Midfoot tuberculosis: Clinical suspicion and early investigation is the key

Abstract

Background: Tuberculosis affecting midfoot is not common, leading to delay in diagnosis further leading to deformity and difficult management. Tissue diagnosis is always not possible at such sites. MRI is the better imaging modality to diagnose earlier than conventional radiographs. The aim of the study is to have a clinical suspicion of tuberculosis in midfoot pain and a low threshold to perform MRI in these patients.

Methods: The data of 7 patients were collected prospectively over 3 years. Inclusion criteria included midfoot pain for more than 4 weeks in a skeletally mature patient with no radiographic findings. MRI and laboratory investigations were done in all the patients. All the patients were given Anti-tubercular therapy and followed up for 12 months. The patients were assessed at 3, 6- and 12-months duration with ESR, CRP, MRI, VAS and AOFAS Midfoot scores.

Results: There were 3 males and 4 females included in the study with a mean age of 55.5 years. The mean duration of symptoms was 5.2 weeks. The mean ESR and CRP at presentation were 46 and 12 respectively which progressively decreased over 12 months. The mean VAS and AOFAS midfoot score at presentation were 4 and 70 respectively. None of the patients had any complication from ATT drugs. Residual pain was present in 4 patients with no functional limitation of the foot. The follow-up MRI showed healed tuberculosis in all the patients.

Conclusions: Tuberculosis can be a cause of vague midfoot pain in tuberculosis endemic countries. The MRI in such patients along with laboratory findings can lead to early diagnosis and the empirical institution of the ATT. The tissue diagnosis is not always possible in the early stages of the disease as there is no radiographic lesion or collection in the midfoot.

Keywords: Empirical Anti-tubercular therapy; Magnetic resonance imaging; Midfoot; Pain; Tuberculosis.