Deep soft tissue fistulae, sinus tracts, and abscesses are better delineated on gadolinium-enhanced images [ Figure 13 ]. Tuberculous osteomyelitis of the second metatarsal bone of the left foot. Sagittal, fat-suppressed, T2W MRI A shows bone marrow edema, adjacent tenosynovitis arrow of the extensor tendon and increased signal within the adjacent soft tissues on the plantar and dorsal aspects of the foot.
Coronal, contrast-enhanced, fat-suppressed, T1W MRI B shows marked enhancement of the soft tissue involvement with central necrosis and abscess formation on the dorsal aspect of the second metatarsal bone arrow. Note the hazy contour of the dorsal cortex of the diaphysis. Location : Primary tuberculous tenosynovitis is considered an extremely rare condition.
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It most commonly involves the flexor tendon sheaths of the dominant hand. Ultrasound : USG is the primary investigation to confirm the diagnosis of tenosynovitis and to reveal the degree and extent of tendon and tendon sheath involvement. As in other forms of chronic tenosynovitis, tendon and synovial thickening predominate, with relatively little synovial sheath effusion; in contrast, in acute suppurative tenosynovitis synovial sheath effusion is the predominant feature.
MRI : MRI may be helpful to delineate the precise extent of soft tissue involvement and any associated osseous or joint involvement. On MRI, the appearance of tuberculous tenosynovitis depends largely on the duration of the disease. Jaovisidha et al. The hygromatous stage is characterized by the presence of fluid inside the tendon sheath without associated sheath thickening.
The serofibrinous stage is characterized by thickening of the flexor tendons and synovium, with multiple tiny hypointense nodules within the hyperintense synovial fluid on T2W images. These tiny nodules correspond to the rice bodies previously reported in the literature. Finally, there is the fungoid stage, which is characterized by a soft tissue mass involving the tendon and tendon sheath. Location : The trochanteric [ Figure 14 ], subacromial, subgluteal, and radioulnar wrist bursae are most commonly affected.
The distended bursa contains fluid, whereas the thickened synovium is of relatively low signal intensity. Plain radiography : Long-standing bursitis is usually complicated by local osteopenia due to hyperemia, while local pressure of the enlarged bursa may result in focal osteolytic bone destruction e. The wall of the distended bursa may contain calcifications, which may be visible on radiographs. MRI: Two patterns of involvement have been reported on MRI: a uniform distension of the bursa or multiple small abscesses in the bursa.
Tuberculous involvement of the muscle or deep fascia is a rare form of musculoskeletal TB and is mostly seen in immunosuppressed patients. Striated muscle is one of the most resistant tissues to mycobacterial infection.
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This has been attributed to several factors, including poor oxygen content, high lactic acid concentration, and a paucity of reticuloendothelial tissue. Location : Any muscle may be involved and there are rare case reports of tuberculous pyomyositis affecting the muscles of the upper and lower extremities as well as of the chest and abdominal wall.
The internal mammary nodes are most commonly involved. It is believed that lymph node enlargement and subsequent caseation necrosis may burrow through the chest wall to form these soft tissue collections. Chest wall tuberculosis. Axial, contrast-enhanced, fatsuppressed, T1W MRI shows a pleural-based mass along the dorsal aspect of the right thoracic wall, with irregular peripheral enhancement. Note the hazy contours of the adjacent rib arrow due to osteomyelitis. Ultrasound : Tuberculous pyomyositis has been rarely reported on USG.
The lesion is of low signal intensity on T1W images and of high signal intensity on T2W images [ Figure 16 ]. Abscess formation is the rule in all cases of pyomyositis. The peripheral wall of the abscess shows a subtle hyperintensity on T1W images and hypointensity on T2W images. This finding is related to oxygen free radicals and iron within macrophages in the wall of the abscess.
Associated cellulitis [ Figure 16 ] and osteoarticular involvement [ Figure 17 ] may also be present. Tuberculous myositis of the forearm.
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Axial, fat-suppressed, T2W MRI shows high signal intensity within the muscle bellies as well as between the various flexor muscles. There is also increased T2 signal within the adjacent subcutaneous tissue. Soft tissue tuberculosis along the medial aspect of the left knee.
There is associated osteomyelitis. Coronal, fat-suppressed, T2W MRI shows a high-signal-intensity soft tissue abscess, with adjacent bone marrow edema involving the medial condyle and a T2 hyperintense focus in the medial proximal tibia, due to the associated osteomyelitis. Extra-axial musculoskeletal TB may involve a wide variety of tissues, including the joints, bones, muscles, tendon sheaths, or synovial bursae, or a combination of these.
USG allows a quick evaluation of soft tissue masses, abscesses, joint effusions, and the degree and extent of tendon and tendon sheath involvement. CT scan may be helpful for the detection of osseous or joint involvement, the presence or absence of periosteal reaction and soft tissue calcifications, sclerosis, and soft tissue abscesses.
USG and CT scan are particularly useful for guiding fine needle aspiration or biopsy to provide material for histopathological examination, PCR-based assay for mycobacterial DNA, and culture. MRI is the preferred technique to demonstrate early bone marrow changes in tuberculous osteomyelitis and arthritis, joint effusion, and cartilage destruction.
Unfortunately, extraspinal musculoskeletal TB, produces no pathognomonic imaging signs and, in the advanced stages, mimics other disease processes. Therefore, appropriate laboratory tests are mandatory to confirm the diagnosis. The authors wish to thank Kristof De Cuyper, MD, for technical assistance in the preparation of this manuscript.
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Read article at publisher's site DOI : SA J Radiol , 24 1 , 29 Sep Korean J Radiol , 19 6 , 18 Oct Curr Health Sci J , 44 3 , 15 Jul To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation. Eur J Radiol , 57 1 , 31 Aug Cited by: 26 articles PMID: Semin Musculoskelet Radiol , 15 5 , 11 Nov Cited by: 11 articles PMID: Microbiol Spectr , 5 2 , 01 Apr Cited by: 5 articles PMID: Cited by: 10 articles PMID: Coronavirus: Find the latest articles and preprints.
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Recent Activity. Recent history Saved searches. Search articles by 'Adelard I De Backer'. De Backer AI 1 ,. Vanhoenacker FM ,. Sanghvi DA. Affiliations 1 author 1. Share this article Share with email Share with twitter Share with linkedin Share with facebook. Free full text. Indian J Radiol Imaging. PMID: Author information Copyright and License information Disclaimer.
Correspondence: Dr Filip M. E-mail: eb. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Go to:. Keywords: Computed tomography, Magnetic Resonance Imaging, musculoskeletal, radiography, tuberculosis, ultrasound.
Open in a separate window. Figure 1 A,B. Causative organisms Mycobacterium tuberculosis is the main causative organism and only a few cases are attributable to Mycobacterium bovis.
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General mechanisms of spread Musculoskeletal TB mostly results from hematogenous dissemination of mycobacteria or lymphogenous spread from a primary or reactivated focus of infection. TB of joints TB of a joint may result from hematogenous dissemination through the subsynovial vessels or, indirectly, from epiphyseal more common in adults or metaphyseal more common in children lesions that erode into the joint space.
Tuberculous osteomyelitis The bones may be involved as a result of hematogenous spread from a primary focus, which is usually in the lung or the lymphatic system. Tuberculous tenosynovitis and bursitis Tuberculous tenosynovitis may result from hematogenous spread or it may be due to periarticular extension of tuberculous arthritis. Tuberculous myositis Skeletal muscle involvement without bony involvement, resulting from hematogenous or lymphatic spread, is extremely rare.
Figure 2 A-D. Figure 3. Figure 4 A-E. Figure 5 A-D. Figure 6. Figure 7.