J Rheum Dis.  2016 Oct;23(5):311-315. 10.4078/jrd.2016.23.5.311.

Tuberculous Osteomyelitis of the First Metatarsophalangeal Joint Misdiagnosed as Gouty Arthritis

• Jeong JS
• Kim JH
• Park SH
• Jeong JH
• Ryu YJ
• Moon KW

• KMID: 2356486
• DOI: http://doi.org/10.4078/jrd.2016.23.5.311

Abstract

A-43-year-old man visited our clinic due to pain and swelling of his left first metatarsophalangeal (MTP) joint since 6-months ago. He was diagnosed as gouty arthritis at private clinic and took hypouricemic agent, but he had progressive pain and swelling. There was swelling, erythema and tenderness and ulceration at base of the left first MTP joint. His laboratory results showed elevated C-reactive protein and normal serum uric acid level. The plain radiograph of foot showed bone destruction of left first MTP joint. MRI revealed joint space narrowing, soft tissue swelling and subchondral cyst. He underwent excisional biopsy and histology demonstrated chronic granulomatous inflammation with caseation necrosis. Tissue polymerase chain reaction for mycobacterium tuberculosis was positive. He was diagnosed as tuberculous osteomyelitis. He started on quadruple anti-tuberculous therapy and his symptom was improved. Early diagnosis and anti-tuberculosis therapy could lead to improve outcomes.

Keyword

Tuberculosis; Osteomyelitis; Metatarsophalangeal joint; Foot; Gout

MeSH Terms

Arthritis, Gouty*
Biopsy
Bone Cysts
C-Reactive Protein
Early Diagnosis
Erythema
Foot
Gout
Inflammation
Joints
Magnetic Resonance Imaging
Metatarsophalangeal Joint*
Mycobacterium tuberculosis
Necrosis
Osteomyelitis*
Polymerase Chain Reaction
Tuberculosis
Ulcer
Uric Acid
C-Reactive Protein
Uric Acid

Figure

• 

  Figure 1. (A) Chest radiograph showed right costophrenic angle blunting. (B) Computed tomography image of chest showed diffuse pleural thickening in right lower lobe.

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  Figure 2. (A) There was no destruction at left first meta-tarsophalangeal (MTP) joint in foot X-ray at 6-months ago. (B) There was bone destruction at left first MTP joint on day of admission. (C, D) Magnetic resonance imaging revealed joint destruction, soft tissue swelling and subchondral erosion in left first MTP joint.

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  Figure 3. Three phase bone scan image showed increased perfusion over left foot in the dynamic images. In the blood flow and pool phase, there was increased flow in the left first metatarsophalangeal joint area. These findings are compatible with osteomyelitis.

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  Figure 4. Tissue from excision biopsy of the left first metatarsophalangeal joint showed chronic granulomatous inflammation with caseation necrosis. This histologic finding is compatible with tuberculosis. (H&E: A, ×40; B, ×100).

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