Description

A young girl child presented with an acute febrile illness followed by symmetric paraparesis and incontinence over the past 3 days. The fever was low-grade and intermittent. She did not have any respiratory illness, headache, vomiting, meningismus, photophobia, seizure, trauma and bleeding from any site. She had a chronic, non-healing ulcer in right elbow for the past 4 months. The lesion was not associated with pain or restriction of movements at the elbow. Her father suffered from pulmonary tuberculosis (TB) 3 years back and received antituberculous therapy (ATT) for 6 months. On examination, she had a large, ovoid lesion over the right elbow measuring 4×3 cm, irregular in shape, clear margin with exuberant granulation tissue and fixed to the underlying bone (figure 1A). There was a gibbus-like deformity in the cervico-thoracic region of the spine with normal overlying skin. She also had symmetrical, flaccid paraparesis with absence of antigravity movements (power 2/5), brisk muscle stretch reflexes, bowel and bladder incontinence, bilateral Babinski’s sign and normal fundi. Rest of the systemic examination was normal. Radiograph of the chest was normal. Radiograph of right elbow showed an eccentric, geographic lytic lesion with a thin sclerotic rim in the metaphysis of the distal end of humerus and extended to the diaphysis (figure 1B). MRI of the spine showed osteolytic destruction of T1 and T2 vertebrae, loss of height of the intervertebral disc, gibbus deformity and prevertebral and paravertebral collection (figure 1C). CT-guided needle aspiration from the paravertebral area showed epithelioid cell granuloma comprising epithelioid histiocytes and lymphocytes, suggestive of TB (figure 1D). However, Ziehl-Neelsen stain for acid-fast bacilli was negative. The erythrocyte sedimentation rate was 26 mm and Mantoux intradermal test was 14×14 mm. She was initiated on four drug ATT (isoniazid 10 mg/kg, rifampicin 15 mg/kg, pyrazinamide 35 mg/kg and ethambutol 25 mg/kg) and methylprednisolone at 30 mg/kg/day for 5 days in addition to ATT. Neurological signs improved in the form of recovery of bladder and bowel symptoms in 5 days followed by improvement in power of bilateral lower limbs upto 3/5 in 2 weeks of initiation of treatment and ambulatory in 6 weeks of ATT. The size of the ulcer also gradually reduced over the 6 weeks. Since there was significant neurological recovery following initiation of treatment and there was no significant deformity (kyphosis) on follow-up, surgery was not considered.

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Figure 1

(A) Chronic non-healing ulcer over right elbow before antitubercular therapy. (B) Anteroposterior X-ray view of right elbow joint showing geographic lytic lesion in distal humerus with medial sclerosis. (C) MRI of dorsal spine showing collapse of T1 and T2 vertebra with loss of height of intervertebral disc and prevertebral and paravertebral collection. (D) Histopathological examination of aspirates from paravertebral lesion showing predominantly of blood and few epithelioid cell granuloma comprising of epithelioid histiocytic and few lymphocytes.

Our case highlights an unusual musculoskeletal presentation of TB in children. The most common site of musculoskeletal TB is the spine, followed by hip and knee joints. TB of the elbow joint is rare in children. In such cases, proximal ulna is the most common site of involvement.1 However, distal humerus was oddly involved in our case. Osteoarticular TB commonly results from hematogeneous dissemination from the primary focus (usually lungs) which may be active or quiescent. Spinal TB lesions are most frequently located in the lower thoracic region in children. As in the index case, the characteristic radiological findings include destruction of two adjacent vertebral bodies, destruction of the intervening disc and paravertebral and epidural abscesses.2 In children, because of the paucibacillary nature, microbiological confirmation of TB is elusive.3 Histopathological evidence of TB inflammation helps in confirming the diagnosis.

Our case highlights that even when children with TB present with acute neurological complications, there are often signs pertaining to other areas which are missed in the initial stages. Involvement of the bone in the form of chronic osteomyelitis, gibbus at the back, paravertebral swellings, spina ventosa, persistent discharging sinuses or non-healing ulceration of the overlying skin are important clues in examination which should not be overlooked.4 5 If not recognised in time, such children present with neurological complication and significant sequelae.