Mycobacterium chelonei tenosynovitis of the hand: a case report

A Series of Nontuberculous Mycobacterial Flexor Tenosynovitis Infections and Cost of Treatment

Background  Nontuberculous mycobacteria (NTM) are rare but potentially devastating causes of musculoskeletal infection and impairment in immunocompetent patients. Purpose  Given the sparse body of literature surrounding these infections, we describe a series of patients with and the cost of treatment of upper extremity NTM infections. Patients and Methods  In a retrospective review of seven patients with NTM infections of the upper extremity treated at a university hospital from 2010 to 2019, we assessed patient demographics, exposures, infection characteristics, management course, outcomes, and costs of treatment. Results  Insidious pain and swelling were the most common clinical manifestation of infection. Despite coupled surgical and medical management, recurrence was common. Two patients required amputation, and three others had lasting functional deficits. The most common pathogen was Mycobacterium avium complex (5 of 7). The estimated median charge related to management was $85,126 with a range from $8,361 to $1,66,229. Conclusions  The treatment of NTM infections is complex and expensive. Diagnosis is usually delayed, which further complicates the management of these patients who often suffer from lasting debilitation. Due to its potentially devastating course, NTM infection should be considered and tested for whenever flexor tenosynovitis is suspected. Regardless of initial presentation, our experience suggests that a protocol of serial surgical debridement immediately after tissue diagnosis is necessary for optimal outcomes. Furthermore, NTM infections require collaboration with infectious disease colleagues to guide antimicrobial regimens based on susceptibility testing and therapeutic drug monitoring for the recommended 6 to 12 months of therapy after the final operative debridement. Level of Evidence  This is a Level IV, case series study.

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.

MYCOBACTERIUM CHELONAE HAND INFECTION: A REVIEW

Six cases of culture-proven Mycobacterium chelonae tenosynovitis were identified through retrospective chart review. Fifteen cases were identified using computerised Medline search. Clinical features, treatment and outcome were described. Infection control was achieved in our patients with an average of 3.2 surgeries each and antibiotic treatment for six months to one year. Eleven published cases were managed by combined surgery and systemic antibiotics, with an average of 1.73 surgeries per patient and seven weeks to 24 months of antibiotics. All our patients were disease free on final follow-up. Thirteen cases were resolved. Functional outcomes were reported for eight cases. Comparison of functional outcome was not possible because different parameters were used in different reports. Aggressive debridement, susceptibility-guided antibiotics, and supervised rehabilitation resulted in infection control and acceptable hand function for our patients. Standardised data collection on subsequent cases would facilitate outcome monitoring and formulation of a treatment guideline for this disease.

Atypical Mycobacterium infections of the upper extremity

BACKGROUND

We encountered five patients with atypical Mycobacterium infections in the upper extremity, and examined their outcomes.

PATIENTS AND METHODS

Two patients were male and three were female. The average patient age was 67 (range, 63-75) years. A wide synovectomy was performed to diagnose all cases followed by a therapeutic regimen of Rifampicin, Isoniazid, and Ethambutol.

RESULTS

The causative atypical organism was Mycobacterium marinum in three cases and Mycobacterium intracellulare in two cases. In one patient, inflammation recurred or did not disappear, and, therefore, three debridements were necessary. The average duration of antimicrobial therapy was 12 (range, 5-24) months. The average follow-up period was 26 (range, 5-66) months, and resolution had been achieved in all cases at the time of follow-up evaluation.

CONCLUSION

Surgical debridement and appropriate mycobacterial culture or PCR method are critical to enable diagnosis and appropriate management.

Mycobacterium chelonae tenosynovitis of the hand

OBJECTIVE

Tenosynovitis of the hand due to atypical mycobacteria is an uncommon condition. We present a case of tenosynovitis of the hand due to Mycobacterium chelonae in a patient without a recognized penetrating injury, who was treated successfully with clarithromycin and antituberculous medications and without debridement. We reviewed the available literature to summarize the experience with this infectious entity.

METHODS

Case report and review of the literature (MEDLINE 1976-2003). Only cases that were sufficiently detailed were included.

RESULTS

Twelve cases of upper extremity infection due to M. chelonae have been reported: hand tenosynovitis in most and arthritis in a few. These infections resulted from percutaneous inoculation or hematogenous seeding. The clinical course was indolent initially but insidiously destructive. Previously, treatment always included surgical excision of the infected tissues and antibiotic therapy. This is the first case of M. chelonae musculoskeletal infection that resolved with only antimicrobial therapy.

CONCLUSIONS

Musculoskeletal infections by nontuberculous mycobacteria are clinically indistinguishable from those of tuberculosis and diagnosis is usually delayed. Prompt diagnosis of atypical mycobacteria with appropriate antimicrobial treatment may avoid the need for surgical debridement. Relevance We recommend a trial of antibiotics for M. chelonae before surgical debridement.

Atypical mycobacterial flexor tenosynovitis presenting as carpal tunnel syndrome: Presentation of three cases and review

Three patients with carpal tunnel syndrome secondary to atypical mycobacteria flexor tenosynovitis are presented. Aggressive surgical debridement combined with long term antitubercular pharmacotherapy resulted in a good outcome, but the lag time to diagnosis and course of disease were long. Diagnosis of these infections requires a high suspicion index, adequate surgical biopsy and appropriate cultures. Atypical mycobacteria infections must be considered in the differential diagnosis in any patient with evolving chronic tenosynovitis, even if the patient has no history of immunosuppression, and especially if environmental risk factors are present.

Non-tuberculous mycobacterial tenosynovitis: a review

The clinical characteristics, outcome and treatment of non-tuberculous mycobacterial tenosynovitis are reviewed. From lesions localized in the hand, 10 different species of non-tuberculous mycobacteria have been reported. The most common are Mycobacterium marinum and Mycobacterium kansasii. Other less frequent organisms are Mycobacterium avium complex, Mycobacterium szulgai, Mycobacterium terrae, Mycobacterium fortuitum, Mycobacterium chelonae, Mycobacterium abscessus, Mycobacterium malmoense and Mycobacterium xenopi. The infections appear to be the result of previous trauma, surgical procedure, corticosteroid injection or non-apparent inoculation (water contamination). Immunosuppression is sometimes associated with the infections and can be considered as a risk factor. Surgical debridement and appropriate mycobacterial cultures are critical to enable diagnosis and appropriate management. Specimens should be inoculated on a range of media and incubated at a range of temperatures in order to isolate mycobacteria with different growth characteristics (with prolonged incubation). The optimal treatment of these infections is discussed.

Tenosynovitis due to Mycobacterium avium intracellulare and Mycobacterium chelonei: report of two cases with review of the literature

Atypical mycobacteria can induce soft tissue infections such as tenosynovitis. We observed one case of finger flexor tendon tenosynovitis infected with Mycobacterium avium intracellulare and one case of knee and ankle arthritis with lateral peroneal tendon tenosynovitis due to M. chelonei. In the first patient, a tenosynovectomy only was performed leading to resolution of the infection. The second patient was immunocompromised as a result of corticosteroid therapy and the mycobacterial infection was treated with tenosynovectomy and multidrug chemotherapy. This patient died from infectious pneumonitis. Previously reported cases of infectious tenosynovitis due to these atypical mycobacteria are reviewed.

Atypical Mycobacterium infections of the upper extremity

Thirty-three patients with culture-positive atypical Mycobacterium infections of the upper extremity underwent surgical debridement and antimicrobial therapy. The causative atypical organism was M. marinum in 12 cases, M. avium-intracellulare in 7, M. terrae in 4, M. chelonei in 4, M. kansasii in 3, M. fortuitum in 2, and M. ulcerans in 1. The tenosynovium was the most common location of infection (14 patients). The average follow-up period was 36 months. Duration of antimicrobial therapy averaged 10 months. The average delay between onset of symptoms to correct diagnosis was 1 year. There were seven superficial infections; six were caused by M. marinum and one was caused by M. ulcerans. All of these cutaneous infections resolved following incisional or excisional biopsy and pharmacologic therapy. The remaining 26 infections involved the deeper tissues, and M. avium-intracellulare was the most common organism. The immune status of the host was an overwhelming predictor of eventual outcome. In the 15 patients with competent immune systems, resolution occurred in 13. However, in the immunocompromised patient population, only 4 of the 10 had resolution of deep infection at time of the follow-up evaluation.

Retroperitoneal abscess caused by Mycobacterium chelonae and treatment

OBJECTIVE

To report a case of retroperitoneal abscess caused by Mycobacterium chelonae and treatment.

DESIGN

Case report.

SETTING

Private community teaching hospital.

PATIENTS

A patient was admitted to the hospital following a gunshot to the flank. The bullet passed through the iliac crest and lodged in the abdomen.

INTERVENTION

The patient was treated with cefazolin, trimethoprim/sulfamethoxazole, and amikacin at different times.

OUTCOME

The patient responded well to pharmacologic treatment and at 18-month follow-up, he is disease free.

CONCLUSIONS

Antimicrobial agents with in vitro activity against M. chelonae, especially amikacin-containing regimens, are recommended for treating M. chelonae infection.

A Mycobacterium Malmoense Infection of the Hand Presenting as Carpal Tunnel Syndrome

We report an atypical tuberculous infection by Mycobacterium Malmoense of the synovium of the flexor tendons at the wrist presenting as carpal tunnel syndrome. This is the first time this organism has been described in a site other than the lungs or the cervical lymph nodes.

Hand Infections with Mycobacterium Chelonei: A Case Report and Review of the Literature

A case is reported of soft-tissue infection in the hand due to Mycobacterium chelonei, presenting as a chronic painful swelling of a finger.