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| Ahead of print
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| Spina Ventosa: An often Missed Diagnosis |
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Ankur Agarwal1, Sheetal Agarwal2, Savitri Singh3, Sumi Nandwani4
1 Department of Orthopaedics, Super Specialty Pediatric Hospital and Postgraduate Teaching Institute, Noida, Uttar Pradesh, India
2 Department of Pediatrics, ABVIMS and RML Hospital, New Delhi, India
3 Department of Pathology, Super Specialty Pediatric Hospital and Postgraduate Teaching Institute, Noida, Uttar Pradesh, India
4 Department of Microbiology, Super Specialty Pediatric Hospital and Postgraduate Teaching Institute, Noida, Uttar Pradesh, India
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| Date of Submission | 10-Jun-2020 |
| Date of Acceptance | 24-Jun-2020 |
| Date of Web Publication | 29-Jan-2021 |
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 Abstract | | |
Rare and varied presentations of tuberculosis make it difficult for treating clinicians to arrive at the diagnosis. An adolescent female presented to the orthopedic outpatient department with slowly increasing swelling over the dorsum of the hand near the base of the third digit for 5 months. With multiple consultations, she was being treated with antibiotics as a case of abscess. On examination, the swelling was soft bulging with whitish watery discharge. Plain radiography revealed periosteal elevation with bony destruction of the proximal phalanx. Magnetic resonance imaging revealed signal intensity changes with collection suggestive of infection. Blood investigations were within the normal limits, except slightly raised erythrocyte sedimentation rate. A differential diagnosis of chronic osteomyelitis was performed. Since the swelling was growing with the overlying skin likely to give way, it was treated with incision and drainage. Cytology with Gram's and auramine staining helped in confirming the diagnosis of spina ventosa. Biopsy is the gold standard for diagnosis, and antitubercular therapy forms the mainstay of treatment. Keywords: Sausage digit, spina ventosa, tubercular dactylitis, tuberculosis of short bones
A 12-year-old female presented with slowly increasing swelling over the dorsum of the right hand near the base of the middle finger for 5 months, with a recent history of discharge. She also complained of dull aching pain and lethargy. There was no history of injury. She was being treated with antibiotics as a case of abscess. On examination, the swelling was soft bulging with whitish watery discharge. X-ray showed periosteal elevation with bony destruction of the proximal phalanx of the third digit. Chest radiograph was normal. Magnetic resonance imaging revealed signal intensity changes with collection suggestive of infection [Figure 1]. Hematological investigations were within the normal limits, except slightly raised erythrocyte sedimentation rate. The Mantoux test was positive. Chronic osteomyelitis, foreign body granuloma, mycotic, syphilitic dactylitis, and enchondroma formed differential diagnosis.[1],[2],[3] Since overlying skin was likely to give way, surgical incision and drainage was done.[4] The material obtained showed granulomas with giant cells and caseous necrosis on Gram's staining. Although ZN staining was negative, fluorescent auramine staining showed few tubercle bacilli, which helped in making the diagnosis.[5],[6] Aerobic culture sensitivity and fungal KOH smear were negative. CBNAAT showed rifampicin sensitivity. Standard 4 drug antitubercular treatment (ATT) was given, as 4 months intensive, followed by 10-month continuation phase.[7] The patient's hand was splinted in volar plaster for 4 weeks, followed by functional bracing. Clinical and radiological assessment was done up to 2 years [Figure 2]. The lesion completely healed with no residual deformity, except slight shortening owing to bony destruction. | Figure 1: (a) Clinical, (b) Magnetic resonance imaging, and (c) Radiological picture at presentation
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 | Figure 2: (a) Functional outcome and (b) Radiological picture at 2 years of follow-up
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Tubercular dactylitis leads to endosteal destruction and subperiosteal new bone formation resulting in spindle-shaped ballooning of short bones earning the name sausage digit or spina ventosa (Latin for wind-filled digit).[8],[9] Several researchers have presented this rare case, but with the use of ATT, incidence has drastically reduced [Table 1]. Hence, a high index of suspicion is needed for arriving at the diagnosis. | Table 1: A review of cases of spina ventosa reported in the literature (PubMed) over the past 70 years
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Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Tuli SM. Tuberculosis of Short Tubular Bones. Tuberculosis of the Skeletal System. 5 th ed.. New Delhi: Jaypee Brothers Medical Publishers; 2016. pp. 168-70.  |
| 2. | Sahli H, Roueched L, Bachali A, Sbai M, Tekaya R. The epidemiology of tuberculous dactylitis: A case report and review of literature. Int J Mycobacteriol 2017;6:333. [ PUBMED] [Full text] |
| 3. | Agarwal A, Agarwal S. Retained foreign body masquerading as chronic osteomyelitis: A series of 3 cases and literature review. J Clin Orthop Trauma 2019;10:816-21. |
| 4. | Dhillon M, Prabhakar S, Aggarwal S, Bachhal V. Tuberculosis of the foot: An osteolytic variety. Ind J Orthop 2012;46:206. |
| 5. | Thatoi P. Multifocal tubercular dactylitis: A rare presentation of skeletal tuberculosis in an adult. J Clin Diag Res 2017 ;11(6):OD23-OD24. |
| 6. | Agarwal A, Singh S, Agarwal S, Gupta S. Needle aspiration and cytology for suspected osteoarticular tuberculosis in children. Malays Orthop J 2018;12:31-7. |
| 7. | Rekik S, Ben Ammar L, Soumaya B, Zehani A, Sahli H, Cheour I, et al. Spina ventosa: An uncommon case report of primary tuberculosis infection. Rheumatology 2017;57:996. |
| 8. | Fenger C. Tuberculosis of bones and joints. JAMA. 1889;13(17):587-96. |
| 9. | Tarentino AL, Maley F. A comparison of the substrate specificities of endo-beta-N-acetylglucosaminidases from Streptomyces griseus and Diplococcus pneumoniae. Biochem Biophys Res Commun 1975;67:455-62. |
Correspondence Address:
Ankur Agarwal,
Department of Orthopaedics, Super Specialty Pediatric Hospital and Postgraduate Teaching Institute, Sector 30, Noida, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jgid.jgid_198_20
[Figure 1], [Figure 2]
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