Delays in the diagnosis and treatmentof bone and joint tuberculosis in the United Kingdom

• Published in: Journal of bone and joint surgery. British volume Vol. 100-B; no. 1; pp. 119 - 124
• Main Authors: Broderick, C, Hopkins, S, Mack D J F, Aston, W, Pollock, R, Skinner, J A, Warren, S
• Format: Journal Article
• Language: English
• Published: London British Editorial Society of Bone & Joint Surgery 01.01.2018
• Subjects: Biopsy; Bones; Medical diagnosis; Tuberculosis
• ISSN: 2049-4394; 2049-4408
• DOI: 10.1302/0301-620X.100B1.BJJ-2017-0357.R1

AimsTuberculosis (TB) infection of bones and joints accounts for6.7% of TB cases in England, and is associated with significantmorbidity and disability. Public Health England reports that patientswith TB experience delays in diagnosis and treatment. Our aims wereto determine the demographics, presentation and investigation ofpatients with a TB infection of bones and joints, to help doctorsassessing potential cases and to identify avoidable delays.Patients and MethodsThis was a retrospective observational study of all adults withpositive TB cultures on specimens taken at a tertiary orthopaediccentre between June 2012 and May 2014. A laboratory informationsystem search identified the patients. The demographics, clinical presentation,radiology, histopathology and key clinical dates were obtained frommedical records.ResultsA total of 31 adult patients were identified. Their median agewas 37 years (interquartile range (IQR): 29 to 53); 21 (68%) weremale; 89% were migrants. The main sites affected were joints (10,32%), the spine (8, 26%) and long bones (6, 19%); 8 (26%) had multifocaldisease. The most common presenting symptoms were pain (29/31, 94%)and swelling (26/28, 93%). ‘Typical’ symptoms of TB, such as fever,sweats and weight loss, were uncommon. Patients waited a medianof seven months (IQR 3 to 13.5) between the onset of symptoms and referralto the tertiary centre and 2.3 months (IQR 1.6 to 3.4.)) betweenreferral and starting treatment. Radiology suggested TB in 26 (84%),but in seven patients (23%) the initial biopsy specimens were notsent for mycobacterial culture, necessitating a second biopsy. RapidPolymerase Chain Reaction-based testing for TB using Xpert MTB/RIFwas performed in five patients; 4 (80%) tested positive for TB.These patients had a reduced time between the diagnostic biopsy andstarting treatment than those whose samples were not tested (medianeight days versus 36 days, p = 0.016).ConclusionPatients with bone and joint TB experience delays in diagnosisand treatment, some of which are avoidable. Maintaining a high indexof clinical suspicion and sending specimens for mycobacterial cultureare crucial to avoid missing cases. Rapid diagnostic tests reducedelays and should be performed on patients with radiological features ofTB.Cite this article: Bone Joint J 2018;100-B:119–24.