A Case Report of a 20 year old male patient with ankle TB Osteomyelitis with associated sural nerve neuralgia
Case Report of a 20 year old male patient with ankle TB Osteomyelitis with associated sural nerve neuralgia
Case description
This is the case of a 20 year old male, farmer by occupation who presented to our hospital with chief complaints of pain over the right ankle and dorsum of the foot which was causing difficulty in walking.
Patient developed pain over dorsum of the right foot on one morning in the month of January 2022, the pain was sudden in onset, and of mild intensity following which he was advised to take painkillers by the physician in his locality. Pain subsided on taking painkillers and patient continued to eat these everyday for the next 4 months.
Gradually he developed a painful swelling over the right foot, the pain and the size of the swelling kept increasing because of which he once again seeked medical attention from a tertiary hospital where an MRI was done and the following findings were revealed:
1. Hyperintensity signal seen in the anterior part of the calcaneum, talus, navicular, sign of marrow edema
2. Cortical irregularity seen in talus, calcaneum with hyperintensity of the adjoining tissues
3. Ankle joint effusion noted with encysted fluid collection seen in anterior part of ankle joint sign of infective change
4. Mild fluid along flexor hallucis longus tendon favouring tenosynovitis.
Post MRI patient was posted for an exploratory ankle arthrotomy on the 22nd of June. Surgery was conducted under local anaesthesia and pus from the swelling was drained. Sutures were placed which were removed after 2 weeks.
A biopsy was taken on removal of sutures and the following histopathological findings were revealed:
1. 2 x 1 cm mass with histiological features of tubercular lesion. Follow up MRI revealed the following:
1. Destruction with patchy confluent areas altered marrow density involving talonavicular joint.
The findings after biopsy and exploratory arthrotomy suggested that patient had talonavicular joint septic arthritis with osteomyelitis with tubercular pathology.
Post surgery patient was prescribed Clindamycin, vitamin C, vitamin D and calcium supplements to provide antimicrobial cover and aid healing of bony erosions.
Patient started ATT(Anti-tubercular treatment) on the 18th of July 2022. He was prescribed HRZE ( intensive phase)fixed dose combination QID uptil 13th September 2022, post which patient was put on HRE( continuation phase) fixed dose combination QID uptil 15th January 2023. Patient has tested negative for Tuberculosis thrice, once in January,once at the end of the ATT regimen and once in February 2023.
Patient was adhering well to treatment regimen but did not find much improvement in symptoms of pain and was concerned about inability to support his family adequately due to difficulty in engaging in farming activities because of which he once again seeked medical treatment and reported to our hospital.
On examination Right lower limb showed wasting over the calf and reduced bulk, patient had a limping gait due to pain over the right ankle on application of pressure. He also reported painin the left hip and lower back most likely caused by increased dependence on the left lower limb
On admission patient was subjected to imaging by means of XRAY on the 9th of September which revealed hyperdense lesion over the talonavicualar joint. He was referred to the Orthopaedic department where he was prescribed Vitamin B6 supplements OD ( prophylaxis for peripheral neuritis caused by isoniazid in ATT regimen), calcium supplements, and Hifenac (a short acting NSAID) BD for a week.
There was some alleviation of pain symptoms but it still persisted. Patient was then prescribed Tramadol and Acetaminophen ( fixed dose combination of 18.75mg Tramadol 162.5mg Acetaminophen) QID for 3 days along with Tablet Naproxicin OD 3 days a week for one week.
Pain symptoms were reduced and swelling was non tender on discharge. On returning home he could resume normal day to day activities and was able to actively engage in farming once again.
A follow up XRAY was done on the 16th of April to monitor healing and it revealed near normal bony architecture of the right talo navicular joint
He has been under regular follow up through a PaJr group through which he is able to report even minute changes in his symptoms. At present his pain is of mild intensity and is maximum at the start of the day before any activity and alleviates on activity.
In the April of 2023 he noticed reduced sensation over the right foot dorsum and ankle joint. Retrospectively he believes that this reduction in sensation and numbness has been present ever since the exploratory arthrotomy. Which leads me to believe the cause could be incisional damage to the sural nerve( since only sensory loss is noted and no motor loss is observed) or sural neuralgia as a sequelae of tubercular osteomyelitis or a combination of both etiologies.
The patient was counselled and made aware of possible nerve damage and was offered sural nerve testing following which steroidal injections and
physiotherapy would be mainstay of treatment, but due to patients’ limited understanding and poor socioeconomic status no futher testing was conducted as it would simply add to financial burden with virtually no difference in disease progression and treatment modality.
He will however be observed for any deterioration in nerve function.
Case discussion
Incidence:
In India according to the NTEP (National Tuberculosis elimination programme ) annual report, 2021 witnessed a 19% increase from the
previous year in TB patients’ notification—the total number of incident TB patients (new and relapse) notified during 2021 were 19,33,381.
It is estimated that one-third of the world's population has been diagnosed with tuberculosis infection.
The prevalence is estimated to be 9.4 million new cases per year worldwide. Tuberculosis most commonly presents with pulmonary symptoms. However, approximately 23-30% of patients found to be infected with tuberculosis have extrapulmonary symptoms.
Of those, only 1-3% have been found to have bony involvement. It usually affects major weight-bearing joints such as the hip and knee. Tuberculosis infections of the foot and ankle account for only 1% of all tuberculosis infections.
Difficulties arise in the timing of diagnosis, patient compliance of therapy and awareness of the less obvious presenting symptoms. Its uncommon site, non-specific presenting symptoms and its ability to mimic numerous disorders make it more difficult confirm diagnosis and, in turn, leads to delay in treatment
Response time and alleviation of pain symptoms in TB osteomyelitis following ATT regimen:
In a study as mentioned in Tuberculous osteomyelitis by Rajeev Vohra, Harinder S. Kang, Sameer Dogra, Radha R. Saggar, Rajan Sharma From Mohan Dai Oswal Cancer Treatment and Research Foundation, Ludhiana, India (https://boneandjoint.org.uk/article/10.1302/0301-620x.79b4.0790562/pdf)
The mean follow-up was 41 months (13 to 96). All patients were relieved of pain within six months of the initiation of treatment and sinuses healed within 14 weeks. In 20 patients the ESR returned to normal within six months of the beginning of treatment. Demineralisation of the affected region persisted for a maximum of five months. During healing, we noticed increased radiodensity in all cases. By the end of treatment for nine months 23 patients had regained full range of painless movements of the adjacent joints; only two had slight limitation.
In our patient however even after 6 months of ATT regimen and testing negative for TB pain symptoms persisted. He gained full range of movements
but experiences pain on beginning activity after a brief period of rest and on intense labour.
Post surgery neuralgia, incisional nerve damage:
Incisional nerve injury could range from grade 2 to grade 5 of Sunderland classification with grade 2 showing probable wallerian degeneration and then spontaneous regeneration while remaining grades do not show spontaneous recovery.
According to the paper, Surgically-Induced Neuropathic Pain (SNPP): Understanding the Perioperative Process (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546123/)
The initiating surgery and nerve damage set off a cascade of events that
includes both pain and an inflammatory response, resulting in ‘peripheral’ and ‘central sensitization’, with the latter resulting from repeated barrages of neural activity from nociceptors. In affected patients these initial events produce chemical, structural and functional changes in the peripheral (PNS) and central nervous (CNS) systems. The maladaptive changes in damaged nerves lead to peripheral manifestations of the neuropathic state – allodynia, sensory loss, shooting pains etc., that can manifest long after the effects of the surgical injury have resolved.
Surgically-Induced Neuropathic Pain (SNPP) is a significant clinical problem, with persistent pain estimated to occur in 10–50% of individuals after common operations. Postsurgical neuropathies may be a consequence of transection, contusion, stretching, or inflammation of the nerve, and is the only neuropathic pain syndrome that is fully under our control.
Pre-surgically, patients may have premorbid conditions including ongoing acute or chronic pain, psychobiological or genetic conditions that may predispose to chronic pain following nerve damage.
Surgery and Perioperative Events: Surgery may set of a cascade of events including pain. Pain is not always prevented during surgery and complete pain control is difficult to obtain throughout the perioperative process.
Temporal Processes: A cascade of events unfold – after nerve damage aside from afferent bursts of activity that travel to the CNS the nerve begins to unfold that includes central sensitization, a process that may be concurrent with nerve damage and in the perioperative period or as the neuropathic pain state, and centralization of pain where alterations in the CNS take place. Most of these brain changes are difficult to reverse by medications. One surgical example relates to removing pain sources in a chronic nociceptive pain syndrome, hip osteoarthritis, where brain changes in cortical volume can be reversed by hip arthroplasty.
Treatment of sural nerve damage:
According to the paper Pulsed Radiofrequency Ablation for Treating Sural Neuralgia (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855431/)
Sural neuralgia is persistent pain in the distribution of the sural nerve that provides sensation to the lateral posterior corner of the leg, lateral foot, and fifth toe. Sural neuralgia is a rare condition but can be challenging to treat and can cause significant limitation
Common causes of sural neuralgia are direct trauma, external compression, vasculitis, and diabetes. A more concerning cause of sural neuralgia is sural nerve entrapment in which the sural nerve is entrapped by scar tissue that pulls and compresses the nerve, leading to pain. Sural nerve entrapment is a feared postoperative complication of many orthopedic procedures involving the ankle, such as Achilles tendon repair, ankle surgery, fifth metatarsal fracture surgery, and ganglion cyst removal
Pulsed radiofrequency ablation may be a safe and effective treatment for patients with sural neuralgia that does not respond to conservative therapy (Like steroidal injections)
In our patient this treatment modality could not be tested due to socioeconomic limitation but can be considered incase of worsening of symptoms.
Learning outcomes:
Tuberculosis of the talonavicular joint is rare and has less than 1% incidence in the world and thus has limited research and information available.
It usually occurs following trauma and infection or as a secondary to pulmonary tuberculosis by means of spread by bloodstream.
However in our patient there was no history of trauma or pulmonary tuberculosis,there was no history of any pulmonary symptoms suggestive of Tuberculosis. The patient is however a farmer by occupation and works on paddy fields, it can be theorized that he suffered minor superficial cuts which were infected by Mycobacterium bovis causing tuberculous osteomyelitis.
Typical findings on MRI coincide with our patient, the findings being:
1. Hyperintensity signal seen in the anterior part of the calcaneum, talus, navicular, sign of marrow edema
2. Cortical irregularity seen in talus, calcaneum with hyperintensity of the adjoining tissues
3. Ankle joint effusion noted with encysted fluid collection seen in anterior part of ankle joint sign of infective change
4. Mild fluid along flexor hallucis longus tendon favouring tenosynovitis
Typical findings on XRAY coincide with our patient, the findings being
,hyperdense lesions in the talonavicular joint.
Typically, it is treated by ATT regimen and symptoms are alleviated by 6 months with full gain in range of motion and sometimes mild limitation in mobility.
In our patient, there is persistence of mild grade pain and swelling over the right ankle which is maximum on starting activity after a period of rest, reduces on continuation of activity and again increases on intense labour for prolonged periods of time.
The mild loss of sensation post arthrotomy ( possible sural neuarlgia) is typically treated using steroidal injections and physiotherapy.
In our patient however these modalities haven’t been tried due to patient hesitancy and poor socioeconomic status.
On telecommunication, patient relationship and SWOT(strength, weakness
,opportunity and threat) analysis:
The patient came to our hospital with complaints of persistent pain despite of surgical and medical interventions and the consultation began with hopes of reducing this pain and gaining full range of movements in order to get back to work and normal day to day activities.
Since the patient was face to face and under our direct care it was easy to establish good patient relationship.
Within the first week there was marked alleviation of his pain symptoms due to extensive medication which was key in gaining patients’ trust and willingness for follow up and regular communication through texts, calls and PaJr groups despite having the disadvantage of only virtual connection.
He exhibited great trust in medical advice and showed willingness to learn more about his condition despite many barriers like distance, limited understanding of disease.
Strength: Willingness to follow up, give elaborate and accurate details, well documented clinical history, adherence to treatment
Weakness: Poor socioeconomic status, limited understanding
Oppurtunity: Exploring varying sequelae of Tuberculous osteomyelitis and Creating awareness on Prevention of post surgical neuropathic pain and rehabilitative measures.
Threat: Limited affordable and available treatment modalities for loss of sensation over the right foot.
References
3. Pulsed Radiofrequency Ablation for Treating Sural Neuralgia
4. Surgically-Induced Neuropathic Pain (SNPP): Understanding the Perioperative Process
Timeline
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