common and rarely presents in the immuno-competent host.
Patients who have skeletal TB are at a greater risk of concurrently presenting with
pulmonary TB.15,16 The most common locations of infection in skeletal TB are spondylitis,
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arthritis, and osteomyelitis.7,12,14,17 The finding of isolated intra-articular pathology, as seen

in this case, is rare, especially for the age group of this patient, as other articles have
reported older patients presenting with these symptoms.7,10,15-19

The origin of this infection can be caused by direct inoculation of the microbe into the joint
or secondarily as an aseptic reactive arthritis, which is usually related to extra-pulmonary
tuberculosis and, thus, it is suggested that patients with a diagnosis of skeletal TB be
investigated for the presence of pulmonary TB.12,20 After careful review of the patients case
and final follow-up, we believe that this patient may have had a course of directly inoculated
TB infection without noticing the traumatic event that led to the inoculation of the disease
process. This later led to the insidious onset that may also have limited the clinical
inflammatory signs.
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Articular TB infections are hard to diagnose.9,10,16 Oftentimes, arthroscopy or arthrotomy

might reveal the presence of this infection, even though other more common causes are
usually thought to be the culprits, including bacterial and viral infections.1,5 Lyme infection
is another commonly found pathology, but this is location dependent. Lee et al. reviewed
their series of 33 children who were diagnosed with TB arthritis. Their description of only
33 cases in a period of 12 years (1979–1991) demonstrated how rare this entity is.15 The
authors described that 96% of patients had positive Mantoux tests and 59% had CXR

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findings of active or healed TB. Furthermore, only 76% of the 25 knees had a definite
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diagnosis of TB, which was done by either acid-fast bacilli on microscopy, histology, or
positive culture. After classifying the radiographical appearance of the knees on plain
radiograph, the authors found that radiographical appearance during the initial visit
predicted the outcome of the patient. A recent systematic review evaluated 154 articles and
concluded that no single diagnostic investigation can reliably identify a joint infection in
children.1 Thus, it is important that various causes of arthritis be evaluated when examining
children with a new onset of arthritis.

Treatment for TB arthritis is based on three primary goals, which are: 1) joint lavage 2) long
term antimicrobials, and 3) rule out of extra-articular pathology. Thompson et al. described
their case scries of 24 patients treated with arthroscopy for septic arthritis in very young
patients (three weeks to six years) and found that this technique was safe (only one transient
complication) and effective at eradicating infection.16 Only three patients required a second
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intervention. In this case, an arthrotomy was performed because of the great degree of
synovitis and the fact that it remains the gold standard for joint lavage.8,10,19

CONCLUSION
Patients of all age groups may present with septic arthritis of the knee caused by m.
tuberculosis, even without risk factors or apparent inoculation or trauma. TB should always
be considered in the differential of a pediatric septic arthritis of the knee.

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Figure 1.
Bilateral knee, AP x-ray demonstrating no change in bony structures, no fractures, no
evident soft tissue swelling, no air, and no fistulas.
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Surg Technol Int. Author manuscript; available in PMC 2019 March 01.