|IMAGES IN RHEUMATOLOGY
|Ahead of print publication
Tubercular dactylitis: A rare entity
Siddharth Raj Yadav, Nitesh Gupta, Pranav Ish
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi, India
Department of Pulmonary, Critical Care and Sleep Medicine, VMMC and Safdarjung Hospital, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Keywords: Adult, spina ventosa, tubercular dactylitis
A 17-year-old girl presented with complaints of swelling and pain of the left middle finger for 1 month along with low-grade fever. There was no history of any trauma, weight loss, joint pains, diabetes mellitus, or previous significant drug history. General examination revealed a thinly built female with no peripheral lymphadenopathy. There was a swelling on the left middle finger, around 2 cm in diameter, tender, nonmobile, firm with slight increase in local temperature [Figure 1].
|Figure 1: Photograph showing swelling of the middle finger of the left hand with distal mehendi application in all digits|
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The patient was conscious, oriented with stable vitals. Hematological investigations and blood sugar were preserved. She was HIV negative. Chest X-ray [Figure 2] and ultrasonography abdomen was normal and sputum for acid-fast bacilli was negative. The roentgenogram of the left hand [Figure 3] revealed reduced density of all visualized bones, significant swelling around the proximal interphalangeal, and juxta-articular sclerosis of the middle and proximal phalanges along with erosion in the articular surfaces of proximal phalanges. Rheumatoid factor was negative. Her Mantoux test showed 20 mm induration. Fine-needle aspiration cytology of the digital swelling revealed epithelioid cell granulomas and necrosis [Figure 4]. A diagnosis of tubercular dactylitis was made and antitubercular therapy was given for 1 year with favorable response.
|Figure 2: Chest radiograph revealing no significant abnormality except for clothing artifacts in the outermost parts of bilateral middle zones|
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|Figure 3: Hand radiograph posteroanterior view showing mixed lytic and sclerotic destruction of the middle phalanx of the middle finger with bulbous thickening of soft tissue around the proximal interphalangeal joint. The distal end of the proximal phalanx also showing ill-defined sclerosis. However, proximal interphalangeal joint space is well maintained and no periosteal reaction is seen|
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|Figure 4: Giemsa-stained smears showing epithelioid cell granulomas with evidence of caseous necrosis (×400)|
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Vertebral tuberculosis is the most common form of skeletal tuberculosis followed by hip, knee, elbow, ankle, and sacroiliac joints. Tuberculosis of metacarpals, metatarsal, and phalanges of hands and feet is known as tubercular dactylitis, which is distinctly rare (4%–8%) in adults as the epiphyseal centers are well established. Infections start in medullary cavity of the bone which is supplied by the nutrient artery where the first inoculum of infection is lodged, and the granulation tissue extends into the cortex.,, Layers of new bone are formed underneath the periosteum, resulting in a spindle-shaped expansion of the bone called spina ventosa (meaning wind-filled sail); abscess and sinus formation is also seen.
Differential diagnostic considerations include pyogenic osteomyelitis, Brodie's abscess, Kaposi's sarcoma, and luetic dactylitis. Clinically, pyogenic osteomyelitis tends to be acutely painful, swollen, and hot with fever. Psoriatic dactylitis involves sausage-shaped fingers with skin and nail changes. In reactive arthritis, dactylitis is also sausage shaped associated with enthesopathy, sacroiliitis, scleritis, and anterior uveitis. Enchondromas present with multiple swellings involving hands and feet with pathological fractures with a histopathology diagnosis. Tuberculous osteomyelitis is relatively benign with mild pain and minimal pyrexia.
To conclude, tubercular dactylitis is a rare form of osteoarticular tuberculosis. A high index of suspicion with appropriate investigations can help in an early diagnosis and treatment of this curable illness.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Abebe W, Abebe B, Molla K, Alemayehu T. Tuberculous dactylitis: An uncommon presentation of skeletal tuberculosis. Ethiop J Health Sci 2016;26:301-3.
Thatoi P, Parida M, Barik R, Das B. Multifocal tubercular dactylitis: A rare presentation of skeletal tuberculosis in an adult. J Clin Diagn Res 2017;11:OD23-4.
Ranjan R, Goel L, Sud A, Sinha A, Tulika, Kumar R. Bilateral Tubercular Dactylitis: Unusual presentation of an usual disease. Indian J Tuberc 2019;66:346-352. doi: 10.1016/j.ijtb.2017.05.002.
Sahli H, Roueched L, Sbai MA, Bachali A, Tekaya R. The epidemiology of tuberculous dactylitis: A case report and review of literature. Int J Mycobacteriol 2017;6:333-5.
] [Full text]
Sbai MA, Benzarti S, Sahli H, Sbei F, Maalla R. Osteoarticular tuberculosis dactylitis: Four cases. Int J Mycobacteriol 2015;4:250-4. [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4]