A 24-year-old Indonesian male who worked in an internet rental shop came to the orthopedic department of Bhayangkara Brimob hospital (Depok, Indonesia) with left arm pain and left elbow joint swelling. Physical examination revealed skin perforation with yellowish discharge on the left elbow. The patient experienced fever on the first few days as the left elbow became swollen, weight loss, and a decreased appetite, but no respiratory complaints.
Chronologically, one year prior to coming to the hospital, the patient noticed another pain in his left arm both in the upper and lower arm. He then chose to undergo regular traditional massage therapy every week for almost one year instead of seeking for medical treatments. At the first hospital visit, the elbow pain had gotten more severe and became swollen. Within a month, discharge emerged from a small skin perforation located on the inner side of the left elbow. The patient finally went to the orthopedic department and underwent surgery. The patient had a history of undergoing reflexology massages on between the fingers of his left hand to alleviate his toothache.
Upon physical examination, the left elbow joint appeared swollen and discharge was exuding from the perforated skin, as depicted in Figure 1. The patient could not lift his left arm because it was be painful. Flexion and extension were also difficult due to the severity of the pain. The patient's social environment has a culture of seek help from local traditional massage therapist who is known to be uncertified for various health problems, and instead of recovering, the patient showed symptoms that are worsening.
Laboratory examination revealed a leukocyte count of 15,000 (normal range: 5000-10,000 cells/mul), erythrocyte sedimentation rate (ESR) of 40 mm/hour (normal range: 0-10 mm/hour), eosinophils 9% (normal range: 1-3%), and monocytes 10% (normal range: 2-6%). Radiological examination by posteroanterior (PA) chest X-ray did not show any abnormality ( Figure 2), anteroposterior (AP) and lateral projection of the left elbow joint radiographs showed erosion of the distal cortex of the humerus and radial bone, destruction of the distal cortex, and swelling of the soft tissue of the left elbow area ( Figure 3).
The patient was suspected with TB of the elbow joint. He then underwent left elbow arthrotomy and synovial fluid aspiration. The surgery was performed with the patient supine under general anesthesia. Incisions were made layer by layer on the posterior region of cubiti sinistra. White granulation tissue and thick yellow intra- and extra-articular pus were evacuated. Histopathological examination was also performed. The wound was irrigated with 2 L of 0.9% NaCl and hecting was performed layer by layer subsequently. Specimens were collected and sent for microbiological and pathological analyses. The result of the AFB examination was based on types of grading scale by the World Health Organization and the International Union against Tuberculosis and Lung Disease (WHO-IUATLD) was 2+. Tissue culture was found to be positive. Histopathological examination showed granulomatous inflammation, swollen connective tissues containing epithelioid tubercle nests with necrotization, and datia Langhans cells ( Figure 4). The results were consistent with TB. Furthermore, the anti-human immunodeficiency virus (HIV) test was negative. The patient was subsequently diagnosed with TB of the elbow joint.
The patient was given a standard first-line oral regimen of extrapulmonary TB treatment; an intensive phase for two months with rifampicin 450 mg once daily, isoniazid 300 mg once daily, pyrazinamide 1000 mg once daily, and ethambutol 1000 mg once daily (2HRZE) and seven months of a continuation phase with rifampicin 450 mg once daily and isoniazid 300 mg once daily (7HR). The patient had been undergoing continuation phase of the treatment and his condition showing improvements, including decreased pain, increased appetite, and weight gain. However, flexion and extension are restricted. The patient reported clinical improvement and discharge was decreased. Left elbow joint radiographs showed minimal improvement ( Figure 5). Computed tomography (CT) scan results showed destruction of the lateral epicondylus of the humeral bone and the processus olecranon of ulna bones, after two months of the treatment ( Figure 6).