Giri* was 25-years-old when he felt a persistent pain around his left shoulder joint which also affected the movement of his arm. Initially, he was treated for frozen shoulder, but when the area became warm and swollen, it prompted further evaluation. An MRI revealed destruction in the upper part of the humerus - the long bone of the arm - along with fluid accumulation. Samples sent to the lab for tests confirmed tuberculosis (TB).
The Gurgaon-based man was then started on anti-tubercular treatment, which continued for over nine months. Follow-up scans showed healing of the bone, and his arm movement improved significantly within six to eight weeks of treatment
According to Dr RandeepGuleria, chairman of internal medicine, respiratory and sleep medicine, Medanta, Gurugram, bone tuberculosis is one of the forms of tuberculosis, and, compared to lung or lymph node TB, it is less common but fairly frequent in India.
“However, it is often misdiagnosed initially because patients may present with atypical symptoms. Many patients are treated for simple inflammation or muscular pain for some time before the underlying infection is identified,” he said.
Bone tuberculosis is caused by Mycobacterium tuberculosis, the same bacteria responsible for pulmonary TB. The bacteria can spread through the bloodstream from the lungs or another infected site, reaching the bones or joints.
Once there, it can cause bone destruction, a condition known as osteomyelitis. In some cases, an abscess may form around the bone. If the infection spreads to nearby joints, it can lead to septic arthritis.
This was the case with an IT professional in Chennai. Suffering from back pain, he had visited many doctors and underwent treatment for his back pain with painkillers and physiotherapy, but got no respite. Finally, an MRI confirmed he has TB. Due to involvement of multiple vertebrae with a large abscess (collection of pus), he underwent a spinal stabilisation procedure followed by anti-tuberculosis therapy of nine months. He rejoined his work after recovering rapidly from post-surgery.
In both cases, both doctors and the patients were initially unaware that it was bone TB or skeletal TB. It is not their fault alone. Most people in India, which contributes about one-fourth of the world's tuberculosis (TB) burden, think of tuberculosis linked only with pulmonary TB or TB that affects the lungs.
According to a study published in the Cureus Journal of Medical Science, the diverse clinical spectrum of musculoskeletal TB has earned it the nickname “great mimicker,” owing to its nonspecific presentations and ability to mimic various infectious and non-infectious conditions on both clinical and radiological grounds.
This, the study said, frequently leads to delayed diagnosis. India records around 2.5 million new TB cases and nearly 3,00,000 deaths annually. Of this, an estimated number of bone TB cases is 30,000-90,000 per year.
According to a study by the TB Research Centre in Chennai, although bone TB is less common than pulmonary TB, it still accounts for approximately 2% of all TB cases. However, other studies have reported that skeletal TB accounts for 5-20% of all TB infections.
The good news, however, is that bone TB is curable.
Early initiation of anti-tubercular therapy (ATT) achieves cure rates of up to 95% in early-stage disease, highlighting the critical role of timely diagnosis, experts said. “The key is maintaining a high index of suspicion so that the condition is diagnosed early. Often, patients first consult physiotherapists or orthopaedic specialists for the pain before TB is suspected,” said Dr Guleria, the former director of AIIMS, New Delhi.
Once diagnosed, the patient requires ATT, sometimes for a longer duration than standard TB treatment. “In certain cases, surgical intervention may also be required, particularly if there is significant bone damage or abscess formation. With appropriate treatment, patients can recover well,” he added.
Dr UmeshSrikantha, additional director, neuro and spine surgery, Fortis Hospital, Bannerghatta Road, Bengaluru, said, India carries one of the world’s highest tuberculosis burdens.
TB medicines, he said, serve two purposes – they eliminate the bacteria and stop additional bone destruction. “If surgical intervention is needed in tuberculosis, it can be done with minimally invasive techniques, which decreases surgical trauma to the spine when there is already bone destruction due to the infection itself,” he added.
However, experts said that if the disease is not showing a healing response within four to five months, despite multi-drug therapy, one should consider such cases as “resistant” and treat them accordingly.
Speaking about the IT patient he treated, Dr SenthilKamalasekaran, orthopaedic surgeon at Apollo Spectra Hospitals, Chennai, said that missing the diagnosis could have been catastrophic. “Dormant bacteria can reactivate years later, especially when immunity is weakened.”
(*name changed)