Although prosthetic joint infections caused by Mycobacterium tuberculosis are rare, they may occur in immunocompromised patients or in people from regions where tuberculosis is endemic, researchers reported in a recent study.
Such infections are uncommon, “clinical suspicion should be raised in those with epidemiologic and clinical risk factors for active tuberculosis infection, and may include failure to respond to prior antibiotics for treatment of” prosthetic joint infection, they wrote.
“Although there is existing literature to support optimal management of tuberculosis, there are few to none published on management of prosthetic joint infections due to Mycobacterium tuberculosis,” Carson K. L. Lo, MD, a researcher in the McMaster University infectious diseases residency program, told Healio. “We tried to collate the information presented in case reports or series of what others have tried successfully or not in terms of diagnosis and management of this infection.”
Lo and colleagues assessed two cases of prosthetic joint infection caused by M.tuberculosis. The first was in a 71-year-old immune competent, nondiabetic woman who reported left hip pain starting in 2013. According to the study, in April of 2017, the woman reported increasing difficulty ambulating and had radiographic signs of severe arthropathy, leading to surgery. Two months following surgery and multiple hip aspirates, one aspirate was positive for M.tuberculosis.
Lo and colleagues noted that the patient was treated with isoniazid, rifampin and ethambutol for 2 months, followed by isoniazid and rifampin for an additional 10 months. In September 2018, she underwent a revision total hip arthroplasty to improve mobility and remained clinically well.
The second case was in a 50-year-old man with worsening mobility who was unable to work following a prosthetic hip infection in 2016. According to the study, his medical history included osteomyelitis as a child, complicated by osteoarthritis that required multiple surgeries.
Eventually, he underwent a total hip arthroplasty in 2013 at age 47. In 2014, he underwent a joint washout with 6 weeks of ceftriaxone, vancomycin and rifampin for culture-negative prosthetic joint infection and he continued rifampin monotherapy until reassessment in June 2016.
According to the study, he was treated with isoniazid, rifampin, ethambutol and pyrazinamide for 2 months, followed by isoniazid and rifampin for an additional 7 months. He responded well to treatments and rehabilitation and remained clinically well.
Lo explained that, based on these two cases and a subsequent literature review, clinical presentations of TB prosthetic joint infection are often nonspecific with varying symptom onset. Lo added that, although most still rely on a mycobacterial culture of tissue or fluid sample obtained from a joint, there may be interest in rapid molecular diagnostics if they are available.
“Although tuberculosis prosthetic joint infection is a rare manifestation of tuberculosis, one should consider this in their differential diagnosis if a patient presents with prosthetic joint infection who fails to respond to initial empiric antibiotics and/or have joint cultures negative for bacterial growth,” Lo said. “Treatment remains [on] a case-by-case basis but often involves both antimycobacterial drugs and surgical management.”