Tuberculosis of the hand

Imaging features of shoulder tuberculosis with rice bodies formation: A case report

Osteoarticular tuberculosis is less common than pulmonary tuberculosis and is often overlooked in the differential diagnosis of people with joint disease. In this article, we present a case of a 71-year-old female patient admitted to the hospital because of pain and limited movement of her right shoulder for a year. The patient had diabetes for 10 years, and no history of tuberculosis or previous history of tuberculosis exposure. Blood test results showed inflammatory condition and positive IGRA test. X-ray, ultrasound and magnetic resonance imaging images revealed osteolytic and sclerotic lesions of the humeral head, diffuse thickening of the synovial membrane, and loose bodies in the joint and bursa. The clinical diagnosis was tuberculous inflammatory osteoarthritis of the right shoulder. The patient underwent arthroscopy surgery to remove loose bodies and the inflamed portion of the synovium and send them to the pathology department. Histopathological examination of the loose bodies and synovial membrane revealed features suggestive of tuberculosis of the shoulder joint. Afterward, the patient was treated with antituberculosis drugs according to the guideline and rehabilitation exercises. After 3 months of treatment, the clinical symptoms were reduced, the pain rating was decreased and the range of motion was increased.

My journey in hand surgery: combining patient care, clinical and basic science research

This review is about my clinical and research journey in hand surgery. The journey has been a worthwhile and meaningful one, especially when I felt there were areas I could influence management, whether this be rare cases, common conditions or where a suggested algorithm may be helpful. I also had the unique privilege of working with geneticists, which has resulted in clinical-pathological publications that could influence patient management, as shared from a clinician's perspective. It is hoped this article will inspire young clinician scientists to pursue a journey of collaboration with other researchers.

Mycobacterial Infections of the Hand

BACKGROUND

Hand infections caused by mycobacteria are relatively uncommon compared to infections caused by other pathogens; therefore, much of the available literature consists of case reports and limited case series. Broadly categorized into tuberculous and nontuberculous mycobacterial (NTM) infections, both tuberculous and NTM infections are typically insidious with long incubation periods and with the ability to remain dormant for prolonged periods.

METHODS

We reviewed the most current literature on the epidemiology, presentations, treatment methods, and resistance patterns of mycobacterial infections of the hand focusing on the indications and outcomes of nonoperative as well as operative interventions.

RESULTS

The worldwide burden of tuberculosis remains high and while the overall rate of new diagnosis drug resistant tuberculosis has been on the decline some regions of the world have demonstrated staggeringly high resistance rates to first-line tuberculosis therapies. Signs and symptoms of mycobacterial hand infection are typically inconsistent, and highly dependent on the specific structures of the hand that are affected; therefore, these infections may mimic other infections of the hand like tenosynovitis, joint space infections, and cutaneous infections. The main stay of treatment remains antimycobacterial therapies including but not limited to rifampin, isoniazid, pyrazinamide, and ethambutol.

CONCLUSIONS

The complications associated with mycobacterial hand infections can be significant. Prompt evaluation, including a thorough history to evaluate for potential exposures to infectious sources, followed by appropriate antibiotic choice and duration, with surgical management as needed, is key to reducing the chance that patients experience lasting effects of the infection.

Clinical features and treatment outcome of wrist tuberculosis in adult- a retrospective study of 84 consecutive cases with minimum of 2 years follow up

Background

Wrist tuberculosis (TB) is a rare disease that may result in residual deformity, pain, or stiffness even after proper antitubercular chemotherapy (ATT) and surgical intervention. The aim of our study is to present clinical features and functional outcomes of wrist TB in a consecutive series of 84 adult patients with a minimum of 2 years of follow-up.

Methods

Clinical features and treatment outcomes of 84 consecutive adult patients with wrist TB from January 2003 to June 2018 including 45 men and 39 women, with a mean age of 46.8 years (18–84) were retrospectively analyzed. Data were collected on participants’ demographic details. The primary outcome measures were QuickDASH score, grip strength, Visual Analogue Scale (VAS), and PRWHE. Secondary outcomes include health-related quality of life was evaluated using the EuroQol five-dimension five-level (EQ-5D-5L), assessment and postoperative complications of patients who underwent operation were also recorded.

Results

All 84 patients with an average follow-up of 50.8 (24–105) months. The mean duration of symptoms before treatment was 10.5 months (2–21). There were 27 patients with bony and 57 with primarily soft-tissue involvement based on preoperative evaluation of plain radiographs and MRI. There were 33 patients treated with ATT and 51 patients were treated with surgery followed by ATT. Among them, 13 patients (15.5%) underwent incision and decompression, 14 patients (16.7%) underwent wrist synovectomy, 13 patients (15.5%) underwent wrist joint fusion by plate fixation, and 11 patients (13.1%) underwent wrist joint fusion by external fixation. At the last clinical visit, the QuickDASH, and PRWHE scores of all patients decreased significantly, the VAS improved from 5.9 to 1.4, EQ-5D-5L utility index improved from 0.36 to 0.88, EQ-VAS improved from 40.2 to 89.1. All patients indicated good wrist recovery at the last follow-up, and the treatment achieved satisfactory clinical outcomes.

Conclusion

The onset of wrist TB is insidious; early diagnosis, good patient compliance, and surgery combined with ATT are crucial steps for treatment of wrist TB, and also essential for the patient's postoperative recovery. Wrist arthrodesis has achieved satisfactory results in the treatment of severe wrist TB.

Synovial tuberculosis in wrist diagnosed based on metagenomic next-generation sequencing: A case report

Synovial tuberculosis in the wrist is a rare disease that is usually misdiagnosed at the early stage. In this case, we presented a 67-year-old male with wrist joint tuberculosis who presented repeated left wrist joint edema for more than 2 years. The patient received surgery twice. During the second surgery, the combination of metagenomic next-generation sequencing (mNGS) and pathological analysis contributed to the detection of Mycobacterium tuberculosis in lesion tissues. Conventional anti-tubercular therapy confirmed the diagnosis of synovial tuberculosis in the wrist joint. In conclusion, mNGS contributed to the rapid and accurate detection of tubercle bacillus.

Sausage digit: Isolated tuberculous tenosynovitis of the middle finger

Isolated tuberculous tenosynovitis is a rare form of extra-pulmonary tuberculosis that frequently eludes assessment and constitutes diagnostic challenges

A diffuse granulomatous inflammation secondary to a trauma of hand: a case report

Granulomatous inflammation is rare in the musculoskeletal system and difficult to diagnose. Here we describe a case of a 62-year-old woman with a history of being stabbed by a fishbone presented with a soreness, swelling, and limitation of movement of her right palm and wrist for 4 months. Surgery was done and the histopathology of specimens demonstrated granulomatous lesion, which was negative for acid-fast bacilli. This case demonstrates the diagnosis of granulomatous tenosynovitis on MRI, ultrasound, and surgical examination under anesthesia.

Ancient foe spectra: Case series of Mycobacterium tuberculosis presentations

Extrapulmonary tuberculosis frequently eludes assessment through atypical presentations and constitute diagnostic challenges. High degree of suspicion with aids of GeneXpert MTB/RIF can clinch the diagnosis and avoid unnecessary consequences.

Hand Tuberculosis: a Common Disease at an Uncommon Site

Tuberculosis (TB) is one of the major health problems in developing countries. India has the highest TB burden with approximately 27% of global TB [6]. (India TB Report 2018 Revised National TB Control Programme (2018)). The most common form of tuberculosis constitutes pulmonary tuberculosis. Among extra pulmonary tuberculosis, the musculoskeletal tuberculosis accounts for about 10–15% cases (Mohd Altaf Mir, Imran Ahmad, Mihd Yaseen (2016) World J Plast Surg 5(3):313–318). Hand involvement is seen in 10% of patients with musculoskeletal disease. There has been recent interest in tuberculosis of the hand because of a rising incidence owing to increasing numbers of immigration, an aging population, and immunosuppressed people including affected patients with human immunodeficiency virus [3,7] (Centre for Disease Control (1995) MMWR 14:1–16), Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Omawi M (2011) J Hand Surg 36:1413–1422). Tuberculous tenosynovial disease (TBTS) is the most common presentation of hand tuberculosis. In the hand, the flexor tendon sheath and radio-ulnar bursae are the most common sites of tenosynovitis. Tuberculosis of hand is more commonly seen in the dominant hand of the male population (Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Omawi M (2011) J Hand Surg 36:1413–1422). Here, we present a case of TBTS affecting extensor compartment of dominant hand in a post renal transplant immunosuppressed individual.

Hand Surgery in Saudi Arabia

Hand surgery is a unique field that incorporates multiple specialties, aiming to provide the patient with a best possible functional and aesthetic results. Hand surgeons deal with different pathologies that require skills in several aspects of surgery. The field of hand surgery has evolved significantly over the past decades across the globe. This specialty has also been evolving in Saudi Arabia over the past 25 years. Some of the services offered to patients include specialized centers for brachial plexus, peripheral nerve, and pediatric hand surgery as well as centers for work-related hand injuries. There has also been significant contribution to the hand surgery literature from the hand surgeons working in Saudi Arabia, with hundreds of papers published in journals pertaining to hand surgery, orthopedic surgery, and plastic surgery, as well as the publication of several novel mutations causing congenital hand defects in journals concerned with genetics. The recent approval of a hand and microsurgery fellowship program in Saudi Arabia will also help boost this field in the country and the region.

Infiltration of synovitis into the flexor tendon: a case report

Synovitis is a type of aseptic inflammation that occurs within joints or surrounding tendons. No previous reports have described a hypertrophic synovium eroding the tendon sheath and manifesting as synovitis within the flexor tendon. We herein report a case involving a 10-year-old girl who presented to our hospital with a 1-month history of a swollen mass and progressive inability to completely flex her left index finger. The active flexion angle of the proximal interphalangeal joint was limited to 85°. A longitudinal incision of the flexor digitorum profundus tendon was surgically performed. The synovium inside and outside the flexor digitorum profundus tendon was completely removed. After the surgical excision, normal tendon gliding returned without recurrence by the 1-year follow-up. The active flexion angle of the proximal interphalangeal joint improved to 100°. To the best of our knowledge, this is the first case of synovitis affecting the flexor tendon and leading to limited flexion of a finger. The manifestation of a double ring sign on magnetic resonance imaging is quite characteristic. Early diagnosis and monitoring of the hyperproliferation and invasiveness of the synovial tissue are required. Surgical excision can be a simple and effective tool when necessary.

Tuberculous tenosynovitis of the Flexor Tendons of the hand and wrist: A case report and mini-review

Tuberculous tenosynovitis of hand and wrist is a rare disease but it is found sometimes, especially in TB-endemic areas. The clinical presentation is not specific, however, most patients present with painless swelling at the wrist and hand with limited range of motion, and nerve compression symptoms have been reported. The diagnosis of this conditions can be made from histopathology. Antituberculosis drugs are the mainstay treatment while surgery is controversial.

Case presentation

We present the case of an 83-year-old Thai woman with no history of exposure to tuberculosis. She presented with swelling and mild pain at her right wrist and the fifth finger of her right hand for 3 months. Ultrasonography revealed tenosynovitis in the right hand and wrist. Mycobacterium tuberculosis was confirmed with tissue diagnosis after an open biopsy. 2-months regimens containing Isoniazid, Rifampicin, Pyrazinamide and Ethambutol/6-months of isoniazid and rifampicin treatment was successful without complications. We follower her up for 1 year, at which time she had returned to do normal daily activities. Her final DASH score was 10.8.

Conclusion

Tuberculous tenosynovitis is rare, but still occasionally encountered, especially in TB-endemic areas. The challenge is that this condition is difficult to diagnose due to its clinically insidious onset and the presentation is not obviously specific. Laboratory analysis, imaging (MRI, ultrasonography) and microbiology are useful to help reach a diagnosis, but finally confirmation is from histopathology. The treatment mainstay is medical, but surgery may be required if conservative treatment fails or in late stages of the disease.

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Chronic painless swelling of the hand and wrist in TB endemic area should include TB tenosynovitis.

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Tissue pathology is the mainstays for diagnosis.

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The treatment mainstay is an anti-tuberculosis drugs regimen.

Mycobacterial Infections in the Hand and Wrist

Mycobacterial hand infections are uncommon. These infections have an indolent course and are marked by variable and nonspecific presentations, often leading to diagnostic and treatment delays. The pathogens involved in mycobacterial hand infections include Mycobacterium tuberculosis complex, atypical mycobacteria, and M leprae. Initial treatment involves a combination of long-term antibiotics and surgical débridement to cure the infection. Reconstructive procedures aid in restoring hand function lost secondary to the disease.

Hand Infections: Epidemiology and Public Health Burden

Upper extremity infections are common. Most infections can be effectively treated with minor surgical procedures and/or oral antibiotics; however, inappropriate or delayed care can result in significant, long-term morbidity. The basic principles of treating hand infections were described more than a century ago and most remain relevant today. Immunosuppressant medications, chronic health conditions such as diabetes and human immunodeficiency virus, and public health problems like intravenous drug use, have changed the landscape of hand infections and provide new challenges in treatment.

Isolated Tuberculosis of the Wrist: Subtle but Destructive

Tuberculosis is an infection that can occur in every organ of the body, but it rarely affects the wrist joint. We report a rare case of a male patient with wrist tuberculosis with a subtle presentation. Our patient’s left wrist had been swollen for four months and progressively worsened, becoming ulcerated one week prior to presentation to our center. He was asymptomatic, but a previous radiograph showed global destruction of the wrist joint. Clinical investigations, that is, polymerase chain reaction test for tuberculosis and histopathological examination, showed classic findings of tuberculosis, which lead to the initiation of anti-tuberculosis treatment.

Idiopathic tenosynovitis with rice bodies

PURPOSE

Idiopathic tenosynovitis with rice bodies is a rare disease and its non-association with rheumatic diseases, tuberculosis infection or trauma is reported only in few cases in literature.

PATIENTS, MATERIALS AND METHODS

Our study presents a series of five patients diagnosed with tenosynovitis with rice bodies at the flexor tendons of the upper limb. Medical history revealed no associated disease or trauma. Disease duration ranged between two months and four years, two patients presenting symptoms of acute carpal tunnel and three patients tumor mass. In one case, the tumor measured 210 mm in length and a tendon rupture was suspected. Laboratory and imaging investigations could not establish a specific associated pathology and a preoperative diagnosis. Surgical treatment consisting of synovectomy was performed in all patients.

RESULTS

In all five cases, intraoperative appearance could easily determine the presence of rice bodies. Histopathological examination revealed typical aspect for rice bodies and make the diagnosis possible without the need for other more laborious processing (immunohistochemistry). The amount of rice bodies was directly proportional to disease duration. In all cases, the recovery was complete. After a median 30.4-month follow-up, no recurrence was detected. Subsequently performed laboratory investigations and specific tests did not reveal tuberculosis infection, rheumatic disease, or other diseases.

CONCLUSIONS

This is the largest series of patients with idiopathic tenosynovitis with rice bodies and the bigger tumor mass reported to date. Synovectomy with removal of all rice bodies represents the optimal treatment. A longer disease course may be associated with a larger number of rice bodies, which may be associated with tendon rupture. The etiopathogenesis remains unclear, further studies being necessary to establish it.

Tuberculous Arthritis of the Knee with Rice Body Formation: A Report of a Rare Case

In this report, we present the case of a 53-year-old man with rice body formation in the right knee caused by tuberculous arthritis (TB arthritis). The patient visited our hospital in January 2018 with a seven-month history of swelling and pain in the right knee. He had no previous history of tuberculosis, and the results of the routine laboratory tests were within normal limits; he also tested negative for rheumatoid factor. Magnetic resonance (MR) imaging revealed multiple rice bodies in the right knee, measuring 5-8 mm. He underwent an arthroscopic operation in the right knee in January 2018 and received antituberculosis polytherapy for 6 months. He was followed-up for more than 01 year. The patient regained good function of the operated knee with no evidence of recurrence during the last follow-up in February 2019. Conclusion. The biggest challenge in diagnosing tuberculosis arthritis is the consideration of its possibility in the differential diagnosis, not only in endemic countries where tuberculosis is frequent. A high level of suspicion for TB should be maintained for every infection of the knee joint, particularly in the case of intra-articular rice bodies.

Synovial tuberculosis of the hand: An ancient disease in an unusual localisation

Background

Tuberculosis is the most prevalent infectious disease in the world. It is mainly caused by Mycobacterium tuberculosis. Osteoarticular tuberculosis represents 1%-3%. Tenosynovitis is the most common form of the disease in the hand.

Aims

The aim of this study is to present an update of synovial tuberculosis.

Materials and Methods

The authors present a literature review, the clinical and surgical management and case reports.

Results

The outcomes were satisfactory and were not report complications.

Conclusions

Early diagnosis, surgical transection of the transverse carpal ligament, debridement and complete excision of the infected synovium may be required, along with antituberculosis drugs. Knowledge of this disease in the hand can provide a better diagnosis and outcome.

Hand Infections

Infections are common in hand surgery and proper management is important to achieve optimal outcomes. Although most cases are not urgent, less common, severe infections such as flexor tenosynovitis and necrotizing fasciitis require urgent identification with both medical and surgical management. It is common for diagnoses to be missed or delayed because clinical and laboratory indicators are often variably present. Delayed identification and management can result in poor outcomes with permanent deficits. This article will provide a review of hand infections with a focus on identifying serious hand infections requiring urgent or emergent treatment, and distinguishing these from less urgent scenarios.

Rice-body formation without rheumatic disease or tuberculosis in a "sausage" ring finger

Rice bodies are very unusual lesions, generally encountered in chronic synovitis due to rheumatoid diseases or tuberculosis. A 31-year-old right-handed man presented with a 15-year history of progressively growing "sausage-like" swelling of the 4th finger and palm of his right hand. There was an immovable, painless mass with restriction of the finger's ROM without local or general associated signs. Imaging showed a large non-aggressive mass within the tendon sheath. Complete excision of the mass was performed. Histopathological examination showed synovial villi with rice bodies and central necrosis suggestive of tuberculous synovitis or rheumatoid arthritis (RA). Tests for mycobacterial infections were all negative and there was no argument in favor of a rheumatoid pathology. There is no established standard treatment in a case like ours, which has no origin in tuberculosis or RA. Prolonged follow-up will be needed to confirm absence of recurrence after complete excision.

Carpal synovitis with capitate bone tuberculosis in a child

We present a 10-year-old boy with 2-month duration non-traumatic wrist pain and inflammatory signs. Due to elevated inflammatory markers on blood tests, with an increase in radiocarpal and intercarpal joints synovial fluid and no bony lesions, the patient was submitted to wrist arthrocentesis for the suspicion of septic arthritis. The patient did not improve on conventional treatment, however. An MRI showed synovitis around the carpus and a lytic lesion of the capitate bone due to osteomyelitis. A biopsy was able to identify the causative agent as Mycobacterium tuberculosis, and the patient was treated with antibiotics. He improved significantly, with no pain and signs of normal capitate bone remodelling on the last radiograph.

Tuberculous osteomyelitis of the wrist presenting as a monoarthritis syndrome

Osteoarticular tuberculosis is the third most frequent location of tuberculosis after the lung and lymph nodes, accounting for approximately 10%-20% of all cases of extrapulmonary disease. Tuberculosis of the hand and wrist is the rarest osteoarticular location after the shoulder. The authors report the case of a 50-year-old woman without medical history who was diagnosed with isolated tuberculosis of the wrist presenting as monarthritis. The diagnosis was confirmed by histopathological and microbiological examination. Late stages of osteomyelitis are even rarer without any predisposing factors such as immunosuppression. This case underlines the importance of including tuberculosis in the differential diagnosis of monoarthritic syndromes to prevent delayed initiation of therapy and consequent complications and bone damage.

Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: Is Tenosynovectomy Imperative?

The treatment of flexor tenosynovitis in the hand and wrist due to tuberculosis is controversial. Although some authors recommend the antituberculous chemotherapy, the others recommend the surgical treatment. In this article, 12 patients with synovial tuberculosis of the flexor aspect of the hand and the wrist were evaluated with respect to diagnosis and treatment modalities. None of the patients had a history of tuberculosis, concomitant disease, immunosuppressive drug use, drug abuse, and human immunodefficiency virus positivity. A chest x-ray and family screening were performed in all of the cases, none had evidence of tuberculosis in the lung. The biopsy, histopathological examination, acid-fast bacillus staining, and BACTEC tuberculosis culture were performed. Antituberculous chemotherapy was initiated in patients diagnosed with tuberculosis by either histological or microbiological examinations. The patients did not undergo any further surgery after biopsy procedures. The lesions regressed totally in all patients after 3 months of treatment. Carpal tunnel syndrome symptoms and signs recruited at five months of treatment. In patients with flexor tuberculosis tenosynovitis, it is possible to achieve good results by applying only medical therapy after a biopsy, and without the need for further surgery.

Acute Deep Infections of the Upper Extremity: The Utility of Obtaining Atypical Cultures in the Presence of Purulence

PURPOSE

In the setting of acute deep upper extremity infections, evidence is lacking to guide the decision whether to send atypical cultures (fungal and acid-fast-bacillus [AFB]) during surgical debridement, especially in the presence of purulent fluid that is commonly observed with typical bacterial infections. Our purpose was to determine the frequency of positive atypical cultures and the frequency with which they alter treatment, and identify factors associated with positive atypical cultures.

METHODS

We retrospectively identified 100 adult patients undergoing surgical debridement of acute deep infections of the upper extremity in which fungal and/or AFB cultures were sent. Necrotizing and superficial infections were excluded. Descriptive statistics were used to describe patient characteristics, infection diagnoses, number of cultures sent with corresponding rates of positivity, and treatments. Cohorts with positive and negative atypical cultures were compared with bivariate analysis for all collected variables.

RESULTS

One or more immunocompromising comorbidities were present in 46% of patients. Diagnoses included soft tissue abscess (46%), suppurative flexor tenosynovitis (22%), septic arthritis (21%), osteomyelitis (9%), and septic bursitis (2%). Aerobic bacterial, anaerobic bacterial, fungal, and AFB cultures were sent in 100%, 99%, 94%, and 82% of patients, respectively. Corresponding rates of positivity were 74%, 34.3%, 5.3%, and 2.4%, respectively. Atypical cultures were positive for 7% of patients and 2.9% of all atypical tests sent. Antibiotic treatment was influenced by atypical culture data for 4% of patients. For patients with positive atypical cultures, purulence was observed during surgery in 86% of cases. Bivariate analysis demonstrated symptom duration greater than 7 days as potentially associated with atypical culture positivity.

CONCLUSIONS

Intraoperative purulence at the time of surgical intervention should not deter the surgeon from obtaining atypical cultures. As expected, atypical cultures are infrequently positive given the rarity of associated diseases. Symptoms greater than 7 days may predict a higher incidence of atypical culture positivity for patients being treated surgically within 30 days of initial symptom onset.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Tuberculous monoarthritis of the wrist in a patient with systemic lupus erythematosus: a case report

Background

Unusual forms of tuberculosis are common among immune-suppressed patients, leading to challenges in diagnosis and management. We present a Sri Lankan patient with systemic lupus erythematosis, investigated for chronic wrist pain with low inflammatory markers and without systemic symptoms, who was subsequently diagnosed to have tuberculosis of the joint.

Case presentation

A 31-year-old woman with systemic lupus erythematosis in remission was evaluated for chronic left wrist pain without significant examination findings on presentation. She did not have any constitutional symptoms. Basic investigations did not reveal any significant abnormalities. She was treated with increasing immunosuppression as for lupus related arthritis. Subsequently she developed a wrist effusion with high inflammatory markers, and was treated as septic arthritis. Synovial biopsy features suggested tuberculosis. The patient’s symptoms improved with surgical intervention and anti-tuberculosis treatment.

Conclusion

Tuberculosis should be considered in patients with systemic arthritis with unusual symptoms. Delayed diagnosis along with continuing immunosuppression can lead to extensive tissue damage. Clinically detectable effusions should be analyzed along with synovial biopsy in order to exclude concurrent infections. Radiography of the joint has poor sensitivity to detect early joint damage, but changes may be evident early on magnetic resonance imaging, sothis should be considered in patients with unusual features.

Osteoraticular Tuberculosis-Brief Review of Clinical Morphological and Therapeutic Profiles

Osteoarticular tuberculosis (OATB) is a rare form of tuberculosis (TB) whose incidence rose significantly nowadays especially in the underdeveloped countries. The main risk factors predisposing to this new challenge for the medical system are the Human Immunodeficiency Virus (HIV) epidemic, the migration from TB endemic areas and the development of drug and multidrug-resistant strains of Mycobacterium tuberculosis (Mt). The disease affects both genders and any age group although the distribution depending on gender is controversial and that depending on age has a bimodal pattern. In most cases the initial focus is elsewhere in the organism and the most frequent pathway of dissemination is lympho-haematogenous. The clinical picture includes local symptoms as pain, tenderness and limitation of motion, with some particularities depending on the segment of the osteoarticular system involved, sometimes accompanying systemic symptoms specific for TB and other specific clinical signs as cold abscesses and sinuses. The radiographic features are not specific, CT demonstrates abnormalities earlier than plain radiography and MRI is superior to plain radiographs in showing the extent of extraskeletal involvement. Both CT and MRI can be used in patient follow-up to evaluate responses to therapy. TBhas been reported in all bones of the body, the various sites including the spine (most often involved) and extraspinal sites (arthritis, osteomyelitis and tenosynovitis and bursitis). Two basic types of disease patterns could be present: the granular type (most often in adults) and the caseous exudative type (most often in children) one of which being predominant. The algorithm of diagnosis includes several steps of which detection of Mt is the gold standard. The actual treatment is primarily medical, consisting of antituberculosis chemotherapy (ATT), surgical interventions being warranted only for selected cases. It is essential that clinicians know and refresh their knowledge about manifestations of OATB.

Isolated Tuberculosis of Capitate and Triquetrum

Musculoskeletal system is involved in about 20% of the patients diagnosed with tuberculosis. Although musculoskeletal tuberculosis generally affects spine and large joints (hip and knee), hand involvement of the tuberculosis is seen in 10% of the patients with musculoskeletal involvement and also isolated tuberculosis of hand or wrist is much rarer. In the following report, we discuss the case of a 23-year-old male patient who was diagnosed with isolated tuberculosis of the capitate and triquetrum bone. The patient presented with a nonhealing sinus on the left wrist joint. Imaging revealed lytic lesions of the capitate and triquetrum. The diagnosis of tuberculosis was confirmed by histopathological examination on the bone specimen obtained from the debridement and curettage. Antituberculosis therapy was started postoperatively and 1 month later, healing of the sinus was observed. There was no sign of reactivation seen at follow-up 22 months after treatment.

Miliary tuberculosis and acquired immunodeficiency syndrome - 'a cursed duet'

Tuberculous osteomyelitis is rare and usually involves the vertebrae but is seldom found in the foot. The uncommon site and ability to mimic other disorders clinically and radiographically leads to diagnostic and therapeutic delays. We report a case of a 40-year-old man who initially presented to his podiatrist with intermittent pain and swelling of his right ankle and foot that lasted for a year. He also started to exhibit significant weight loss and unexplained fevers and was subsequently hospitalized for cellulitis of his right foot. On further workup, patient was found to have miliary tuberculosis (TB) and acquired immunodeficiency syndrome (AIDS). Patient was treated with anti-TB therapy for 9 months and highly active anti-retroviral therapy. Our patient presented with ongoing chronic right foot and ankle pain that was proven to be secondary to TB osteomyelitis of cuneiform bones of the right ankle in the setting of AIDS. The patient's clinical presentation was unusual due to symptom duration and lack of systemic characteristics. Like our case, reported incidence of osteomyelitis of bone/joint in extrapulmonary TB is estimated to be 10%, and out of all bones/joint TB cases, only 1% are found to be in the foot.

Pseudotumoral form of soft-tissue tuberculosis of the wrist

Tuberculosis is a major public health problem in developing countries. Hand and wrist is a rare localization for extra-pulmonary tuberculosis, a pseudotumoral form of soft tissue tuberculosis of the wrist is exceptional. We report the case of a 45-year-old male presenting with a painful swelling of the dorsal aspect of the right wrist evolving for six months. Clinical study was evoking a ganglion cyst of the wrist. Intraoperatively a pseudotumoral mass with rice bodies was found, suggesting tuberculous tenosynovitis. The histopathological study revealed caseating giant cell granulomas with epithelioid cells. Cultures on Löwenstein-Jensen medium detected Mycobacterium tuberculosis. Synovectomy with removal of all the rice bodies followed by anti-tuberculous chemotherapy provided uneventful recovery.

Primary cutaneous tuberculosis in a 27-year-old medical intern from needle-stick injury: a case report

The authors report a case of cutaneous tuberculosis in a 27-year-old African male medical intern who contracted primary cutaneous from a needle-stick injury. Cultures of pus aspirated from the finger initially grew Staphylococcus aureus that led to a delay in the diagnosis.

Bifocal musculoskeletal tuberculosis in upper limb: Unusual case

Bifocal musculoskeletal tuberculosis is a rare presentation of the disease. The following report documents the case of a 28-year-old Moroccan man presenting simultaneously with a swelling of the palm of the hand and the sternoclavicular joint. The HIV serology and hepatitis (B, C) serology were negative, as well as the tuberculin skin test. The radiographs of both locations were normal. The histopathology confirmed the diagnosis. The antibacillary chemotherapy produces excellent results. It is therefore indispensable to bear in mind the possibility of such atypical presentations of tuberculosis when making a rapid and pertinent diagnosis and prescribing the appropriate treatment.

Chronic hand infections

Chronic infections of the hand are uncommon, and a high index of suspension is required for their early diagnosis. These can be grouped based on the microorganism. Mycobacterial infections include tuberculosis, atypical mycobacterial infections, and leprosy. Other bacterial infections include actinomycosis, cat-scratch disease, syphilis, tularemia, bacillary angiomatosis, and actinomycetoma. Fungal infections may be classified as cutaneous (affecting the skin, the paronychia or nail plate), subcutaneous (mainly lymphocutaneous sporotrichosis and dermatiaceous infections), and deep fungal infections. Each type of deep fungal infection has a "classic" presentation and this is emphasized. Finally, common chronic viral infections of the hand include warts and orf.

Treatment of chronic isolated finger flexor tenosynovitis through 50% dehydrated alcohol installation

The isolated idiopathic finger flexor tenosynovitis is a rare condition, related to diversed etiologies. The traditional treatment of flexor tenosynovitis includes medications and injection of steroids. If the conservative treatment is not effective, surgical management is usually recommended. And alcohol installations have been rarely performed. We are reporting an extremely rare case of a 56-year-old man who had chronic idiopathic isolated finger flexor tenosynovitis which was treated through alcohol injections. The patient had not yet been treated despite of medication and serial injections of steroid. We performed 1 mL of 50% ethanol injection for the initial treatment and the second injection was done in the same way 10 months later due to the improvements of the patient's clinical symptoms and images of the follow-up ultrasonography. As a result, the authors suggest alcohol installation as an alternative non-surgical treatment for flexor tenosynovitis when other conservative managements are not effective enough.

Tuberculous extensor tenosynovitis of the hand

Tuberculous tenosynovitis is a rare manifestation of extrapulmonary tuberculosis (Tb), especially if solely the dorsal hand compartment is affected. In this report, we present the medical history of an immuno-competent 32-year-old man presented with a painful swelling of the right dorsal wrist. Initial inflammation onset had occurred 6 months before he consulted our service, resulting in consultation of several physicians and extensive diagnostic procedures without gaining a specific diagnosis. Finally, after extensive diagnostic tests, a tenosynovectomy was performed and tuberculosis-induced extensor tenosynovitis was detected. The diagnosis was established by positive histology, repeated specific PCR and T-SPOT.TB. Tuberculous tenosynovitis can easily be overlooked as a cause of chronic tenosynovitis particularly in immunocompetent young people lacking any risk factors.

Three unusual factors contributing to compressive median neuropathy in the distal forearm in a single patient

Although there are varied aetiological factors responsible for compressive neuropathy of the median nerve in the carpal tunnel syndrome, it is rare to encounter several aetiological factors in a single case. This article reports a case in which three aetiological factors were present.