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Year : 2006  |  Volume : 40  |  Issue : 4  |  Page : 264-266
Role of polymerase chain reaction in osteoarticular tuberculosis

1 Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
2 Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

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Background : Tuberculosis is a serious disease of global importance with a rising incidence worldwide. Available investigations like AFB stain, culture have low sensitivity and specificity, so there is need for a diagnostic test which is more sensitive and specific and less time consuming to provide final result. PCR is said to provide result within 36-48 hrs with high specificity and sensitivity.
Method : Forty one cases showing clinicoradiological features of osteoarticular tuberculosis were studied with 20 cases taken in negative control group. Samples for PCR included synovial fluid and tissue Biopsy. PCR was used to amplify IS6110 genomic sequence of M. tuberculosis in the sample material to provide diagnosis.
Results : The sensitivity of PCR was found to be 73.17%; and specificity 100%. The report of PCR was available within 36-48 hrs.
Conclusion : By our study we conclude that PCR is a rapid highly sensitive and specific modality for detecting osteoarticular tuberculosis.

Keywords: Polymerase chain reaction; Osteoarticular tuberculosis; Mycobacterium tuberculosis

How to cite this article:
Sareen A, Khare G N, Nath G, Singh S. Role of polymerase chain reaction in osteoarticular tuberculosis. Indian J Orthop 2006;40:264-6

How to cite this URL:
Sareen A, Khare G N, Nath G, Singh S. Role of polymerase chain reaction in osteoarticular tuberculosis. Indian J Orthop [serial online] 2006 [cited 2020 Mar 29];40:264-6. Available from:

   Introduction Top

The world at large has nearly 30 million people suffering from tuberculosis people a year. It is estimated that India alone has got one-fifth of the total world population of tuberculous patients. Thus, there are nearly six million radiologically proven cases of tuberculosis in India, and perhaps a quarter of these are sputum positive. Of all the patients suffering from tuberculosis nearly one to three percent have involvement of the skeletal system.

The diagnosis of tuberculosis is based on compatible history, clinical features, lesions in X-ray chest, positive tuberculin and/or BCG test and in the cases of effusions, characteristic fluid biochemistry, demonstration of acid-fast bacilli (AFB) in smear, culture of fluids for Mycobacterium tuberculosis and response to treatment. However, the clinical findings and fluid biochemistry may be variable and tuberculin/ BCG test may be falsely negative. Furthermore, success of AFB positivity in fluid is <20% (requires 1000­10000 bacilli/mm 3 ) and fluid culture positivity is also poor 18­38% (require 10-100 bacilli/mm 3 ) and it takes 6-12 weeks for result. Under such circumstances, the anti-tuberculous therapy is started empirically, waiting for clinical improvement. So, it becomes imperative to find some rapid and useful test, which is reliable in the diagnosis of osteoarticular tuberculousis.

Polymerase chain reaction (PCR) is a new diagnostic modality which specifically amplifies the insertion sequence IS6110 specific for Mycobacterium tuberculosis [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] . PCR is considered to have high sensitivity and specificity and provides results within 48hrs. In view of these observations, the present study was done with the objective of to determine the role of PCR in the diagnosis of osteoarticular tuberculosis.

   Material and methods Top

The present study was carried out in our hospital from March 2003 to December 2004.

The criterias for inclusion in diseased group were clinical features suggestive of osteoarticular tuberculosis, radio­logical features suggestive of osteoarticular tuberculosis, and positive response to antitubercular treatment.The criteria for inclusion in control group were clinical features suggestive of septic arthritis with positive culture report.

Subjects were divided in two groups.Group A (Diseased group) included 41 cases, and Group B (Control group) had 20 cases. Nested PCR using primers based on IS 6110 on synovial fluid and biopsy material was carried out.

   Results Top

Confidence limit in patients already on ATT at time of sample procurement is (CI = 47.53 to 89.31) and confidence limit in patients not on ATT at time of sample procurement is (CI= 59.77 to 94.77).As the confidence limit shows significant overlaping figures it indicates that positivity of PCR is not affected by ATT intake [Table - 1].

In cases of core biopsy confidence limit is (CI=38.79 to 86.21). In cases of aspirate confidence limit is (CI=62.48 to 97.52). In cases of open biopsy confidence limit is (CI=44.95 to 115.04. As values of confidence limit for core-biopsy, aspirate and open biopsy are overlapping it indicates that detection of Mycobacterium tuberculosis by PCR technique is not affected by nature of sample) [Table - 2].

Sensitivity of PCR = True positive / Total diseased person (Group A) = 30/41 = 73.17%. Specificity of PCR = True negative / Total disease free patients (Group B) = 20/20 = 100%. Predictive value of positive test = 30/30 = 100%. Predictive value of negative test = 20/31=64.52%. Percentage of false positives = 0/20 = 0%. Percentage of false negatives = 11/41 = 26.83%. Thus this shows that nested PCR techniques has high sensitivity and specificity in cases of osteoarticular tuberculosis with 100% positive predictive value and no false positivity [Table - 3].

   Discussion Top

Early osteoarticular tuberculosis presents with non­specific signs and symptoms leading to diagnostic dilemma. Being the paucibacillary in nature, the isolation of Mycobacterium tuberculosis in joint fluid by AFB staining or culture is difficult; moreover, culture study takes too long to allow an early diagnosis.

Berk[12] studied the detection of Mycobacterium tuberculosis in formaldehyde solution-fixed, paraffin­embedded tissue by PCR in Pott's disease the sensitivity of PCR was 94.7%, specificity was 83.3% and accuracy was calculated as 92%.

Sun studied the samples of 60 patients with bone tuberculosis and 20 patients without bone tuberculosis by PCR, light microscopy and culture technique to detect Mycobacterium tuberculosis13. The positivity rate was 83% in PCR technique, 3% in light microscopy and 7% in culture technique for patients with bone tuberculosis.

Compared to conventional test like AFB stain sensitivity <20% and culture positivity 18-38%, PCR in our study has sensitivity 73.17 and specificity 100% and results are available with in36-48 hrs, so it indicates superiority of PCR over other diagnostic test, moreover Nested PCR can detect even single bacterium in given sample[14].Thus the results of our study are in concordance with the results of previous studies[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14].

Hence it would be rationale approach to combine clinical presentation with PCR to solve the diagnostic dilemma in patients presenting with osteoarticular tuberculosis.

   References Top

1.Sjobring U, Mecklenburg M, Anderson AB et al. Polymerase chain reaction for detection of Mycobacterium tuberculosis. J Clin Microbiol. 1990; 28: 2200-04.  Back to cited text no. 1    
2.Pao CC, Yen B, You J et al. Detection and identification of Mycobac­terium tuberculosis by DNA amplification. J Clin Microbiol. 1990; 28: 1877-80.  Back to cited text no. 2    
3.Manjunath N, Shankar P, Ranjan L, Bhargava A, Saluja S, Shrinivas. Evaluation of polymerase chain reaction for the diagnosis of tuberculo­ sis. Tubercle. 1991; 72: 21-7.  Back to cited text no. 3    
4.Van der Spoel van Dijk A, MCleod A, Botha PL, Shipley JA, Kapnoudhis MA, Beukes CA. The diagnosis of skeletal tuberculosis by polymerase chain reaction. Cent Afr J Med. 2000; 46 (6): 144-9.  Back to cited text no. 4    
5.Kolk AH, Schutema AR, Kinjper S. et al. Detection of Mycobacte­rium tuberculosis in clinical samples by using polymerase chain reaction and a non-radioactive detection system. J Clin Microbiol. 1992; 30: 2567-2575.  Back to cited text no. 5    
6.De Wit D, Steyn L, Shoemaker S et al. Direct detection of Mycobac­terium tuberculosis in clinical specimen by DNA amplification. J Clin Microbiol. 1990; 28: 2437-2441.  Back to cited text no. 6    
7.Miller NS, Hernandez SG, Cleary TJ. Evaluation of Gen-probe ampli­fied Mycobacterium tuberculosis direct test and PCR for direct detec­tion of Mycobacterium tuberculosis in clinical specimens. J Clin Microbiol. 1994; 32: 393-7.  Back to cited text no. 7    
8.Mullis K. The unusual origin of the polymerase chain reaction. Scien­tific American. April 1990; 56-65.  Back to cited text no. 8    
9.Naber SP. Molecular pathology: Diagnosis of infectious disease. N Engl J Med. 1994; 331: 1212-1215.  Back to cited text no. 9    
10.Brisson-Noel A, Gicquel B, Lecossier D, et al. Rapid diagnosis of tuberculosis by amplification of mycobacterial DNA in clinical samples. Lancet. 1989; 2: 1069-71.  Back to cited text no. 10    
11.Shankar P, Manjunath N, Lakshmi et al. Identification of M. Tubercu­losis by polymerase chain reaction. Lancet.1990; 1: 423.  Back to cited text no. 11    
12.Berk RH, Yaziei M, Atabey N, Ozdamar Os, Pabucouglu U, Alliei E. Detection of Mycobacterium tuberculosis in formaldehyde solution­fixed, paraffin-embedded tissue by polymerase chain reaction in Pott's disease. Spine. 1996;21:1991-5.  Back to cited text no. 12    
13.Sun Y, Zhang Y, Lu Z. Clinical study of polymerase chain reaction technique in the diagnosis of bone tuberculosis. Zhonghua Jie He He Hu Xi Zhi. 1997; 20 (3): 145-8.  Back to cited text no. 13    
14.Loudon DM, Colares JKB, da Fonseca BAL. Combined use of polymerase chain reaction and detection of adenosine deaminase activ­ity on pleural fluid improves the rate of diagnosis of pleural tuberculosis. Chest. Sept 2003; 124: 909-914.  Back to cited text no. 14    

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Atul Sareen
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  [Table - 1], [Table - 2], [Table - 3]


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