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Musculoskeletal » Lower Extremity
Tarsal-metatarsal joints tuberculous arthritis
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Presentation A 73 year old woman with history of bilateral calf vein thrombosis, secondary varix, infected calf ulcers and iron deficiency anemia, was admitted to the hospital for pain and partial functional compromise of the legs. She described a 2 year history of gradually increasing calf pain, left greater than right. One month before admission, the patient noted the presence of an ill defined, reddish area, edema and a painful mass in the lower third of the left calf. Local examination showed in the distal third of the left calf a tender pseudotumoral lesion, with hyperpigmentation of the neighboring skin. The patient was referred for a soft tissue ultrasound examination of the calf.
Caption: Longitudinal section, dorsal left foot.
Description: Soft tissue edema. An inhomogeneous fluid collection is seen at the level of the tarsal – metatarsal joint space. Irregularity of the bone surface and detached little bone fragments are also seen.
Caption: Cross section of the dorsal left foot
Description: A fluid collection containing detached bone fragments surrounds the proximal epiphysis of the metatarsal.
Caption: Longitudinal section of the ventral left foot
Description: Hypoechoic, moderately vascularized mass surrounds the metatarsals
Caption: Longitudinal section of the ventral left foot
Description: Hypoechoic, inhomogeneous mass, suggesting multifocal infectious arthritis of the left foot associated with sole abscess.
Caption: Latero-lateral radiograph of the left foot
Description: Soft tissue calcifications along the vessels and diffuse osteoporosis. This view depicts better the changes at the level of the tarsal – metatarsal joints
Caption: Comparative foot radiograph, dorsoplantar view
Description: Prominent changes in the structure of II – V tarso-metatarsal joints of the left foot, with osteoporosis, osteolysis and partial destruction of the epiphyses of the metatarsal level.
Differential Diagnosis Rheumatoid arthritis: This disease is characterized by symmetrical articular involvement. In this case, the lesions were unilateral and there were no symptoms at the level of the hands.

Abscess of the sole of the foot: bacterial seeding occurs either directly (open injuries) or hematogenously (sepsis);

Tarso-metatarsal osteoarthritis. 

Neurotrophic arthropathy (Charcot joint): The early clinical signs are joint swelling, deformity and instability. Causes include syphilis, syringomyelia, or diabetes. They usually occur in weight-bearing joints. In spite of the radiologic appearance, the patient had none of the clinical conditions known to produce this disease.

Final Diagnosis Tarso-metatarsal joints arthritis (of tuberculous origin, at pathology).
Discussion Tuberculosis of bones and joints may appear in any part of the skeleton. In most cases, the infection is monoarticular, but polyarticular involvement is also possible [1]. The most commonly involved part of the skeleton is the spine (50%), but the most frequently affected joints are the hip or knee [3]. In the beginning, there are few clinical signs and symptoms. This is the reason why the diagnosis can be delayed for months or even years. Frequently, the disease begins with local tenderness, decreased range of motion and swelling. The symptoms improve at rest, and their intensity is proportional to the gravity load of the affected region. Low grade fever and weight loss can be also present [4]. Immunosuppression (AIDS), corticosteroid therapy, trauma or alcohol abuse are well known predisposing factors [4]. Any age group may be affected. Natural evolution: due to cartilage and bone destruction, subluxation or ankylosis may appear [2]. 

Under appropriate treatment, the healing may be complete, but in the absence of correct treatment, ankylosis may result. Chest radiography shows active disease in less than 50% of cases [3]. The diagnosis is difficult to establish because the disease is rare and the radiographic signs are difficult to differentiate from other types of septic arthritis. Evocative radiological signs comprise the Phemister triad, consisting of: osteoporosis around the joint, peripheral bone erosions and gradual narrowing of joint space [2]. Bone scintigraphy and MRI may also play a role in the diagnosis of this entity. The final diagnosis is obtained either by aspiration and culture of the joint contents or by pathologic examination of bony fragments from the diseased joint. 

In the present case ultrasound examination has the following merits:
- It established the location of the lesions, which was different from where the clinical symptoms pointed;
- It suggested the diagnosis of arthritis in spite of the radiologic appearance, even though it could not specify the cause;
- To the best of our knowledge, the ultrasound appearance of tarsometatarsal tuberculous arthritis was not previously described.
Case References 1) Edeiken J. Radiologic Approach to Arthritis, Semin. Roentgenol., 1982,17:8-15.
2) Resnick D., Petterson H. Skeletal Radiology, The Nicer Institute, Oslo, 1992.
3) Sutton D. Textbook of Radiology and Imaging (sixth edition) volume 1, 1993, pg.51-53.
4) Ooms E., Schepper A De, Simoens W., Radiology, Antwerp University Hospital, Wilrykstraat 10, b – 2650 Edegem, Tuberculous arthritis of the knee.
Technical Details - Ultrasound images were obtained with MEDISON KRETZ SONOACE 8800 MT scanner, with a 7.5 MHz linear transducer.
- Digital radiographs were obtained on a Swissray GEN-X-2000 machine
Follow Up Laboratory examination revealed the presence of inflammation and anemia: increased sedimentation rate (45 –84 mm/h), increased fibrinogen value (575 mg/dl), decreased hemoglobin value (10g/dl) and decreased hematocrit value (29). The radiographs of the foot are presented in figures 5 and 6. Surgical intervention for removal of all bone fragments and necrotic tissue at the left tarsometatarsal level was performed. At pathology, the exam of the bone fragments and soft tissue showed the presence of tuberculous granulomas with caseous foci. The pathologic diagnosis was tarsometatarsal tuberculous arthritis of the left foot. Appropriate drug therapy was started and the patient was scheduled for reconstructive surgery.
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