The Journal of Foot & Ankle Surgery 54 (2015) 112–115

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Case Reports and Series

Multifocal Bilateral Metatarsal Tuberculosis: A Rare Presentation Vipul Vijay, MS, DNB 1, Alok Sud, MS 2, Anil Mehtani, MS 2 1 2

Surgeon, Department of Orthopaedics, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi, India Professor, Department of Orthopaedics, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi, India

a r t i c l e i n f o

a b s t r a c t

Level of Clinical Evidence: 4

Tuberculosis, or phthisis (consumption) as it was popularly known in the Greek era, has been endemic in Southeast Asia and Sub-Saharan Africa; however, the human immunodeficiency virus epidemic has seen the re-emergence of this disease in the areas in which it was not very commonly reported. With this, the need for understanding and treatment of rare presentations of tuberculosis has become of paramount importance to achieve the World Health Organization millennium goal of a “reversal of incidence by 2015.” Foot involvement has been reported in 0.1% to 0.3% of extrapulmonary cases. Multifocal lesions have an incidence of 50% of their TB cases in foreign nationals increased from 23 in 2001 to 34 in 2011. Asia and Africa accounted for the maximum number of cases

Fig. 5. Photomicrograph of the biopsy specimen showing caseating granuloma with the typical Langerhans giant cells surrounded by epithelioid cells. Hematoxylin and eosin stain, original magnification 20  10.

Fig. 7. Radiographs at the second follow-up visit at 6 months showing healing of the lesion in the right first metatarsal and signs of healing in the left third metatarsal.

Fig. 4. Radiograph of the left foot taken at admission for the biopsy showing a lytic lesion in the base of the third metatarsal with the typical “coke-like sequestrum” in the center.

V. Vijay et al. / The Journal of Foot & Ankle Surgery 54 (2015) 112–115

Fig. 8. Radiographs at the final follow-up visit at the end of treatment showing the healed lesion in the head of the first metatarsal and the healed lesion in the base of the third metatarsal.

in 2011. An estimated 12 million cases of TB were reported in 2011, for a ratio of 170 cases per 1,000,000 population (1). As reported in the World Health Organization world report in 2011 (1), the global incidence of TB has started to show a downward trend. However, with the downward trend in the incidence of TB and the focus on a 0 incidence of TB by 2015, the emphasis on the identification of rare presentations of TB has increased manifold. TB of the foot is rare, and the incidence has been reported to be 0.1% to 0.3% (2). TB of the foot can be an articular, soft tissue mass or an isolated osseous tubercular lesion. Isolated osseous involvement of the tarsus has been reported to have a decreasing incidence as follows: calcaneum, talus, distal end of first metatarsal, navicular, cuneiform, and cuboid (7). Dhillon et al (2) in their report of 74 cases, reported only 4 cases of metatarsal involvement. Moreover, they reported only a single case of bilateral foot involvement. Multifocal TB, such as in the present case, was described as a clinical entity by Jungling (8) in 1910, who described it as “polycystic tuberculous osteitis,” but the term multifocal TB was first used in 1952 (9). The source of the multifocal infection has been considered to be from a pulmonary lesion; however, in approximately 50% of cases, such a lesion has not been found in the lungs (10), just as in our patient. There are 2 possible theories regarding the presence of multifocal TBdeither dissemination of the bacteria had already occurred and with the decrease in immunity, the sites of localization flared up or repeat dissemination occurs from the primary source. In the search of the medical data, case series of multifocal TB have been reported in children (11) and adults (12) but not of multifocal TB involving both feet. The lytic lesion in the foot, just as in our patient, can have multiple differential diagnoses, including low-grade pyogenic osteomyelitis, hyperparathyroidism, fungal infection (Madura foot), and metastasis, among others. The most important pathologic entity that needs differentiation from TB in a patient presenting with multifocal lytic lesions in the foot is metastasis. Metastasis to the foot (acrometastases) are rare, and the sites that routinely result in acrometastases to the foot are mainly subdiaphragmatic, such as the gastrointestinal, vesical, renal,

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and uterine systems (13,14). The presentation is very similar to infective pathologic features in the foot, except for the absence of a local increase in temperature, which could help in the clinical differentiation (15). Madura foot (fungal osteomyelitis) is a pathologic entity endemic in Central and South Asia and South America. It is commonly found in patients with a history of barefoot walking. The common presentation is single or multiple sinus discharging colored granules and tumefaction (tumor-like mass). The classic finding on a computed tomography scan is a “dot in circle” sign (16). Patients with multifocal TB can lack the constitutional symptoms and have normal findings on a chest radiograph. The only pointer might be an elevated erythrocyte sedimentation rate. The differentiation among the various diagnostic possibilities can be achieved by open biopsy. Positive stains and cultures are difficult to attain in foot TB because of the paucibacillary nature of the lesion (2). Treatment with antitubercular drugs will result in a good outcome in most cases of foot TB (2). The treatment in our patient was prolonged for a period of 17 months, because the disease was multifocal. The first sign of improvement in the case of foot TB has usually been improvement of osteoporosis in the foot (2). In the present case, the left foot lesion was late to respond to treatment. This discrepancy in a case of multifocal TB, with 1 lesion responding later than the other, should not be taken as a marker for surgical intervention, because it might simply be an indication that the 2 lesions are at a different stage. The present case had a variety of unusual findings. Isolated involvement of the foot in an immunocompetent patient is, in itself, rare. The multifocal involvement in both the feet made the present case even more interesting. Identification of bilateral lytic lesions of the foot substantiates the consideration of numerous etiologies, including infection, tumor, and systemic disease. Although rare, TB should be considered within the differential diagnosis. Appropriate biopsy, culture, and sensitivity testing are paramount in ascertaining the correct diagnosis. Consultation with the infectious disease department, if available, will assist in the obtaining the appropriate treatment regimens.

References 1. Global Tuberculosis Control, 2011. Available at: www.who.int/tb/publications/ global_report. Accessed November 30, 2011. 2. Dhillon MS, Singh P, Sharma R, Gill SS, Nagi ON. Tuberculous osteomyelitis of the cuboid: a report of 4 cases. Foot Ankle Surg 39:329–335, 2000. 3. Davidson PT, Horowitz I. Skeletal tuberculosis: a review with patient presentation and discussion. Am J Med 48:77–84, 1970. 4. Watts HG, Lifeso RM. Tuberculosis of bones and joints. J Bone Joint Surg Am Surg 78:288–298, 1996. 5. Sievers ML. The second “great imitator”dtuberculosis. JAMA 176:809–810, 1961. 6. Miltner LJ, Fong HC. Diagnosis and treatment of tuberculosis of the bones of the foot. J Bone Joint Surg 18B:287–293, 1936. 7. Osterhouse MD, Guebert GM. Bilateral acrometastasis secondary to breast cancer. J Manipulative Physiol Ther 27:275–279, 2004. 8. Jungling O. Ostitis tuberculosa multiplex cystica (eine eigenartige form der knochentuberkulose). Fortschr Roentgenstr 27:375–383, 1920. 9. Komins C. Multiple cystic tuberculosis: a review and revised nomenclature. Br J Radiol 25:1–8, 1952. 10. Davidson PT, Horowity I. Skeletal tuberculosis: a review with patient presentations and discussions. Am J Med 48:77–84, 1970. 11. Dhammi IK, Jain AK, Singh S, Aggarwal A, Kumar S. Multifocal skeletal tuberculosis in children: a retrospective study of 18 cases. Scand J Infect Dis 35:797–799, 2003. 12. Kumar K, Saxena MB. Multiple osteoarticular tuberculosis. Int Orthop 12:135–138,1988. 13. Kundu S, Shankar S, Mitra S, Acharya S, Roy A, Dastidar AG. Below-elbow and below-knee metastases in breast cancerda case report. Indian J Med Paediatr Oncol 28:38–40, 2007. 14. Libson E, Bloom RA, Husband JE, Stoker DJ. Metastatic tumours of bones of the hand and foot: a comparative review and report of 43 additional cases. Skeletal Radiol 16:387–392, 1987. 15. Venkatswami S, Sankarasubramanian A, Subramanyam S. The Madura foot: looking deep. Int J Low Extrem Wounds 11:31–42, 2012. 16. Cherian RS, Betty M, Manipadam MT, Cherian VM, Poonnoose PM, Oommen AT, Cherian RA. The “dot-in-circle” signda characteristic MRI finding in mycetoma foot: a report of three cases. Br J Radiol 82:662–665, 2009.

Multifocal bilateral metatarsal tuberculosis: a rare presentation.

Tuberculosis, or phthisis (consumption) as it was popularly known in the Greek era, has been endemic in Southeast Asia and Sub-Saharan Africa; however...
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