Clinical images: Tuberculous rice bodies of the wrist

Idiopathic tenosynovitis of the wrist with multiple rice bodies: A case report and review of literature

BACKGROUND

Multiple rice bodies in the wrist is a rare disorder that requires surgery, and there are still many uncertainties regarding its diagnosis and treatment.

CASE SUMMARY

We described a rare case of chronic idiopathic tenosynovitis with rice bodies of the wrist in a 71-year-old man and reviewed similar topics in the literature. A total of 43 articles and 61 cases were included in the literature review. Our case had a usual presentation: it was similar to those in the literature. The affected population was mainly older adults, with an average age of 59.43 (range, 3 to 90) years. The male-to-female ratio was 1.54:1 (37/24).Most of them showed limited swelling and pain, only 23.0% had carpal tunnel symptoms, and the average disease duration was 18.03 (0.5-60) mo. Wrist flexor tendon sheath involvement was the most common (95.1%, 58/61), and only 3 cases had extensor tendon sheath involvement.The main causes were tuberculosis (34.4%, 21/61), non-tuberculous mycobacteria (24.6%, 15/61), idiopathic tenosynovitis (31.1%, 19/61), and others (9.84%, 6/61). There were 10 patients with recurrences; in 6 of them, were due to non-tuberculous mycobacterial infections.

CONCLUSION

We reported a case of wrist idiopathic tenosynovitis with rice body formation, and established a clinical management algorithm for wrist tenosynovitis with rice bodies, which can provide some reference for our clinical diagnosis and treatment. The symptoms of rice-body bursitis of the wrist are insidious, nonspecific, and difficult to identify. The aetiology is mainly idiopathic tenosynovitis and mycobacterial (tuberculosis or non-tuberculous) infections; the latter are difficult to treat and require long-duration systemic combination antibiotic therapies. Therefore, before a diagnosis of idiopathic tenosynovitis is made, we must exclude other causes, especially mycobacterial infections.

Tenosynovitis: a rare presentation of tuberculosis better known by hand surgeons than infectious diseases specialists

PURPOSE

Clinical presentation of tuberculosis is pleomorphic. Some forms are rare and better known by surgeons than infectious disease specialists.

METHODS

We describe a rare case of isolated chronic tenosynovitis of the wrist due to Mycobacterium tuberculosis in a 66-year-old man and review similar cases in the literature.

RESULTS

On literature search, only 23 other cases of tuberculous tenosynovitis were retrieved. Our case is similar, with an insidious classical presentation. The diagnosis was suggested at the surgical presentation by the presence of rice body masses.

CONCLUSION

The diagnosis of tuberculous tenosynovitis should be considered in chronic tenosynovitis. Functional prognosis may be committed without adequate treatment.

[Presence of riziform bodies in a patient with juvenile idiopathic arthritis: case report and literature review.]

Riziform bodies are structures formed by fibrin and cells that can be found in the synovial fluid or attached to the synovium, and have this denomination due to its rice grain-like appearance. They have already been described in several diseases such as tuberculous arthritis, rheumatoid arthritis, and rarely in juvenile idiopathic arthritis (JIA). This is the case of a boy with a 4-month course of chronic monoarthritis of the left knee, with family history of sarcoidosis in which diagnostic investigation showed the presence of these riziform bodies in the synovial biopsy. Diagnostic investigation ruled out sarcoidosis, tuberculosis and malignancies, establishing the diagnosis of JIA. Our objective was to describe what we believe is the 9th case reported on the presence of riziform bodies in JIA, which are probably underdiagnosed, and should be considered mainly in cases of severe arthritis of difficult medical treatment.

[Tuberculous rice body synovitis of the shoulder joint]

The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.

[Giant bursitis with rice bodies of the shoulder/neck region in a patient with rheumatoid arthritis without joint-connection]

Giant bursitis with rice bodies is an important clinical entity recognized in rheumatoid arthritis. Usually the bursitis is connected to a joint space. In this unusual case of a giant bursitis of the shoulder/neck region, no connection to a joint could be found. The bursitis lays directly on a rib. The clinical and radiological findings are presented and this special case is discussed in comparison to the literature.