Progress in Orthopedic Science DOI: 10.5455/pos.20160609035952 www.scopemed.org Prog Orthop Sci ● 2016 ● Vol 2 ● Issue 2 17 Rice bodies: a rare presentation of tubercular arthritis of the knee joint Nadeem Ali 1 , Abedullah Bhat 2 , Firdous Ahmad Bangroo 2 , Ajaz Hamid Wani 1 , Shivani Kalhan 2 , Manjeet Singh Dhanda 2 ABSTRACT Rice bodies are most of the times encountered in rheumatological disorders. They have also been seen in tuberculosis, though rarely. With tuberculosis, rice bodies are usually associated with bursae and tenosynovium and very rarely with large joints. We report a rare case of intra articular rice bodies associated with tuberculosis of the knee joint that mimicked monoarticular rheumatoid arthritis and pigmented villonodular synovitis clinically, with absent constitutional and laboratory features suggestive of tuberculosis. KEY WORDS: Rice bodies; Tuberculosis; Rheumatoid arthritis; Synovium. 1 Department of Orthopaedics, SKIMS Medical College and Hospital, Bemina, Srinagar, Jammu and Kashmir, India. 2 Department of Orthopaedics, SHKM Government Medical College, Mewat, India. Address for correspondence: Dr Nadeem Ali, Mughal Mohalla, Lalbazar, Srinagar, J & K, INDIA – 190023, drnadeeem@gamil.com Received: April 03, 2016 Accepted: June 09, 2016 Published: July 01, 2016 Case Report INTRODUCTION Skeletal tuberculosis accounts for 1 to 3 % cases of extra- pulmonary tuberculosis with spine the most common site followed by hip and knee joint [1, 2, 3]. Although formation of intra articular rice bodies was first described by Riese in 1896 in case of tubercular arthritis, the entity is more commonly encountered in rheumatological disorders of the joints [3, 4]. In tuberculosis, rice bodies have more common association with bursae and tenosynovial sheaths rather than joints. There are very few cases of rice bodies in tubercular arthritis of large joints in the orthopaedic literature [5]. We report a rare case of tuberculosis of the knee joint with intra articular rice bodies. CASE REPORT Thirty two year old male patient presented to our hospital with progressively increasing pain and swelling in the right knee for the last six months. There was no history of any trauma and similar type of involvement of any other joint. There was no history of any evening rise of temperature and loss of appetite. On examination there was diffuse swelling of the knee with obliteration of the parapatellar gutters. Local temperature was not raised. Joint line tenderness was present. Cross fluctuation was present but patellar tap absent. Terminal 30 degrees of flexion at knee joint was painful. Haemogram, total leukocyte count, differential leukocyte count and erythrocyte sedimentation rate were within normal range. Serum for C reactive protein was negative. Serology for rheumatoid arthritis was negative. Radiograph of the knee joint demonstrated a well maintained joint space without any articular erosion or juxta-articular osteopenia. Metaphysis of distal femur and proximal tibia did not have any lesion. MRI of the knee joint was advised and patient refused due to financial constraints. Aspiration of the joint from the suprapatellar pouch was negative. A differential diagnosis of pigmented villonodular synovitis or monoarticular rheumatoid arthritis was made. Diagnostic arthotomy and synovial biopsy was planned. Knee joint was explored through a lateral parapatellar approach. On opening the joint there was egress of synovial fluid along with hundreds of white coloured shiny round to oval bodies with size ranging from 3 to 6 millimetres (Figure 1). Synovium of the joint was hypertrophied with brick red discoloration. There was erosion of the lateral femoral condyle with exposure of the subchondral bone. The joint was thoroughly lavaged with normal saline and partial synovectomy was performed (Figure 2). The shiny bodies and the synovium were sent for histopathological examination. On histopathology, rice bodies consisted of an amorphous core surrounded by a layer of fibrin and interspersed chronic inflammatory cells (Figure 3). Histopathology of the synovium showed multiple caseating epitheliod cell granulomas surrounded by mononuclear infilitrate and scattered langhan and multi nucleate giant cells suggestive of granulomatous synovitis (Figure 4). Ziehl Neelsen staining for acid fast bacilli was negative. Based on histopathology, a diagnosis of tubercular arthritis of knee joint with intraarticular rice body formation was made. The leg was immobilized in a back slab and antitubercular drug therapy started. At two weeks intermittent active and passive range of motion of the knee joint was started. Weight bearing with ambulatory support was started after three months. Antitubercular chemotherapy was administered for a total duration of nine months (Isoniazid, rifampin, pyrazinamide and ethambutol for two months followed by isoniazid and rifampin for seven months). At the final follow up of two years patient’s knee joint was pain free with full range of motion at the joint.