COVID-19 and Osteoarticular Tuberculosis: Challenges and Perspectives from a Developing Nation

Dear Editor, Osteoarticular tuberculosis (OA-TB) is a disabling disease which requires prompt medical and sometimes even surgical correction. COVID-19 pandemic has created a big impact by delaying patient presentation [Figure 1], diagnosis, drug therapy, and surgical interventions in OA-TB, further worsening morbidity. Such effects are even more profound in developing nations like India, where we have a huge existing burden of OA-TB and the emerging burden of COVID-19. India has the highest tuberculosis burden in the world. OA-TB comprises only around 1'–5' of all forms of TB. In India, 2' of all and 11' of extrapulmonary TB is musculoskeletal in origin, which for a highly populated country like India translates into high numbers.[1]Figure 1: Neglected cases of oseoarticular tuberculosis involving proximal phalanx of little finger presented with large soft-tissue massFollowing the effect of pandemic, lockdown and movement restrictions, care of patients with osteoarticular TB have faced a multitude of challenges.[2] Some predictive models have tried to find impact on TB care in India. A model developed from Imperial College, London, predicted that there could be a 70' reduction in TB testing lab capacity and availability of health care staff in India.[3] The TB clinics have shut due to diversion of staff, shortage, and risk of too much social contact in these clinics. Supply chains of drugs become harder to sustain during a time of physical and economic shutdown.[4] This is a highly relevant and pertinent issue for rheumatologists as many patients on biologics need evaluation for tuberculosis. Lack of screening for tuberculosis and the frequent use of biologics for rheumatological disorders and even for COVID-19 (Tocilizumab and other off-label drugs) can lead to increased incidence of tuberculosis, which eventually will go undiagnosed. This will further lead to increased sequalae, drug-resistance, and spread. A recent article found that nearly half of patients started on biologicals by rheumatologists developed tuberculosis. It was predominantly extra-pulmonary and required clinical suspicion, Mantoux/IGRA and radiology to diagnose the same.[5] Limited access to medical care, follow-up and investigations pose a risk of delayed or missed diagnosis in the COVID-19 era. Thus, there have been multiple challenges in the diagnosis and management of OA-TB in the COVID-19 pandemic. However, these challenges have made the authorities and medical fraternity realize the importance of managing both these illnesses by using the resources judiciously. Public education and distancing with appropriate use of the mask can help control the spread of both these diseases. The need of the hour is to manage the new pandemic (COVID-19) and simultaneously not forget the silent and persistent endemic (Tuberculosis). Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.