Bone and joint tuberculosis in children

Introduction to pediatric bone and joint tuberculosis Tuberculosis of bone and joint (tuberculosis of bone and joint) is the invasion and growth of tuberculosis, which causes a series of pathological changes in bone or joint, also known as bone and joint tuberculosis. With the economic development, the living standards and children's health care work continue to improve, and its incidence has been decreasing year by year, but the disease is still clinically common. basic knowledge The proportion of sickness: 0.007% Susceptible people: children Mode of infection: non-infectious Complications: abscess joint dislocation malnutrition

Pediatric bone and joint tuberculosis

(1) Causes of the disease

Most of the diseases are secondary tuberculosis lesions. Among them, 80% of the tuberculosis lesions are invaded from the bones and blood vessels, and the joints are caused by a small number of secondary infections in the lymph nodes and digestive tract. The direct infection of bones and joints is rare.

(two) pathogenesis

Pathological changes are more complicated, it can be divided into bone tuberculosis, synovial tuberculosis and total joint tuberculosis, basic lesions including local caseous necrosis, tuberculous granuloma formation and consequent secondary destruction of bone tissue, articular cartilage and synovial tissue Bone tuberculosis can occur in any bone, but vertebral tuberculosis is the most common; followed by hand, foot bone and ulna and ulna. The pathological changes of bone tuberculosis are different in cancellous and dense bone. If cancellous bone tuberculosis occurs in The central part is mainly infiltrated and necrotic. The necrotic bone is free to form a dead bone, while the marginal cancellous bone tuberculosis only forms a localized cortical defect. The dense bone tuberculosis starts in the medullary cavity and is mainly caused by osteolytic destruction. There is no dead bone, but the pus is collected under the periosteum along the Folkman tube, which can stimulate the periosteal proliferation and form a pericarp-like periosteal reaction. The synovial tuberculosis of the joint is mainly synovial congestion, edema, exudation and inflammatory cell infiltration. Later, synovial hyperplasia occurs. Total joint tuberculosis refers to the three types of tissues that make up the joints, namely, articular cartilage, cancellous bone at the end of the bone (children, or callus) and synovium are involved in the pathological state, common site of disease. In turn, knee, hip and elbow joints, cartilage itself lacks blood vessels, so blood-borne cartilage tuberculosis is rare, and the chance of simultaneous infection of cancellous bone and synovial membrane is rare. Therefore, early joint tuberculosis is mostly simple. Sexual end-tube tuberculosis or synovial tuberculosis, when the granulation tissue of synovial tuberculosis invades the upper and lower part of the articular cartilage, causing it to break off and affect and destroy the cancellous bone at the end of the bone, or the pus wear of the cancellous bone tuberculosis Broken joint cartilage enters the joint cavity and infects the synovial tissue, which leads to total joint tuberculosis. If the lesion cannot be effectively controlled in the early stage, most of the articular cartilage will be destroyed. Even if the lesion has stopped, the joint function will be mostly lost or even occur. Fibrous or bony rigidity.

Pediatric bone and joint tuberculosis prevention

1. Control the source of infection and reduce the chance of infection: Tuberculosis smear-positive patients are the main source of tuberculosis in children. Early detection and rational treatment of smear-positive tuberculosis patients is a fundamental measure to prevent tuberculosis in children, and infants and young children suffer from active tuberculosis. Family members should be examined in detail (thoracic chest, PPD, etc.). Regular physical examinations should be conducted for primary and child care institutions to detect and isolate infection sources in a timely manner, which can effectively reduce the chance of tuberculosis infection in children.

2. Popularization of BCG vaccination: Practice has proved that vaccination with BCG is an effective measure to prevent tuberculosis in children. BCG was invented by French physicians Calmette and Guerin in 1921, so it is also called BCG. China has vaccinated BCG in the neonatal period and vaccinated according to regulations. At the upper end of the left upper arm deltoid, intradermal injection, the dose is 0.05mg / time, the scratch method is now rarely used, the Ministry of Health in 1997 to cancel the 7-year-old and 12-year-old BCG re-integration plan, but if necessary, the age Children with negative serotonin test can still be vaccinated. BCG vaccine can be injected in the same day as hepatitis B vaccine, and contraindications for BCG vaccination: positive sputum reaction; eczema or skin disease patients; acute infectious disease recovery period (1 month) Congenital thymic dysplasia or severe combined immunodeficiency disease.

3. Prophylactic chemotherapy: Mainly used for the following subjects:

(1) Infants under the age of 3 have not been vaccinated with BCG and have a positive test.

(2) Close contact with patients with open tuberculosis (multiple family members).

(3) The sputum test has recently changed from negative to positive.

(4) The sputum test is a strong positive responder.

(5) Children with positive serotonin test need to use adrenocortical hormone or other immunosuppressive drugs for a long time. The main drug for chemopreventive drugs is isoniazid, the dose is 10mg/(k·d), and the course of treatment is 6-9 months. Parents of children under 6 years of age who are newly diagnosed with tuberculosis and neonates born with tuberculosis should be treated with isoniazid regardless of the results of the test. The dose is the same as above, and the test is performed after 3 months of treatment. If positive, continue to use isoniazid for 9 months; if the test is negative (<5mm), stop isoniazid.

Anti-HIV-positive children with a history of tuberculosis should receive isoniazid for 12 months regardless of the outcome of the nodule test.

If the tuberculosis patient contacted by children is resistant to isoniazid, the chemotherapeutic drug should be changed to rifampicin, 15mg/(kg·d), 6-9 months; if it is resistant to isoniazid and resistant to rifampicin, It is recommended to give pyrazinamide plus ofloxacin for 6 to 9 months, or pyrazinamide plus ethambutol for 6 to 9 months.

Pediatric bone and joint tuberculosis complications Complications, abscess, joint dislocation, malnutrition

Cold abscess can occur, joint stiffness or fixed deformity, often associated with joint dislocation and deformity, vertebral tuberculosis can be seen vertebral destruction, narrowing or disappearing of intervertebral space, can cause malnutrition in children.

Pediatric bone and joint tuberculosis symptoms common symptoms fatigue appetite loss hypothermia joint deformity joint swelling joint rigidity

Bone and joint tuberculosis are chronic infectious diseases, so the incidence is concealed. Patients often have low fever, fatigue, loss of appetite and weight loss. Although there are pains in the lesions, they are not severe. Infants and young children can often cry at night because of pain. Joint dysfunction and muscle atrophy are not obvious, and often can be found abnormally compared with the healthy side. As the lesion develops, the joint function will be significantly restricted, or the joint will be stiff or fixed deformed due to knee, ankle, elbow and wrist. The joint position is shallow, the joint swelling and tenderness are easier to find, while the deeper shoulder, hip and spinal tuberculosis are not easy to attract attention, but in the vicinity of the lesion or in the distant part, cold abscess can be found, and there is rice soup after the abscess is broken. Pus, cheese-like material and fine broken bones flow out.

Pediatric bone and joint tuberculosis examination

Laboratory tests lack specific indicators. During the active period of the disease, the erythrocyte sedimentation rate increases rapidly, the white blood cell count is normal or slightly increased, and the tuberculin test is positive for children who have not been vaccinated with BCG. It has important reference value for the diagnosis of this disease, pus, slippery. Positive fluid culture can confirm the diagnosis, but the false negative rate is higher.

X-ray examination is of great significance for the diagnosis of this disease. In the early stage of cancellous bone central tuberculosis, the local trabecular bone is blurred, showing a frosted glass-like change, followed by free dead bone, which has an elliptical shape and a higher density than the surrounding pine. After the bone is absorbed, the bone cavity is visible. The marginal cancellous bone tuberculosis shows localized osteolytic destruction and the edge is slightly dense.

The dense bone tuberculosis is mainly osteolytic destruction in the medullary cavity, new bone formation in the periosteum, simple synovial tuberculosis only shows osteoporosis and local soft tissue swelling, and early total joint tuberculosis in addition to the above performance, also visible articular surface blur And irregular destruction, the joint margin of the late total joint tuberculosis is mostly blurred and destroyed, the joint space is narrow or disappeared, often combined with joint dislocation and deformity, vertebral tuberculosis can be seen changes in the physiological curve of the spine, vertebral body destruction, narrowing or disappearing of the intervertebral space As the pus spreads to both sides, the soft tissue shadows on both sides of the vertebrae are widened or calcified.

Diagnostic diagnosis of pediatric bone and joint tuberculosis

diagnosis

According to the history of tuberculosis exposure, the tuberculin test is positive, the presence of tuberculosis and the above special symptoms are diagnosed, and X-ray findings are helpful for diagnosis.

Differential diagnosis

Spinal tuberculosis should be differentiated from racitic kyphosis, congenital or acquired deformity of the spine, acute osteomyelitis, spinal cord and spinal tumors; joint tuberculosis should be associated with septic arthritis, rheumatoid arthritis, rheumatoid arthritis Sexual arthritis, chronic osteomyelitis, traumatic synovitis (traumatic synovitis) and congenital syphilitic arthritis.

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