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CASE REPORT Table of Contents   
Year : 2004  |  Volume : 38  |  Issue : 3  |  Page : 189-190
Tuberculosis of the patella - A case report


Department of Orthopaedics, Physical Medicine, Parapelgia and Rehabilitation, Pt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak 124001, Haryana, India

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How to cite this article:
Singh R, Gupta R. Tuberculosis of the patella - A case report. Indian J Orthop 2004;38:189-90

How to cite this URL:
Singh R, Gupta R. Tuberculosis of the patella - A case report. Indian J Orthop [serial online] 2004 [cited 2019 Dec 11];38:189-90. Available from: http://www.ijoonline.com/text.asp?2004/38/3/189/37292

   Introduction Top


Extrapulmonary tuberculosis in the form of skeletal involvement is fairly common, though isolated patellar involvement is rare[1],[2],[3]. Two such cases are discussed with their clinical and radiological features which help in differentiating tuberculosis from other similar lesions.


   Case Report Top


Case I : An apparently healthy 22 year male presented with a complaint of pain, swelling and some restriction of movements of the right knee for last 2 months. Patient had no constitutional symptoms and denied any history suggestive of tuberculosis. Examination of the knee revealed swelling and tenderness over the patella, mild effusion, no synovial thickening and loss of terminal 20-30o of flexion. There was mild atrophy of the quadriceps and significant inguinal lymphadenopathy. Laboratory investigations revealed a haemoglobin of 11 gm/dl, a total leucocyte count of 8300 mm3 with lymphocytosis and a high erythrocytic sedimentation rate (ESR) of 42 mm/1st hour (Westergren). Mantoux test gave an induration of 20 mm at the end of 72 hours. Chest X-ray was normal. Radiograph of the knee joint demonstrated a lytic lesion in the lower pole of patella containing sequestrate without any marginal sclerosis.

Case II: Our second patient was young female with rural background who presented with progressive pain and swelling over the anterior aspect of the right knee for last four months. Patients had no past history of cough or expectoration, though she had some loss of weight and appetite. On examination knee was found to be swollen and warm, but the range of knee motion was normal. Tapping on the patella was painful and no synovial thickening was present. Matted inguinal lymphnodes were present. Laboratory investigations revealed a haemoglobin of 7.4 gm/ dl, total leucocyte count of 6200/mm3 with mild lymphocytosis and ESR of 52 mm/1st hour. Mantoux test gave an duration of 22mm at the end of 72 hours. Chest X-ray was normal. Anteroposterior, lateral and skyline view of the knee joint showed osteolytic lesion of patella containing sequestrate [Figure - 1]. Fine needle aspiration cytology revealed classical tubercular granulomas.

Both the patients were subjected to surgical debridement. Operative findings consisted of cavities full of unhealthy granulation tissue with few sequestrate lying inside but there was no communication to the joints. Knees were immobilized postoperatively to give rest to the part. Histopathological examinations in both the patients revealed chronic granulomatous tissue with areas of caseous necrosis and Langhans type giant cells, confirming the diagnosis of tubercular infection. The patients were put on appropriate antitubercular regimen. After a follow up of 12-18 months lesions healed clinically and radiologically with full knee movements in both the patients [Figure - 2].


   Discussion Top


Knee joint is the third most common joint affected by osteoarticular tuberculosis after spine and hip joint[4]. Isolated tubercular patellar involvement is very uncommon with literature reporting an incidence of 0.09 to 0.15%[1]). Differential diagnosis of such lesion varies from tumours like chondroblastoma, osteoblastoma, infected aneurysmal bone cyst to metastatic lesions; tumor like conditions eg. Brown tumor; and inflammatory lsions such as gout, pyogenic and fungal osteomyelitis [2],[5].

Osteolytic lesion with a sequestrum is usually considered to be infective in nature and absence of marginal sclerosis should suggest tuberculosis, through, its value as absolute diagnostic criteria is debated in the literature. Although radionuclide bone scan and CT scan have been reported in the literature as excellent diagnostic aids for diagnosing such lesions[2],[3], but these are not universally available and are expensive. Patellar bone is easily accessible bone for the needle aspiration cytology and it can be used for early confirmation of diagnosis, as was done successfully in our second case. Surgical debridement can also serve as a diagnostic tool for confirmation of the diagnosis, besides being therapeutic in nature.

An early diagnosis followed by definitive treatment is desirable in such cases in view of proximity of the knee joint to such lesions. Results in both of our patients after surgical debridement and ATT were good as the diagnosis was made early and prior to the involvement of the joint. Tuberculosis is not so common in the west, but is fairly common in countries like India. Hence in osteolytic lesions of the patella possibility of tuberculosis should always be considered, inspite of it being rare.

 
   References Top

1.Dhillon MS, Rajsekhar C, Nagi ON. Tuberculosis of patella ; report of a case and review of literature. Knee. 1995 ; 2 : 53-56.  Back to cited text no. 1    
2.Shah P, Ramakantan R. Tuberculosis of the patella. Br J Radiol. 1990; 63 : 363-364.  Back to cited text no. 2    
3.Dhillon MS, Rao SS, Sandhu MS, Vasisht RK, Nagi ON. Tuberculosis of the patella. Skeletal Radiol. 1998 ; 27 : 40-42.  Back to cited text no. 3    
4.Tuli SM. Tuberculosis of skeletal system. New Delhi. Jaypee Brothers Medical Publishers. 1991.  Back to cited text no. 4    
5.Ehara S, Khurana JS, Kattapuram SV, Rosenberg AE, El-Khoury GY, Rosenthal DL. Osteolytic lesion of the patella. Am J Roentgenal. 1989 ; 153 : 103-106.  Back to cited text no. 5    

Top
Correspondence Address:
Roop Singh
Department of Orthopaedics, Physical Medicine, Parapelgia and Rehabilitation, Pt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak 124001, Haryana
India
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Source of Support: None, Conflict of Interest: None


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    Introduction
    Case Report
    Discussion
    Introduction
    Case Report
    Discussion
    References
    Article Figures
 

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