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Osteoarticular tuberculosis in paediatrics: A review of 20 years of cases in a tertiary hospital
Tuberculosis osteoarticular en la edad pediátrica, revisión de casos en 20 años en un hospital terciario
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"Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "291" "paginaFinal" => "292" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María José Pérez Durán, Bárbara Moreno Sanz-Gadea, Teresa del Rosal Raves, María José Mellado Peña, Fernando Baquero-Artigao" "autores" => array:5 [ 0 => array:4 [ "nombre" => "María José" "apellidos" => "Pérez Durán" "email" => array:1 [ 0 => "mjopduran@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Bárbara" "apellidos" => "Moreno Sanz-Gadea" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Teresa" "apellidos" => "del Rosal Raves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span 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"es" => array:1 [ "titulo" => "Tuberculosis osteoarticular en la edad pediátrica, revisión de casos en 20 años en un hospital terciario" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tuberculosis (TB) is one of the most prevalent infectious diseases worldwide. Paediatric patients are at significantly higher risk than adults of progressing to tuberculosis disease and developing disseminated and extrapulmonary forms of TB. In addition, in recent years we have witnessed an emergence of multidrug-resistant (MDR) strains of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> (MTB) in Spain, especially in immigrants from highly endemic countries.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> Extrapulmonary forms of TB, and osteoarticular TB in particular, pose a considerable diagnostic challenge on account of their insidious course and atypical manifestations.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> Osteoarticular TB amounts to approximately 1–5% of all cases of paediatric TB, and to 10–17% of extrapulmonary TB cases.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,4</span></a> However, few case series have been published on this form in the literature, and most of these studies were conducted in highly endemic countries.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of our study was to define the characteristics of paediatric osteoarticular TB in Spain. We made a retrospective review of cases of osteoarticular TB diagnosed in patients aged less than 14 years in the Hospital Universitario La Paz over a period of 20 years (January 1996–Debember 2015). We collected epidemiologic, clinical, radiologic, microbiologic, treatment and outcome data. We considered that skin tuberculin tests were positive when the induration was 5<span class="elsevierStyleHsp" style=""></span>mm or greater at 48–72<span class="elsevierStyleHsp" style=""></span>h from the intradermal injection of 2 units of RT-23 tuberculin in 0.1<span class="elsevierStyleHsp" style=""></span>mL solution (Statens Serum Institut; Copenhagen, Denmark). We entered and analysed the data in Excel (Microsoft; Redmond, USA).</p><p id="par0015" class="elsevierStylePara elsevierViewall">We identified 213 cases of children with confirmed TB, of which 11 (5.2%) presented with osteoarticular involvement. This presentation was the third most frequent following pulmonary TB (132 cases, 62%) and tuberculous lymphadenitis (41 cases, 19%). Of the 11 patients with osteoarticular involvement, 4 (36.4%) received a diagnosis of spinal TB (3 dorsal, 1 lumbar); 5 (45.4%) of articular TB (2 in the knee, 1 in the hip, 1 in the ankle, and 1 with polyarticular TB with hip, knee and shoulder involvement); and 2 (18.2%) of isolated osteomyelitis (1 in the femur, 1 in the mastoid process). Five cases (45%) presented with concomitant pulmonary involvement. The male to female ratio was 1.2:1, and the mean age at diagnosis was 5.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.6 years. The median delay in diagnosis was 12 months (range, 2 weeks-3 years). The most frequent reason that led to suspicion of TB was the presence of characteristic findings on magnetic resonance (bone destruction with cold abscesses or synovial hypertrophy) in children of immigrants from countries with a high TB burden (9 patients, 82%). All the patients were immunocompetent. The investigation of contacts identified the index case in 4 patients (36.4%) and relatives with latent tuberculosis infection in 5, and was negative in 2.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The most frequent presenting symptom was functional impairment (64%) accompanied by pain in 45% of cases, and fever in 36% of cases. All patients had a positive tuberculin skin test. The presence of <span class="elsevierStyleItalic">M. tuberculosis</span> was confirmed in 82% (9/11): 2 in joint fluid (PCR and culture) and 7 in a synovial, bone or perilesional abscess biopsy specimens (1 by culture, 6 by PCR and culture), with the additional detection of growth in the gastric aspirate culture of 2 of these patients. The most frequent radiologic findings were bone destruction (82%), cold abscesses (36%) and synovial hypertrophy (27%). Two strains of MDR-MBT were isolated, both in children born in Spain but with index cases from highly endemic countries: one patient had travelled to China and stayed with a grandfather that had TB; the other one was living with a Moroccan man that died of the disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The duration of treatment ranged from 9 to 12 months, except in patients with MDR strains, who were treated for 24 months. One boy needed to switch treatments due to acute drug-induced liver failure. Forty-five percent of patients required surgical intervention (3 to drain the lesion, 2 to stabilise the joint). Forty-five percent developed sequelae in the long term: 3 patients developed kyphosis, 1 leg-length inequality and 1 limited mobility.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In our case series, paediatric osteoarticular TB was the third most frequent form of disease presentation, which was similar to what has been described in the literature.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> We would like to highlight the diagnostic delay and the high percentage of children that required surgical intervention and had sequelae in our study. These findings underscore the importance of including tuberculosis disease in the differential diagnosis of osteoarticular lesions with a slow course, accompanied by pain or with prolonged functional impairment, even in the absence of fever, and especially in immigrant children or children in contact with immigrants from highly endemic countries.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Furthermore, the prevalence of MDR-MBT is higher in these patients, so it is essential that adequate samples are collected to take advantage of the available molecular diagnostic techniques for the early detection of drug resistances.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez Durán MJ, Moreno Sanz-Gadea B, del Rosal Raves T, Mellado Peña MJ, Baquero-Artigao F. Tuberculosis osteoarticular en la edad pediátrica, revisión de casos en 20 años en un hospital terciario. An Pediatr (Barc). 2017;87:291–292.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric extrapulmonary tuberculosis: clinical spectrum, risk factors and diagnostic challenges in a low prevalence region" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Santiago" 1 => "D. Blázquez-Gamero" 2 => "F. Baquero-Artigao" 3 => "J. Ruiz-Contreras" 4 => "J.M. Bellón" 5 => "M.A. Muñoz-Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/INF.0000000000001270" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2016" "volumen" => "35" "paginaInicial" => "1175" "paginaFinal" => "1181" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27753763" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of immigration on pulmonary tuberculosis in Spanish children: a three-decade review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Del Rosal" 1 => "F. Baquero-Artigao" 2 => "M.J. García-Miguel" 3 => "A. Méndez-Echevarría" 4 => "G. López" 5 => "F.J. Aracil" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/INF.0b013e3181d5da11" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2010" "volumen" => "29" "paginaInicial" => "648" "paginaFinal" => "651" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20216334" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric drug-resistant tuberculosis in Madrid: family matters" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B. Santiago" 1 => "F. Baquero-Artigao" 2 => "A. Mejías" 3 => "D. Blázquez" 4 => "M.S. Jiménez" 5 => "M.J. Mellado-Peña" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/INF.0000000000000111" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "345" "paginaFinal" => "350" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24622395" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteoarticular tuberculosis-a ten years case review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.D. Enache" 1 => "I.E. Pleşea" 2 => "D. Anuşca" 3 => "B. Zaharia" 4 => "O.T. Pop" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rom J Morphol Embryol" "fecha" => "2005" "volumen" => "46" "paginaInicial" => "67" "paginaFinal" => "72" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16286988" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spinal tuberculosis in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Eisen" 1 => "L. Honywood" 2 => "D. Shingadia" 3 => "V. Novelli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/archdischild-2011-301571" "Revista" => array:6 [ "tituloSerie" => "Arch Dis Child" "fecha" => "2012" "volumen" => "97" "paginaInicial" => "724" "paginaFinal" => "729" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22734017" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008700000005/v1_201710301006/S2341287917301655/v1_201710301006/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008700000005/v1_201710301006/S2341287917301655/v1_201710301006/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287917301655?idApp=UINPBA00005H" ]
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| 2021 June | 59 | 49 | 108 |
| 2021 May | 52 | 38 | 90 |
| 2021 April | 147 | 68 | 215 |
| 2021 March | 75 | 55 | 130 |
| 2021 February | 45 | 26 | 71 |
| 2021 January | 46 | 20 | 66 |
| 2020 December | 79 | 28 | 107 |
| 2020 November | 54 | 24 | 78 |
| 2020 October | 34 | 17 | 51 |
| 2020 September | 58 | 26 | 84 |
| 2020 August | 58 | 26 | 84 |
| 2020 July | 60 | 17 | 77 |
| 2020 June | 51 | 17 | 68 |
| 2020 May | 43 | 23 | 66 |
| 2020 April | 36 | 18 | 54 |
| 2020 March | 41 | 22 | 63 |
| 2020 February | 47 | 26 | 73 |
| 2020 January | 38 | 29 | 67 |
| 2019 December | 43 | 30 | 73 |
| 2019 November | 33 | 14 | 47 |
| 2019 October | 37 | 15 | 52 |
| 2019 September | 48 | 29 | 77 |
| 2019 August | 58 | 32 | 90 |
| 2019 July | 47 | 48 | 95 |
| 2019 June | 41 | 23 | 64 |
| 2019 May | 50 | 36 | 86 |
| 2019 April | 62 | 24 | 86 |
| 2019 March | 26 | 18 | 44 |
| 2019 February | 42 | 20 | 62 |
| 2019 January | 34 | 24 | 58 |
| 2018 December | 43 | 40 | 83 |
| 2018 November | 68 | 33 | 101 |
| 2018 October | 88 | 16 | 104 |
| 2018 September | 39 | 15 | 54 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 6 | 0 | 6 |
| 2018 June | 8 | 0 | 8 |
| 2018 May | 13 | 0 | 13 |
| 2018 April | 34 | 0 | 34 |
| 2018 March | 26 | 0 | 26 |
| 2018 February | 6 | 0 | 6 |
| 2018 January | 22 | 0 | 22 |
| 2017 December | 20 | 0 | 20 |
| 2017 October | 0 | 9 | 9 |
Show all
