Avascular necrosis of humeral head in an elderly patient with tuberculosis: a case report
Department of Pathology, All India Institute of Medical Sciences
Ansari Nagar, New Delhi-110029
Department of Pathology, Hindu Rao Hospital
Malka Ganj, Delhi-110007
Introduction: Osteonecrosis (avascular necrosis) is known to be caused by high-dose corticosteroid therapy, alcoholism and rarely by infections. However, a tubercular etiology of this condition is very rare. A review of the literature yielded only a few cases of polyarticular tuberculosis with osteonecrosis in immunosuppressed individuals. No case of monoarticular tubercular osteonecrosis diagnosed by aspiration cytology was found. Since tuberculosis is a curable disease, an early and accurate diagnosis is essential. Case presentation: A 60-year-old Indian man presented with diffuse swelling and pain in the left shoulder for the previous 6 months. A computed tomography scan of the left shoulder revealed crescentic lucency in the humeral head, suggestive of osteonecrosis. Fine needle aspiration cytology smears from the swelling showed features of an acute suppurative lesion. Stain for acid-fast bacillus was positive and thus, a final clinico-pathological diagnosis of osteonecrosis of humeral head with tubercular etiology was rendered. The patient was initiated on anti-tuberculous therapy with symptomatic improvement in his condition. Conclusion: Osteonecrosis, a debilitating disease, may rarely occur due to tuberculosis, especially in endemic areas. Fine needle aspiration cytology is an effective and inexpensive modality for an early diagnosis of the tubercular etiology of osteonecrosis.
Osteonecrosis, also known as avascular necrosis (AVN),
occurs in people with risk factors such as high-dose
corticosteroid therapy, excessive alcohol intake, injury,
malignancy, systemic lupus erythematosus, and hematologic
disorders such as sickle cell disease . Among infectious
causes, Human Immunodeficiency Virus (HIV) and
meningococcemia have been reported to cause AVN [2,3].
However, AVN in association with tuberculosis has been
reported in only a few cases [4,5]. In one case, described
by Cheung et al. in 1995, polyarticular tuberculosis with
AVN was identified in a HIV positive patient . No case
of monoarticular tuberculosis associated with AVN has
been reported in the available literature.
Our case depicts a rare association of monoarticular
tuberculosis with AVN in an immunocompetent patient.
A 60-year-old man, Indian by origin, presented with
swelling and pain in the left shoulder of 6 months
duration. There was associated anorexia and loss of weight.
However, there was no history of preceding trauma,
corticosteroid therapy or significant medical or surgical
treatment. He was a non-alcoholic and non-smoker.
On local examination, a diffuse, soft and tender swelling,
4 4 cm, was seen at the left shoulder. There was mild
restriction of movement of the left shoulder. The
overlying skin was warm and erythematous. Hematological
investigations revealed peripheral blood lymphocytosis
and increased erythrocyte sedimentation rate (ESR) (35
mm in the first hour). Mantoux test using 5 tuberculin
units (TU) of purified protein derivative (PPD) showed
significant induration after 72 hours (13 mm). Serological
tests for HIV, rheumatoid factor and anti-nuclear
antibodies (ANA) were negative. Chest X-ray did not show any
evidence of active/healed pulmonary tuberculosis.
Radiographs of the left shoulder joint did not reveal any bony
abnormality. Computed tomography (CT) scan of the left
shoulder showed a crescentic lucency in the humeral head
with associated soft tissue swelling, consistent with a
diagnosis of osteonecrosis (Figure 1). The patient was referred
for fine needle aspiration (FNA) cytology of the soft tissue
swelling to assist in etiological diagnosis.
FNA yielded a purulent aspirate, smears which showed an
acute suppurative lesion with intact and degenerated
neutrophils in a proteinaceous background along with a few
lymphocytes and histiocytes (Figure 2). No epithelioid
cell granulomas were noted. Ziehl Neelsen staining
showed occasional acid-fast bacilli (Figure 2, inset). A
diagnosis of tubercular etiology of osteonecrosis was
rendered. The patient was put on antitubercular therapy, after
which the pain and swelling reduced markedly.
Osteonecrosis, also known as avascular necrosis (AVN),
aseptic necrosis or ischemic necrosis, results from
temporary or permanent loss of blood supply to a part of bone.
As a result of the loss of blood supply, the bone may
ultimately collapse .
Numerous risk factors have been associated with AVN
including corticosteroid therapy, alcohol intake and bony
injury. Other associations include systemic malignancy,
lupus erythematosus, sickle cell disease, Gaucher's
disease, Caissons disease, gout, vasculitis, osteoarthritis,
osteoporosis, radiation therapy, chemotherapy and organ
transplantation, particularly renal transplant . A rare
causal association with infections such as HIV and
meningococcemia (with disseminated intravascular
coagulation) has been reported [2,3]. However, a large number of
cases do not have any obvious etiologic factor and are
reported as idiopathic .
Various imaging techniques have been used for diagnosis
of AVN. Plain X-ray has a low sensitivity and shows bone
damage only in later stages of disease. CT scan is better
than X-rays, however, its sensitivity compared to magnetic
resonance imaging (MRI) is still low, especially in early
Computed tomography scan at the level of the upper
humerus showing crescentic lucency as evidence of
FeFirinagetuinrgeen2deluetarosppihrailtsi oinn as mtheinarnsehcorwotiincgbmacakngyroviuanbdle and
degenFine needle aspiration smear showing many viable
and degenerating neutrophils in a thin necrotic
background. Inset shows an acid-fast bacillus (Giemsa Stain
200, Inset: Ziehl Neelsen Stain 400).
stages of the disease . MRI is currently the accepted
standard for noninvasive diagnosis. The classical MRI
appearance of AVN is that of a segmental area of low
signal density in the subchondral bone on T1-weighted
images . In our patient, a plain radiograph did not
reveal AVN, which could be picked up on CT scan. MRI
could not be performed due to lack of facilities.
The goal of treatment of AVN is to improve the use of the
affected joint, stop further damage to the bone and ensure
bone and joint survival. The underlying cause of AVN has
to be ascertained and eliminated if possible. Surgical
intervention, including arthroscopic debridement, core
decompression, vascularized bone grafting and bone
reconstruction, is advocated when symptoms are
persistent and signs of collapse are evident .
Tuberculosis, caused by Mycobacterium tuberculosis, is a
common infectious disease in the developing countries
and is re-emerging in developed nations due to the
human immunodeficiency virus (HIV) pandemic .
Osteoarticular tuberculosis results from hematogenous
dissemination of Mycobacterium tuberculosis from a
primary infected visceral focus to the skeletal system . Our
present case adds to the myriad of radiological
presentations of osteoarticular tuberculosis, i.e. avascular necrosis.
AVN with tuberculosis as an etiological cause of
osteonecrosis has only been mentioned in rare case
reports. Two cases of AVN of femoral capital epiphysis
following intertrochanteric tubercular osteomyelitis have
been reported . There is a recent report describing AVN
in a HIV positive patient with polyarticular tuberculosis
. To the best of our knowledge, the present case is the
first report documenting an association of monoarticular
tuberculosis with AVN in an immunocompetent patient,
where the etiology of osteonecrosis was confirmed on
aspiration cytology. In this patient, FNA showed an acute
suppurative lesion with a few acid-fast bacilli. This case
underlines the utility of Ziehl-Neelsen stain to diagnose
tubercular etiology in cases with radiological diagnosis of
AVN, especially when the patient is a resident of an
This case report emphasizes that tuberculosis should be
retained as one of the important differential diagnoses in
cases of osteonecrosis, especially in endemic areas, after
other more common etiological disorders have been
excluded. Aspiration cytology offers a rapid, yet
inexpensive method for diagnosis leading to appropriate therapy
ANA: anti-nuclear antibody; AVN: avascular necrosis; CT:
computed tomography; ESR: erythrocyte sedimentation
rate; FNA: fine needle aspiration; HIV: Human
Immunodeficiency Virus; MRI: magnetic resonance imaging; PPD:
purified protein derivative; TU: tuberculin units.
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
RA performed the fine needle aspiration cytology and
wrote the case outline. RG was a major contributor in
writing the manuscript and revising it. SS assisted in
reviewing the slides, provded images and helped in final
drafting of the manuscript. KG assisted in the literature
review and writing of the manuscript. MK interpreted the
fine needle aspiration cytology and critically reviewed the
manuscript for its intellectual content. All authors have
read and approved the final manuscript to be published.
All authors have participated sufficiently to take public
responsibility of the content of the manuscript.