20 year old male with Tuberculous Osteomyelitis
Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.
Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.
I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.
CASE SHEET
Chief complaint: Pain in the right ankle causing difficulty in walking.
History of presenting illness: Patient was apparently asymptomatic 8 months ago.
8 months back he was working in the farm and suddenly started getting pain in the right ankle.
Pain was of low intensity and subsided on taking painkillers.
The pain was continuous and recurred everyday as the effect of the medication wore off.
For 5 months patient would take a painkiller tablet everyday and pain would subside
He went to an RMP where Xray and blood tests were done and everything was apparently normal. Patient continued taking painkillers.
Gradually the pain increased and swelling with pus developed over dorsum of the right foot.
He then again visited a doctor, MRI was done which showed infection and lytic lesions.
Patient got admitted on the 22nd of June 2022 for surgery(ANKLE ARTHROTOMY) under local anesthesia and pus was drained by excision.
Upon removal of sutures after 2 weeks biopsy was done which was suggestive of bone tuberculosis.
This was followed by an MRI which confirmed TB.
Treatment for TB started on the 18th of July 2022.
Patient is on ATT regimen and is regular with medication
Now patient also complains of pain over the left hip and lower back on lifting leg while sitting and also on walking after a long time of rest.
Previously, before the surgery patient's pain was over the swelling in dorsum and is now on over the lateral malleolus
History of past illness: Not a known case if Diabetes, hypertension, epilepsy, asthma
Diagnosed with Bone TB after biopsy report following surgical drainage of pus.
Drug history:
8 months back when pain was of low intensity and subsided on taking medication patient was taking one painkiller tablet everyday for 5 months
On first visit to RMP no other medication was given and patient continued use of painkillers
After surgery patient was prescribed the following medications, following which he reported swelling of the entire right lower limb:
1.Dalacin C
2. Limcee tab
3. Gemcal
4. Deksel nano syrup
Patient is currently on HRZE since 18th July 2022 and will commence HRE regimen from 13th September.
Personal history:
Mixed diet
Normal appetite
Bowel movement normal
Normal micturition
Patient does not report difficulty in sleeping
No addictions
Drug allergy?
Family history: No relevant family history
General examination:
Pallor: Present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Koilonychia: Absent
Lymphadenopathy: Absent
Edema: Absent
Vitals:
Temperature: afebrile
Respiratory rate: 14cpm
Pulse : 82bpm
Blood pressure: 126/90 mm of Hg
CVS examination: S1, S2 heard. No murmurs.
Respiratory system examination: Trachea cental, no vesicular breath sounds, no wheeze
CNS examination:
Higher functions: Patient is conscious and coherent, well oriented to time, place and person. He is able to recollect past events in orderly fashion and doesn't show any defecits.
Speech: Normal and coherent
Motor system examination:
Attitude and position: Normal
Bulk: Right lower limb shows wasting over the calf.
Tone: Normal
Power: 5
Reflexes : Normal
Gait: Limping due to pain in the right ankle
Demonstrated by the following videos:
Sensory System examination:
Normal
Signs of meningeal irritation are absent.
Cranial nerves: Intact and normal
IMAGING:
MRI : done previously before admitting into our ward
Before surgery:
After surgery:
XRAY on 9th September 2022:
Biopsy reports:( before admission into our hospital done at time of removal of sutures post arthrotomy)
Provisional Diagnosis:
Tubercular Arthritis of right ankle with severe bony erosions of talus and navicular
Biopsy suggestive of tubercular pathology
Treatment:
Day1
Referral to orthopedic
Treatment suggested:
1. Continue ATT
2. Tab Hifenac BD
3. Tab Pantop 40 mg OF
4. Tab Benadone Forte 20mg OD
Updated on 13/9:
1. Ultracet 1/2 tab Qid for 3 days
2. Naproxicin 1 Tab OD for 3 days a week
3. Continue ATT regimen and Benadone Forte OD
FOLLOW UP
April
Patient completed ATT regimen in early january and has tested negative for Tuberculosis twice, once in January and once in February.
He complains of mild pain which is maximum on starting activity after a period of rest and reduces on continuing work but aggravatees again on extensive labour.
No tenderness or local rise of temperature is noted.
16th April
CASE DISCUSSION
Response time in tuberculous osteomyelitis patients in ATT regimen:
Taken from the article: TUBERCULOUS OSTEOMYELITIS
RAJEEV VOHRA, HARINDER S. KANG, SAMEER DOGRA, RADHA R. SAGGAR, RAJAN SHARMA
From Mohan Dai Oswal Cancer Treatment and Research Foundation, Ludhiana, India
Relevant excerpt: 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.
Sural nerve damage following arthrotomy
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