DOI: https://doi.org/10.36347/sasjs.2026.v12i10.005

Pages: 835-840

Osteoarticular tuberculosis accounts for 1–3% of all tuberculosis cases, the hip being the second most frequently involved site after the spine. Because tuberculous coxitis produces a slowly progressive destructive arthropathy, it is readily mistaken for other causes of femoral head destruction, in particular osteonecrosis, especially when constitutional signs are absent and pulmonary bacteriology is negative. We report a 50-year-old man with pulmonary tuberculosis treated 20 years earlier and declared cured, who relapsed in 2022 and subsequently defaulted from a second course of therapy after four of six months. He had limped with left hip pain for three years, symptoms having started concurrently with his pulmonary relapse. He was referred with a working diagnosis of femoral head osteonecrosis. Radiographs and computed tomography showed collapse and marginal erosion of the femoral head with acetabular erosion, periarticular osteopenia, joint space narrowing and strikingly sparse osteophytosis a pattern more consistent with tuberculous arthropathy. Sputum bacteriology was negative at referral, yet four-drug therapy was reinstituted on clinical grounds. After seven weeks of chemotherapy, single-stage cementless total hip arthroplasty was performed through a posterior approach with radical synovectomy and multiple tissue sampling. Histopathology showed caseating granulomatous synovitis and GeneXpert MTB/RIF on articular tissue was positive with no rifampicin resistance. The patient completed a nine-month course of chemotherapy under directly observed therapy and was declared cured of his pulmonary disease. At eight months after surgery he was pain-free and walking unaided, with no clinical, biological or radiological evidence of local recurrence. This case illustrates that negative pulmonary bacteriology does not exclude active skeletal tuberculosis, that treatment default is a powerful driver of irreversible joint destruction, and that tissue diagnosis remains manda