Elsevier

The Foot

Volume 28, August 2016, Pages 20-25
The Foot

Tuberculosis around the tarsal navicular: A rare entity

https://doi.org/10.1016/j.foot.2016.09.003Get rights and content

Highlights

  • Three cases of tubercular infection around the tarsal navicular are presented with different presentation.

  • The key to good results is high index of suspicion and obtaining tissue for histo-pathological examination.

  • Good functional results can be expected if the diagnosis is achieved early and adequate anti-tubercular therapy is given.

Abstract

Osteoarticular TB around the tarsal navicular is a chronic, uncommon condition affecting the midfoot, which causes significant morbidity to the patient. Tuberculosis around the tarsal navicular is rarely described in the literature. A series of three cases – two involving the talo-navicular joint and one involving the naviculo-cuneiform joint is described. Biopsy was used in all the cases for achieving diagnosis. All patients had good to fair outcome following medical management with anti-tubercular therapy. Due to the pauci-bacillary nature of the disease, a positive culture of the disease is not always possible. The diagnosis depends on a positive histopathology finding. Once an early diagnosis is achieved, antitubercular therapy is usually the mainstay. Clinical awareness of the rare presentations of this disease can help in early detection, adequate treatment and good to fair outcomes. Due to the destruction of the midfoot joints, some patients report difficulty in walking on uneven surfaces and barefoot, for which triple arthrodesis may be offered.

Introduction

Tuberculosis (TB) has no more remained an endemic disease having been labeled a “Global Emergency” by WHO [1]. This declaration is due to the occurrence of illness in the developed world due to population immigration and an aging population. Also, the human immunodeficiency virus (HIV) pandemic has added to the resurgence of tuberculosis [2]. Even though the number of cases of pulmonary tuberculosis has remained constant (and has even declined in the developed world), the number of extra-pulmonary tuberculosis (EPTB) patients has consistently risen. This increase in the number of EPTB patients led to the involvement of unusual sites more frequently. An early diagnosis and adequate medical management play a critical role in achieving a fair to a good outcome. The knowledge of rare sites of infections and unusual presentations, thus, makes the clinician more adept at picking the subtle early signs of tuberculosis.

Osteoarticular TB affecting the foot is uncommon. The incidence of osteoarticular TB is less than 3% of EPTB cases, with foot and ankle comprising <1% of all instances of osteoarticular TB [3], [4]. The symptoms in the foot are non-specific, and hematological investigations are often inconclusive, making the diagnosis difficult.

Tuberculosis around the tarsal navicular is a highly rare entity, and very few cases have been reported in the literature as case reports [5]. A case series of three patients, two with TB of the talonavicular and one patient with TB of naviculo-cuneiform joint, along with a brief discussion of the possible differential diagnoses and the course of management is presented.

Section snippets

Case 1

A 25-year-old lady presented with pain and swelling in the midfoot, which was insidious in onset and gradually increased over a period of four months. The anteroposterior and lateral radiographs of the foot were done. These showed a reduction of the talonavicular joint space (Fig. 1). The ESR was high (54 mm in the first hour). MRI of the foot was done which revealed a reduction in the talonavicular joint space and presence of edema in the peri-articular area which was hyperintense on T1 and

Discussion

The osteoarticular involvement of tuberculosis is uncommon [6]. The participation of different sites in the foot (like talonavicular and naviculocuneiform joints) and nonspecific clinical symptoms further complicates the situation. The delay in diagnosis, due to lack of awareness causes worsening in the prognosis of the disease and significant morbidity to the patient.

The involvement of the foot, especially in the midfoot, is routinely widespread at presentation because of multiple lymphatic

Funding

No funding has been received for the present study.

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