Imaging features of extra spinal musculoskeletal

tuberculosis
Poster No.:

C-0939

Congress:

ECR 2015

Type:

Educational Exhibit

Authors:

W. Mnari, M. abdelaali, A. Zrig, M. Maatouk, B. Hmida, R. Salem,

M. Golli; Monastir/TN

Keywords:

Bones, Musculoskeletal joint, Musculoskeletal system, CT, MR,

Conventional radiography, Contrast agent-intravenous, Abscess,
Infection, Inflammation

DOI:

10.1594/ecr2015/C-0939

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Learning objectives

To describe and illustrate the common imaging features of various types of

extra spinal musculoskeletal tuberculosis.
To sort out the imaging signs used in the diagnosis process.

Background

Extra-axial musculoskeletal tuberculosis may involve a wide variety of

tissues, including the joints, bones, muscles, tendon sheaths, synovial
bursae, or a combination of these. Plain radiography, ultrasound, CT scan
and especially MRI are precious tools for the diagnosis.
Musculoskeletal tuberculosis accounts for 1-3% of tuberculous infections.
Extraspinal manifestations are the least common ; peripheral arthritis is
60%, of osteomyelitis 38%, and of tenosynovitis and bursitis 2%.
Diagnosis of extraspinal musculoskeletal TB is not possible solely on the
basis of the clinical or imaging findings.
Histopathological examinations and culture identification are the most
accurate methods for diagnosis.

Findings and procedure details

Pathogenesis of extra spinal musculoskeletal tuberculosis

Causative organisms

Agent : Mycobacterium tuberculosis (Koch Bacillus) (fig.1)

General mechanisms of spread

Musculoskeletal TB mostly results from hematogenous or lymphogenous. Rarely,

musculoskeletal TB may be the result of direct inoculation of the organism into the site.TB
of a joint may result from hematogenous dissemination through the subsynovial vessels
or, indirectly, from epiphyseal (more common in adults) or metaphyseal (more common
in children) lesions that erode into the joint space. Tuberculous tenosynovitis may result
from hematogenous spread or it may be due to periarticular extension of tuberculous
arthritis. Skeletal muscle involvement is extremely rare.
Imaging protocols

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Plain radiograph: assessing plain radiographs are essential to the management of

skeletal TB.
CT scan: bone involvement especially the cortical and periosteal reaction.
MRI: always indicated especially to evaluate spongy bone and soft tissues. General
Protocol: T1, T2 Fat sat, T1 Fat sat post Gado.
Ultrasonography allows a quick evaluation of soft tissue masses, abscesses, joint
effusions, and the degree and extent of tendon and tendon sheath involvement.
Patterns of extra axial musculoskeletal tuberculosis
1. Tubercular osteomyelitis (fig.2)
Occurs most commonly in metaphysis of the bones of the extremities. The ribs are also
frequently involved. Plain radiograph and CT scan showed soft tissue swelling, periosteal
reaction, osteolysis, periarticular osteoporosis and erosions. MRI may demonstrate
intraosseous involvement earlier than the other imaging modalities (low and high signal
intensity on T1W and T2W weighted images); show enhancement after intravenous
administration of gadolinium with areas of necrosis, soft tissue fistulae and abscesses.
2. Joint tuberculosis
Tuberculous arthritis is characteristically monoarticular; however, in approximately 10%
of patients, multifocal joint disease does occur. Knee (fig.3 and 4) and hip (fig.5, 6 and
7) are the most communly involved.
Plain radiographic and CT scan findings: periarticular osteoporosis, peripherally located
osseous erosion and gradual diminution of the joint space (Phemister's triad). Later,
tuberculous arthritis is characterized by severe joint destruction and, eventually, sclerosis
and fibrous ankylosis.
MRI is the modality of choice for early detection of joint TB. Synovial proliferation due to
tuberculous arthritis is typically hypointense on T2W (differentiating tuberculous arthritis
from other proliferative synovial arthropathies). Chondral lesions and subchondral bone
erosions may be visible at a stage when the joint space is still well preserved. Associated
bone marrow edema, osteomyelitis, and soft tissue abnormalities such as myositis,
cellulitis, para-articular abscess formation, tenosynovitis, bursitis, and skin ulceration/
sinus tract formation may be seen.
Tuberculous tenosynovitis
Primary tuberculous tenosynovitis is considered an extremely rare condition. Authors
described three stages of tuberculous tenosynovitis: the hygromatous (fluid insight the
tendon), serofibrinous (thickening of the tendon and synovium) (fig.8), and fungoid stages
(soft tissue mass involving the tendon).
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Tuberculous myosistis
Tuberculous involvement of the muscle or deep fascia is a rare form of musculoskeletal
TB and is mostly seen in immunosuppressed patients
Images for this section:

Fig. 1: Scanning electron microscope view : Koch baillus.

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Fig. 2: Diaphysis fracture of the femur complicating chronic tuberculous osteomyelitis in

a 10 year old boy. CT scan shows multiple areas of bone destruction with intralesional
sequestration, abscess (asterisk) and periosteal reaction (arrows). Note also intralesional
sequestration (large arrow).

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Fig. 3: Tuberculosis arthritis of the knee : coronal fat sat T2 and T1 W images showed a
bone marrow edema with severe involvement of the bone and large periarticular abscess
contrsted with preserved joint space (arrow).

Fig. 4: Tuberculosis arthritis of the knee : intra articular effusion with large periarticular
abscess

Fig. 5: Hip tuberculosis ; CT scan shows large erosions with surrounding sclerosis
(arrows).

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Fig. 6: Same patient with hip tuberculosis; note the periosteal abcess (asterisk).

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Page 8 of 10

Fig. 7: Early stage of hip tuberculosis: Bone Marrow oedema.

Fig. 8: Tuberculous arthritis of the foot joints with Achilles tenosynovitis (thickening and
fluid insight the tendon )

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Conclusion
Although imaging features of tuberculosis of joints and tendons are nonspecific, certain
findings such as relatively preserved joint space, juxta articular osteoporosis, cold
abscesses, para articular soft tissue calcification, and rice bodies are suggestive of
tuberculosis infection. Familiarity with these imaging features can help in making an early
diagnosis and prevent serious musculoskeletal destructions.

Personal information
References
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2.

De Backer AI, Mortele KJ, Vanhoenacker FM, Parizel PM. Imaging of

extraspinal musculoskeletal tuberculosis. Eur J Radiol. 2006;57:119-30.
Sanghvi DA, Iyer VR, Deshmukh T, Hoskote SS. MRI features of
tuberculosis of the knee. Skeletal Radiol. 2009;38:267-73

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