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Tuberculosis of the Ankle in Childhood: Clinical, Roentgenographic and Computed Tomography Findings

Division of Pediatric Neurology, University of Catania, Catania, Italy; Departments of Clinical Genetics and Paediatrics, Oxford Radcliffe Hospital NHS Trust, Oxford, UK

Vito Pavone, MD

Orthopedic Clinic, University of Catania, Catania, Italy

Agata Polizzi, MD

Pierluigi Smilari, MD

Divisions of Pediatric Neurology, University of Catania, Catania, Italy

Giovanni F. Di Fede, MD

Pediatric Radiology Unit, Pediatric Clinic, University of Catania, Catania, Italy

Giovanni Sorge, MD

Divisions of Pediatric Neurology, University of Catania, Catania, Italy

Salvatore Musumeci, MD

Pediatric Infectious Diseases, University of Catania, Catania, Italy

We report on three Italian children who presented with unilateral ankle tuberculosis (TB) consecutively during a short time period and in the same geographical area. A 6-year-old-girl with a family history of TB had limited mobility of the right leg at age 9 months; Mantoux test and radiographs at that age yielded normal findings. When severe right tibiotarsal swelling, reddening, pain and restriction of motion became apparent at age 4.6 years, the typical lesions of TB were evident on radiographs and computed tomographic (CT) scans. Mantoux test and synovial biopsy confirmed TB. A three-drug regimen of treatment proved useless: articular cartilage destruction and diffuse osteosclerosis ensued. Only a four-drug prolonged regimen of treatment proved to be somewhat effective. A 5-year-old girl had a 6-month history of painless swelling and limited mobility of the ankle; radiographs and CT showed osteopenia with marginal erosion of cartilages. A 14-month-old boy presented with a 2-week history of painless swelling ankle. Radiographs showed decreased bone density of talocalcanear bones. Mantoux test and synovial biopsy confirmed TB in both patients; treatment with a three-drug regimen greatly reduced symptoms. A careful suspicion of the diagnosis of tuberculosis is paramount in children with chronic or subacute monoarticular arthritis, even in absence of a positive tuberculin test or abnormalities on chest radiograph. When negative early on, the tuberculin test should be repeated after 6 weeks of arthritis, and a needle biopsy of the synovium is required in those children with monoarticular arthritis and a positive tuberculin test. Careful therapy is necessary to avoid sequelae that may lead to severe osteoarticular damage.

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