Osteoarticular tuberculosis: The great mimicker still catches us out —a case report

© 2016 The Author(s). Published by Taylor & Francis on behalf of the Nordic Orthopedic Federation. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial License (https://creativecommons.org/licenses/by-nc/3.0) DOI 10.3109/17453674.2015.1103115 A 79-year-old man of South Asian origin presented at the trauma and orthopedic unit of a district general hospital with atraumatic pain in his right elbow, which he had had for 6 months, and a persistent cough. Given the demographics of the patient and the presenting symptoms, there was high clinical suspicion of tuberculosis, which we investigated accordingly. Routine blood tests and radiographs of the chest and elbow did not give a specific diagnosis (Figure 1). In accordance with National Institute of Health and Clinical Excellence (2011) guidelines, a bronchial lavage was then performed. Samples were sent for microscopy and culture, looking specifically for acid-fast bacilli. The final culture results were reported after 8 weeks and were negative. The elbow was painful but not swollen, and there was no indication for further investigation at this stage. Throughout this time, routine clinical assessments did not reveal any systemic signs or symptoms of acute or chronic infection. The patient remained clinically well and afebrile, and routine blood tests were within reference ranges except for a mild rise in C-reactive protein. This, combined with the negative culture results, reassured us that tuberculosis was unlikely. As the elbow remained painful and swollen, but with no clinical evidence of intra-articular involvement, the patient was given the diagnosis olecranon bursitis and steroid injections were administered, initially with good response. However, a few months later he returned with worsening pain and reduced range of motion. At this time, de novo swellings were noted over the posterolateral distal humerus. He had no further respiratory issues. Aspiration under sterile conditions revealed purulent fluid, which was sent for microscopy and culture. Due to the previous (negative) culture results, tuberculosis was not suspected. Initial results did not reveal any organisms. Because of his swollen and inflamed elbow, he was now started empirically on intravenous flucloxacillin. When there was no response to this intervention, magnetic resonance imaging (MRI) of the elbow was performed and revealed a large, multi-loculated collection in continuity with the elbow joint and marked synovial proliferation with bony erosions (Figure 2). These radiological findings gave high suspicion of