ISOLATED CUNEIFORM TUBERCULOSIS A RARE CASE REPORT

Dr. Jainish Patel 1 , Dr. Parth thakor 1 , Dr. Vilkesh Patel 2 , Dr. Sarvang desai 2 and Dr.Kailashsethi 2 . Department of orthopeadics, Dhiraj General Hospital, SBKS MIRC, Piparia, Vadodara. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Tuberculosis is a challenging infectious health problem for both developed and developingcountries. Skeletal tuberculosis accounts for 1 to 3% of extra pulmonary tuberculosis. The spine ismost commonly affected, and foot and ankle involvement is rare, accounting for about 10% 1 in which Calcaneum is the most common boneinvolved. 2 Diagnosis of tuberculosis of the foot remains a dilemma because of its rarity in lower limb,especially when confined to a single bone with orwithout articular involvement. Hence, the chance ofmisdiagnosis and delay in diagnosis may add tomorbidity. 3 691 Some diseases like chronic pyogenic osteomyelitis,fungal osteomyelitis, Madura mycosis and some bone tumours may mimic tuberculosis of foot. 4 Presumptive diagnosis can be made on the basis of X-ray, MRI and histopathology of the pathological tissue.
Here we are reporting a case of 9 year old girl with swelling and pain over a rightmid foot diagnosed as tuberculosis of cuneiform on subsequent X-ray,MRI and biopsy.

Case Report:-
A 9 year old girl presented with complaints of pain and swelling over right foot for last 6 months. Swelling and pain was progressive in nature. It has increased over the last 2 months such that the patient had difficulty in walking due to pain.Associated history of dry cough since 25 days. There was no history of fever,weight loss, and loss of appetite, any infective foci or any contact of tuberculosis.
On examination, there was swelling of dorsal aspect of the foot. There was exfoliation of skin over the dorsum of foot.There was tenderness over mid foot. The temperature was mildly raised as compared to the other foot. There was inguinal lymphadenopathy. Surgical intervention was done by debridement and curettage of the lateral cuneiform with bonegrafting. Intraoperativelysoft tissue surrounding lateral cuneiform was unhealthy and the cavity inside it contained unhealthy granulation tissue.Tissue and pus was sent for Gram staining, Ziehl Nielsen staining, KOH mount, culture for fungi,pyogenic organisms, and mycobacterium tuberculosis and for histopathological examination. Diagnosis of tuberculosis of lateral cuneiform wasmade and anti-tubercular therapy was advised for 9 months and below knee slab was applied. Nonweight bearing walk was started. At 6 weeks followup, the splint was removed and physiotherapy ofankle was started. Partial weight bearing wasstarted when pain reduced and progressivelyincreased as tolerated.
The patient was followed for one anda half year.Painlessnormal range of motion was present with normal skin condition [ Figure-3].Radiograph showed sclerosis and mineralization ofsurrounding bones.

Discussion:-
Musculoskeletal tuberculosis is difficult to diagnose. The classic presentation of localised pain,fever and weight loss is rarely seen.Radiological features of musculoskeletal 693 tuberculosis may include bone marrow oedema,osteoporosis, lytic lesions or may be nonspecific.The surrounding tissue may show synovitis, jointeffusions, tenosynovitis or abscess.
Isolated tubercular involvement of foot bones withan osteolytic defect is a rare entity. 5 Dhillonet al studied 92 cases of foot, tuberculosis over 20 years, 23 were of osteolytic variety out of which 2had lesions in the cuneiform. 5 Tuberculosis of cuneiform is rare and may mimicfungal osteomyelitis, Madura mycosis, chronic pyogenic osteomyelitis and bone tumours. ESR isalmost always elevated in case of tuberculosis. 6 In our case there was a positive Monteux test,raised ESR, histopathology of the tissue specimen,Ziehl Nielsen staining and isolation ofMycobacterium on Lowenstein Jensen media,which finally lead to diagnosis.Treatment should not be delayed as delay in treatment may result in less than optimal outcome. 7 The aim of anti-tubercular treatment is to eradicatethe organism and to obtain a supple, pain freeweight bearing functional foot. With treatmentradiological changes do take place and cavities may persist for years, which have no clinicalsignificance. 7

Conclusion:-
It is concluded that isolated cystic tuberculosis of laterl cuneiform is rare. Open biopsy ,curettage with bonegrafting and histopathology, Ziehl Nielson staining and culturefor mycobacterium tuberculosis confirms thediagnosis. Antitubercular therapy for a period of 9 months should be given for better prognosis andto prevent recurrence.