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The Open Orthopaedics Journal, 2012, 6, 445-448 445

Open Access
Tuberculous Coxitis: Diagnostic Problems and Varieties of Treatment: A
Case Report§
H. Klein*,1, J.B. Seeger1 and I. Schleicher2

1
Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg (UKGM),
Klinikstraße 33, D-35392 Giessen, Germany
2
Department of Trauma Surgery, University of Giessen and Marburg, Klinikstraße 33, 35385 Giessen, Germany

Abstract: Although the prevalence of tuberculosis reduces, it still belongs to the most important infectious diseases
worldwide even in industrial countries.
We report an unusual case of tuberculous coxitis in a 28-year-old healthy native female with recurrent hip pain. While X-
ray and microbiological examination of the aspirate showed no abnormality, only extended diagnostic measurements and
detailed history led to the diagnosis of TBC. Although the patient did not show any pulmonary symptoms open
tuberculosis was confirmed. After a course of antibiotic treatment she underwent reconstructive surgery which
consecutively improved range of motion. This case report emphasizes that tuberculosis should still be considered as a
significant disease even in healthy patients with uncertain complaints in joints without significant initial radiographic
abnormalities. We recommend the described diagnostic procedures as well as an antibiotic and surgical treatment.
Keywords: Tuberculous coxitis, TBC, tuberculosis.

INTRODUCTION CASE REPORT

Although the prevalence constantly reduces [1] A 28-year old native female patient complained about
tuberculosis still belongs to the most important infectious recurrent pain in the right hip joint without previous trauma
diseases worldwide. The World Health Organisation (WHO) progressing by physical strain starting about 1.5 years
estimated the morbidity of 1.7 billion people in the year before. A MRI of the pelvis performed 3 months before
1990, about more than 3 million people are still dying as a admittance showed a swelling of the capsule and reduction
result of its affection every year [2, 3]. of the cartilage in the right hip joint which was considered as
an early arthritis or coxitis. After treatment with
Coxitis TB is an inflammation of tuberculosis in the hip
physiotherapy and oral non-steroidal antirheumatic
joint leading to the destruction of the articular surface and
medication the symptoms were regressive and no further
accompanied by painful contraction adductions. Coxitis TB
diagnostic procedures were performed.
usually develops in children aged 5-10 when they are in a
weak condition (due to infection, poor living conditions) Caused by recently aggravation of pain in the right hip
after the entry of tuberculosis-causing agents from the main joint within the days before, the patient was not able to stand
focus (usually from the lungs) [4]. In case of tuberculous and walk and the range of motion (ROM) was painfully
coxitis (TBC) a prior pulmonary infection causes the reduced. Blood samples were normal except slightly
affection of the joint by haematogenous spread. Early increased CRP of 4.2mg/l (reference: <0.5mg/l) without any
diagnosis can be difficult as the primary clinical symptoms at local signs of inflammation in the pelvic region. X-ray of the
an early stage as well as radiological findings are often non- right pelvis showed a slight joint space narrowing with
specific [5]. In addition to MRI and CT, diagnosis may be affection of the acetabulum and the femoral head (Fig. 1).
confirmed by joint aspiration and bacteriological culture, An effusion was detected by ultrasound, aspiration of the hip
which unfortunately is negative in 30 % of the cases [6], so joint led to no further diagnosis as aerobic and anaerobic
consequently an open biopsy has to be performed. cultures were sterile. The MRI showed a joint space
narrowing in the cranial part of the acetabulum with
We report an unusual case of TBC in a 28-year-old
increased subchondral sclerosis as well as a synovial
otherwise healthy native female with recurrent hip pain
without a history of long-termed stays in foreign countries. enhancement with bone marrow edema in the femoral head
and the corresponding acetabulum.

*Address correspondence to this author at the Department of Orthopaedics

The further clinical examination with detailed
and Orthopaedic Surgery, University Hospital Giessen and Marburg reconstruction of patient´s history revealed a surgical
(UKGM), Klinikstraße 33, D-35392 Giessen, Germany; Tel: +49-641-985- procedure with extirpation of a lymph node from the left
56094; Fax: +49-641-985-42999; supraclavicular region two years before. The histological
E-mail: [email protected] result was suspicious for tuberculosis with marked
§
The case report was carried out at the Department of Orthopaedic Surgery,
University Hospital Giessen and Marburg in Giessen, Germany.
1874-3250/12 2012 Bentham Open
446 The Open Orthopaedics Journal, 2012, Volume 6 Klein et al.

five months after starting therapy showed active arthritis

with progressive destruction of the right hip joint and a new
appearance of liquid retention in the right acetabulum as a
sign of tuberculous osteomyelitis (Fig. 3).

Fig. (1). Initial X-ray of the right pelvis showing only a slight joint
space narrowing with affection of the acetabulum and the femoral
head.
granulomatous lymphadenitis and caseous degenerated
confluent necrosis, but tuberculin test and sputum sample
examinations by microscopy and culture medium were Fig. (2). X-ray of the right pelvis 3 months after diagnosis with
negative. A CT without any proof of lymphadenopathy and increasing patchy transparence in the femoral head and neck as well
pulmonary infiltration could not confirm this suspicion. In as in the greater trochanter and acetabulum with clear progressive
addition there were no other risk factors except her joint space narrowing.
profession as a veterinarian, especially as she was neither an
immigrant nor had long- termed stays in foreign countries. After seven months the microbiological examination of
So no further treatment had been started at that time. gastric secretion and sputum analysis did not detect open
lung tuberculosis, so the oral therapy was reduced to double
Although the initial microbiological examination of the combination with Isoniazid and Rifampicin. In contrast to X-
first aspirate being inconspicuous, a current Quantiferon-Test ray and MRI results with progressive destruction, the ROM
[7] showed a positive reaction as an indication of a latent or of the right hip joint improved. The patient underwent
active infection with Mycobacterium tuberculosis (M. tbc), reconstructive surgery by extirpation of the granuloma from
Mycobacterium Kansasii, Mycobacterium Szulgai or the acetabulum and augmentation with autologous spongio-
Mycobacterium Marinum. X-ray of the chest showed an saplasty from the ipsilateral iliac crest. Microbiological and
enhanced parenchymal change in both apical segments. A microscopic examination of intraoperative swabs and surface
consequently performed CT of the chest and abdomen biopsies did not detect M. tbc or other pathological results.
revealed the clinical sign of reactivated tuberculosis in the
apical and posterior bronchopulmonary segments with Six weeks after surgery, continuing physiotherapy and
nodular peribronchiovascular focus as a sign of open lung oral double combination, the patient was almost free of pain
tuberculosis. Furthermore a second aspiration of the right hip and ROM was improved. X-ray of the right pelvis revealed
joint confirmed M. tbc by microscopical analysis and an unchanged result compared to the examination after
bacterial culture. Gastric secretion examined by polymerase operation without any progression of destruction and regular
chain reaction (PCR) as well as bacterial culture and positioned autologous spongiosaplasty without dislocation.
microscopy of the sputum showed an amount of M. tbc. The physical load for the right leg was gradually increased
and ROM was continuously improved.
Thereafter by confirming TBC and open lung
tuberculosis, the patient was treated with combination of oral Ten months after starting oral therapy, a CT of the thorax
Isoniazid, Rifampicin, Ethambutol and Pyrazinamid. She detected scars without nodular pathologic infiltrates or
received physiotherapy with partial weight bearing of 10 kg. pleural effusion in both apical parts of the lungs.
Three months later X-ray showed an increasing patchy The ROM of the hip joint in spite of the radiological
transparency in the femoral head and neck as well as in the findings with progressive sclerosis in the acetabulum and
greater trochanter and acetabulum with clear progressive joint space narrowing (Fig. 4) was satisfactory measured
joint space narrowing in the corresponding parts of the hip with 125° for flexion, 35° for abduction, 20° for adduction,
joint (Fig. 2). A complementary MRI with contrast medium 5° for internal rotation and 30° for external rotation. The
Tuberculous Coxitis The Open Orthopaedics Journal, 2012, Volume 6 447

patient was able to walk without crutches suffering only satisfactory [20-22], the major disadvantage of this technique
minor pain. is loss of function due to reduced hip offset. Arthrodesis as
an alternative represents to reduce pain and in the meantime
treats the infection successfully. Besides loosing ROM of the
hip joint, there are often secondary degenerative changes
especially of lumbar spine in the longer term. Performing a
THA should be mentioned as a demanding alternative, which
is often practiced in combination with oral antituberculotic
medication. Local exacerbation is observed in cases with
insufficient systemic treatment, whereas in most of the cases
the results referring to ROM and pain-reduction are
satisfactory.

Fig. (3). MRI 5 months after starting the oral therapy showing an
active arthritis with progressive destruction of the right hip joint and
liquid retention in the right acetabulum as a sign of tuberculous
osteomyelitis (see black arrow).
DISCUSSION
Tuberculosis belongs to the most important infectious
diseases worldwide. Although its prevalence in industrial
countries is decreasing, it still is not eradicated. According to
previous analyses about 10% of extrapulmonary
manifestations refer to joints and bone, mainly to the spinal
column and the hip joint. Thus tuberculosis is considered to
be a significant disease in discovering diagnosis of uncertain
complaints in joints and bones. The early diagnosis could be
difficult as the primary clinical symptoms and radiological
findings at an early stage are often non-specific [5].
In our case the initial radiographic findings, MRI and
standard blood samples were unspecific. Further clinical Fig. (4). X-ray oft the right pelvis 1 year after diagnosis showing a
examination with detailed reconstruction of patient´s history progressive sclerosis of the acetabulum with decreasing joint space
(extirpation of suspicious lymph node two years before) as narrowing.
well as her profession as a veterinarian led to the suspicion
of tuberculosis, which was confirmed by microbiological In our case the patient underwent reconstructive surgery
cultures of the aspirate and a Quantiferon-Test [7]. by extirpation of the granuloma in the acetabulum and
augmentation with autologous spongiosaplasty after oral
In case of TBC prior pulmonary infection causes the antituberculotic treatment.
affection of the joint by haematogenous spread so a
consequently performed CT of the chest revealed pulmonary The reason for our decision to choose a reconstructive
infiltrates as well as microbiological examinations of the bone-saving surgical technique was influenced by different
gastric secretion and sputum analysis showed open factors.
tuberculosis. Consequently, the patient must have had an It is reported that extensive operative interventions as
exposure to M. tbc, which retrospectively could have been THA for TBC continue to be a controversial issue due to the
most probably due to contact with an infected animal [8-10]. potential risk of reactivation of infection [5]. However, the
However, there are several recommendations for the period period of time after beginning oral antituberculotic treatment
of treatment and combination of antituberculotic medication and performing an arthroplasty is discussed [23, 24].
before an operative treatment [11, 12] to reduce potential
risk of reactivation of infection. An argument against Girdlestone resection or arthrodesis
was the improvement of ROM as well as the reduction of
Furthermore different surgical techniques as arthrotomy pain supported by a regular performed physiotherapy during
with debridement, arthrodesis, Girdlestone resection the period before operative intervention.
arthroplasty or total hip arthroplasty (THA) [13-18] have
been performed in cases of extensive disease [5, 19]. Furthermore the patient was young and had the
Although Girdlestone resection arthroplasty is not difficult to compliance for a distinguished rehabilitation. Moreover she
perform and in most of the cases clinical results are was not convinced of a more extensive surgical intervention
448 The Open Orthopaedics Journal, 2012, Volume 6 Klein et al.

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Received: June 4, 2012 Revised: August 7, 2012 Accepted: August 10, 2012

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