A Case of Multiple Tuberculous Arthritis Simulating Malignancy and Charcot Joint

Abstract

ON July 24, 1928, Mr. G. N., a cigarmaker, aged 60, entered the surgical section of the out-patient department complaining of a painful swelling of the left elbow. There were also two lumps the size of walnuts on the right forearm near the wrist, and another below the left knee, but none of the se was as painful as th e left elbow. The patient stated that when he was a baby he was saved from falling downstairs by his father, who caught him by the left leg; in this manner his left hip was dislocated, making him lame th e remainder of his life. He was always healthy, however, following the trade of a carpenter until about nine years previous to the present examination, when his left elbow became stiff, causing him to give up carpentering and become a cigarmaker. In 1922, two small “tumors” were cut out of the elbow region but the swelling had gradually returned unti l now he was almost completely incapacitated. Examination showed the elbow joint to be greatly enlarged (Fig. 1), with the surrounding tissues firm except for an area about 2.5 cm. in diameter on th e posterior surface. There was no movement in the joint. Figure 2 shows the swelling on the right wrist. The swelling below the left knee proved to be a benign chondroma unrelated to the joint condition. A provisional diagnosis of inoperable osteogenic sarcoma was made and the patient was referred to the X-ray department. X-ray Findings.—The left elbow (Fig. 3) showed marked calcification of the arteries, extensive destruction of the lower end of the humerus and upper ends of the radius and ulna, and a large tumor-like mass in the soft tissues containing irregular deposits of calcium. The right wrist (Fig. 4) showed marked destruction of the carpal bones, but the remaining parts were sharply outlined and of normal density. There was no evidence of atrophy due to disuse, although the destruction involved the bases of the metacarpals and the lower ends of the radius and ulna; the whole picture was strongly suggestive of a Charcot joint. The left hip (Fig. 5) showed complete destruction of the head and neck, with the shaft displaced upwards 6 centimeters. There was an extensive and irregular calcareous deposit about the acetabulum, as well as an old calcified abscess lateral to the femoral shaft. The chest showed no evidence of pulmonary tuberculosis. Laboratory Findings.—The urine was normal. Blood count showed hemoglobin 80 per cent; erythrocytes 4,500,000; leukocytes 10,100; differential—polymorphonuclears 67 per cent, small lymphocytes 31 per cent, eosinophiles 2 per cent. The Wassermann test was negative. August 6, 1928, about 8 c.c. of thick opaque yellow pus were aspirated from the soft nipple-like projection on the inner side of the left elbow. Microscopically this contained numerous polymorphonuclear and mononuclear leukocytes, and a great deal of unidentified cell débris, among which were some deeply staining round or oval bodies suggestive of yeast cells.