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CASE REPORTS
First Metatarsophalangeal Joint Arthritis : An Unusual Case
JD Jagiasi, H Argekar, CJ Thakkar, PD Samant, AB Goregaonkar
A case of first metatarsophalangeal joint tuberculosis is described, causing arthritis. An 18 year old male tailor presented with pain and restricted toe movements at the first metatarsophalangeal joint since five months. Patient was treated as chronic osteomyelitis and incision drainage was done two times. Since two months, he developed discharging sinuses, and symptoms did not show any improvement. An arthrotomy followed by first metatarsophalangeal joint fusion was performed, which confirmed histopathologically as tuberculosis.
INTRODUCTION
Skeletal tuberculosis has been a diagnostic and therapeutic problem for many years. It is a rare condition forming 1-2% of tuberculosis, which can be acquired haematogenously or by direct spread. Most commonly tuberculosis affects the diaphysis of small bones i.e. spina ventosa or rarely the metatarsophalangeal joint arthritis. The common variety is dry atrophic form i.e. carries sicca. Rarely there is swelling and cold abscess or sinus formation, presenting in the metaphyseal region along the extensor tendon.1,2 Here we present such an unusual presentation.
CASE REPORT
An 18 year old male tailor presented with pain and restricted toe movements at the first metatarsophalangeal joint since five months. Patient had history of abscess drainage twice in the past three months, which resulted in two discharging sinuses. Patient was empirically started on broad-spectrum antibiotic treatment. X-rays of the foot showed (Fig. 1) a coke like sequestrum at the base of the first metatarsal bone with arthritic changes of the first metatarsophalangeal joint. His ESR was 10 mm/hour. He has been treated as chronic osteomyelitis, but not responding to antibiotics.
Treatment
Patient was explored surgically and a thick sheath of granulation tissue was seen covering the extensor hallicus longus. One-centimeter broad and long sequestrum was removed and the defect created was filled up with bone graft after doing an arthrodesis of the first metatarsophalangeal joint. The material sent for histopathology confirmed to be as tuberculosis.
DISCUSSION
Tuberculosis of the foot1,2 has been appreciated for many years. The incidence has been reported to be 1-2%3 but tuberculosis of the first metatarsophalangeal joint is very uncommon. Most of the cases are treated conservatively, but an abscess when formed requires decompression and drainage. Calcaneum, subtalar joint, mid tarsal joint and the central part of tarsal bones are seen to be affected by tuberculosis. The order of decrease in frequency being calcaneum, talus, first metatarsal, navicular, first and second cuneiform and others.3 Endarteritis causing compression of the nutrient artery may show cavity with or without a typical coke like sequestrum on radiograph. Diagnosis is made by presentation of pain, swelling, tenderness, cold abscess, and sinus formation. X-rays show osteoporosis with destruction.
Differential diagnosis being low grades pyogenic infection and a rare granulomatous condition like mycosis, brucellosis, sarcoidosis, etc. which are diagnosed on histopathology.
ACKNOWLEDGEMENT
Our acknowledgements to the Dean, and Head of Department, Orthopaedics of Lokmanya Tilak Municipal Medical College, Sion for allowing us to publish this data.
REFERENCES
1. Martini M. Tuberculosis of bone and joints Springer - Verlag : Heidelberg, 1998.
2. Silva JF. A review of patient with skeletal tuberculosis treated at the University Hospital, Kuala Lumpur. Int Orthop Scand 1980; 4: 79-81.
3. Tulli SM, Shanmugsundaram. Textbook of skeletal tuberculosis.
EPLERENONE, AN ALDOSTERONE BLOCKER, AFTER MYOCARDIAL INFARCTION
Blockade of aldosterone receptors with spironolactone is beneficial in patients with chronic heart failure. This study evaluated eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction and heart failure after myocardial infarction. Eplerenone reduced overall and cardiovascular mortality by about 15 percent.
Aldosterone blockade is a novel approach to the treatment of heart failure. The new study extends the benefit to the large group of patients with myocardial infarction and ventricular dysfunction, an important therapeutic advance.
N Engl J Med April, 2003;348 : 1305.
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