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1 Candidiasis
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Candidal osteomyelitis most commonly develops in debilitated, malnourished patients undergoing prolonged hospitalization for cancer, neutropenia, trauma, complicated abdominal surgical procedures, or injection drug use Infected intravenous catheters frequently serve as a hematogenous source Prosthetic joints can also be infected by Candida For susceptible Candida species, fluconazole, 200 mg orally twice daily, is probably as effective as amphotericin B (see 36)
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Garbino J et al An unusual cause of vertebral osteomyelitis: Candida species Scand J Infect Dis 2003;35(4):288 91 [PMID: 12839165]
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Most tuberculous infections in the United States are caused by the human strain of Mycobacterium tuberculosis (see 9) Infection of the musculoskeletal system is caused by hematogenous spread from a primary lesion of the respiratory tract; it may occur shortly after primary infection or may be seen years later as a disease reactivation Tuberculosis involving bone or joints accounts for 1 3% of patients with extrapulmonary tuberculosis Tuberculosis of the thoracic or lumbar spine (Pott s disease) is the most common site of bony involvement and usually occurs in the absence of extraspinal infection It is a disease of children in
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2 Coccidioidomycosis
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Coccidioidomycosis of bones and joints is usually secondary to primary pulmonary infection Arthralgia with periarticular swelling, especially in the knees and ankles, occurring as a nonspecific manifestation of systemic coc-
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developing nations and of the elderly in the United States Osteomyelitis accounts for approximately 20% of musculoskeletal tuberculosis and most commonly affects the femur and tibia Tuberculosis of peripheral joints is almost always monarticular, with the knee the most common site
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Complications
Destruction of bones or joints may occur in a few weeks or months if adequate treatment is not provided Deformity due to joint destruction, abscess formation with spread into adjacent soft tissues, and sinus formation are common Paraplegia is the most serious complication of spinal tuberculosis As healing of severe joint lesions takes place, spontaneous fibrous or bony ankylosis follows
Clinical Findings
A Symptoms and Signs
The onset of symptoms is generally insidious and not accompanied by general manifestations of fever, sweating, toxicity, or prostration Pain may be mild at onset, is usually worse at night, and may be accompanied by stiffness As the disease process progresses, limitation of joint motion becomes prominent because of muscle contractures and joint destruction The knee is the most commonly involved peripheral joint Symptoms of pulmonary tuberculosis may also be present Local findings during the early stages may be limited to tenderness, soft tissue swelling, joint effusion, and increase in skin temperature about the involved area As the disease progresses without treatment, muscle atrophy and deformity become apparent Abscess formation with spontaneous drainage externally leads to sinus formation Progressive destruction of bone in the spine may cause a hump spine or gibbus deformity, especially in the thoracolumbar region
Treatment (See also 9)
A General Measures
General care is especially important when prolonged recumbency is necessary; skillful nursing care must be provided
B Chemotherapy
See 9 Cure with chemotherapy without need for operation may be achieved in most cases, even with extensive disease
C Surgical Measures
In acute infections where synovitis is the predominant feature, treatment can be conservative, at least initially Immobilization by splint or plaster, aspiration, and chemotherapy may suffice to control the infection Synovectomy may be valuable for less acute hypertrophic lesions that involve tendon sheaths, bursae, or joints
Franco-Paredes C et al The ever-expanding association between rheumatologic diseases and tuberculosis Am J Med 2006 Jun;119(6):470 7 [PMID: 16750957] Gardam M et al Mycobacterial osteomyelitis and arthritis Infect Dis Clin North Am 2005 Dec;19(4):819 30 [PMID: 16297734]
B Laboratory Findings
The precise diagnosis rests on detecting the acid-fast organism by culture or by polymerase chain reaction (PCR) test of joint fluid, pus, or tissue specimens Biopsy of the bony lesion, synovium, or a regional lymph node may demonstrate the characteristic histopathologic picture of caseating necrosis and giant cells
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