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Patients may be predisposed to mycobacterial musculoskeletal infection by virtue of geographic exposure to Mycobacterium tuberculosis; cell-mediated immunosuppression, including use of immunomodulatory therapies; or traumatic or postsurgical inoculation of environmental mycobacteria.
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Mycobacteria often cause paucibacillary disease and may be fastidious in their growth characteristics. Diagnosis usually requires culture confirmation but newer molecular technologies offer the potential to identify
Mycobacterial Musculoskeletal Infections
Section snippets
Key points
Pathogenesis and host risk factors
Mycobacteria have evolved alongside humans for millennia. Over this period of coevolution, agents of mycobacterial disease have developed a variety of molecular mechanisms that allow them to evade immune detection, avoid destruction within the host, and eventually propagate to effect clinical disease if left unchecked. On initial inhalation, MTb adheres to complement, Fc receptors, and mannose receptors present on the surfaces of macrophages.2 Like other mycobacteria, the initial stage of
Risk factors for musculoskeletal involvement
In a susceptible host, mycobacterial musculoskeletal infections may occur via several different mechanisms. Tuberculosis generally spreads to osteoarticular sites via the hematogenous route. During primary infection with MTb, bacillemia may occur, although it is usually contained by cell-mediated immunity. When cellular immunity is impaired, bacillemia may lead to seeding of sanctuary sites, including bones and joints. Osteoarticular tuberculosis may manifest during primary infection, although
Incidence of musculoskeletal mycobacterial infection
Of more than 250,000 patients with tuberculosis reported in the United States between 1993 and 2006, 19% had extrapulmonary disease, of whom 11.3% (2% of all patients with tuberculosis) had osteoarticular involvement.21 Infections caused by nontuberculous mycobacteria do not require public health reporting, and therefore their exact incidence is not known. More than 120 different species of NTM can cause human infection; the heterogeneity among this diverse group makes these infections
Tuberculosis
Among cases of osteoarticular tuberculosis, the spine is the most commonly affected site of disease. Up to 50% of osteoarticular cases show vertebral involvement23, 24, 25; this is followed by native septic arthritis primarily involving large joints such as hips and knees. Small joint septic arthritis and osteomyelitis of the extra-axial skeleton occurs less commonly. Multifocal osteoarticular tuberculosis can also occur.25 Rarely, tuberculosis may cause prosthetic joint infection.26 A minority
Diagnosis
Because the treatment of infections caused by mycobacteria require different therapies than those caused by conventional bacterial pathogens, confirming a microbiologic diagnosis is of paramount importance. The diagnosis of mycobacterial musculoskeletal infections may be definite (microbiologically confirmed) or probable (eg, more common in tuberculosis, where there is isolation of mycobacteria at another site, and a concomitant compatible osteoarticular manifestation, with or without
General Approaches
Once the diagnosis of musculoskeletal mycobacterial infections is suspected or confirmed, medical management should be planned, and surgical management may need to be considered. Although virtually all musculoskeletal mycobacterial infections require medical therapy, some can be managed with close monitoring but without the need for surgery. Care teams consisting of infectious disease specialists, orthopedic surgeons, rheumatologists, and radiologists may work together to determine optimal
Summary
Although less common as causes of musculoskeletal infection than pyogenic bacteria, mycobacterial musculoskeletal infections remain important causes of morbidity worldwide. Although tuberculous arthritis and osteomyelitis have been recognized for millennia, infections caused by NTM are being identified more often, likely because of both a more susceptible host population and improvements in diagnostic capabilities. Infections caused by mycobacteria remain challenging to diagnose, because of the
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Disclosures: None of the authors have any relevant disclosures or financial conflicts of interest.