Tenosynovitis with rice body formation in a non-tuberculosis patient: a case report

Rice body synovitis in pediatrics: three different case reports

Rice body synovitis (RBS) is a rare disease, especially in children. Rheumatoid disorders and tuberculosis are the first two reasons for the formation of the RB. The diagnosis is mainly based on imaging and histopathological features. Herein, we report three cases of RBS in children diagnosed with congenital synovial chondromatosis, tuberculosis (unconfirmed), and ANA -positive juvenile idiopathic arthritis. Clinical features, radiographic findings, pathophysiology, treatment process, and prognosis were reviewed and documented meticulously to enhance cognition in this population and provide some references for clinicians in diagnosing and treating the disease.

Candida parapsilosis-Caused Arthritis with Rice Body Formation: A Case Presentation and Literature Review

A 68-year-old male patient came to the orthopedics department because of swelling and pain in his left shoulder joint. He received more than 15 intraarticular steroid injections in the shoulder joint at a local private hospital. MRI showed that the synovial membrane of the joint capsule was thickened and swollen, and there were extensive "rice body-like" low T2 signal shadows filling. Arthroscopic removal of rice bodies and subtotal bursectomy were performed. The observation channel was placed through the posterior approach, and a large amount of rice bodies in yellow bursa fluid were observed to flow out. Rice bodies with a diameter of approximately 1-5 mm filled the joint cavity were seen in the observation channel. The histopathological examination of the rice body showed that it was mainly composed of fibrin without a clear tissue structure. Bacterial and fungal cultures of synovial fluid suggested Candida parapsilosis infection, so the patient received antifungal treatment. However, the shoulder swelled again after three weeks, MRI revealed that there was significant fluid accumulation in the subacromial-subdeltoid region with necrotic synovial tissue floating and ultrasound examination showed joint cavity effusion, synovial hyperplasia, and some synovium looked like "floating weeds". After 2 weeks, there were recurrent rice bodies in the articular cavity. Arthroscopic surgery was performed again to clean the joint and a catheter was placed for irrigation and drainage, and a large amount of necrotic synovial tissue floating as seen in ultrasound. Finally, patient received sensitive antifungal treatment and did not relapse within 6 months. During the recurrence in the current case, we recorded the process of rice body formation, which has for the first time been reported.

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.

Rice bodies in the wrist

Rice bodies are a rare finding in medicine and offer a therapeutic challenge. As their occurrence varies over multiple rheumatic as well as infectious diseases, multiple hypotheses have been made about their origin. While rice bodies are most frequently reported in the shoulder and knee joints, flexor tendon synovitis with accompanying rice bodies is rarer. We report a case of extensive flexor tenosynovitis with rice bodies in the wrist in a 90-year-old patient with seronegative rheumatoid arthritis. The patient reported a 5-month history of painful swelling of the right wrist. Ultrasound showed pronounced swelling of the synovial tissue of the flexor tendons. Laboratory test were negative for rheumatology tests with normal C-reactive protein and sedimentation rates. T2-weighted magnetic resonance imaging demonstrated an extensive synovitis reaching from the distal forearm into the hand with inclusions, better known as rice bodies. Synovectomy including carpal tunnel release was performed with dissection of the mass revealing an extensive synovitis with a multitude of rice bodies. Histopathology showed lymphohistiocytic infiltrates consistent with rheumatoid nodules. After surgery, the patient regained full function of the wrist within 2 weeks without any pain or remaining mass in the affected limb.

Rice body formation due to Haemophilus parainfluenza-associated chronic arthropathy

A 68-year-old woman with a medical history significant for psoriatic arthritis was found to have an enlarged, painful lump on her left hip 15 months after intramedullary rod placement for a left subtrochanteric femur fracture sustained in a fall. Histopathological findings showed rice body formation (RBF) with concurrent H. parainfluenza. RBF is a relatively rare arthropathy of a subset of chronic inflammatory disease such as rheumatoid arthritis or tuberculous arthropathy. RBF associated with psoriatic arthritis or orthopedic hardware placement has been reported in a handful of cases in the literature but there has not been any definitive evidence for RBF as a result of Haemophilus parainfluenza infections and is a rather unusual characteristic of this case.

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.

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.

Non-tuberculous Mycobacterium or Fungus Induced Chronic Tenosynovitis with Rice Body of the Hand

BACKGROUND

Chronic tenosynovitis of the wrist and hand is commonly seen by orthopedists, especially hand surgeons. However, cases with rice body formation are comparatively rare. Thus, we retrospectively reviewed the cases of chronic tenosynovitis in our department and evaluated the necessity of antibiotic therapy in the early post-surgical stage.

METHODS

We analyzed the medical and surgical records of patients who had undergone surgery for chronic tenosynovitis with rice body formation in our department from 1997 to 2015. We evaluated the causes of chronic tenosynovitis, culture findings, pathological findings, and post-operative treatment courses.

RESULTS

Nineteen patients with 23 involved hands underwent surgery for chronic tenosynovitis, and 9 patients had rice body formation. The most common cause of chronic tenosynovitis was non-tuberculous mycobacteriosis, and other causes were fungal infection and infection of unknown origin. Recurrence was observed in 2 cases of mycobacteriosis and 1 case of fungal infection; 1 case of mycobacteriosis also had a re-recurrence.

CONCLUSIONS

In the diagnosis of chronic tenosynovitis with rice body formation, it is necessary to consider not only non-tuberculous mycobacteriosis, but also fungal infection as its origin. However, it is difficult to define the cause of synovitis, but in cases in which these infections are suspected, anti-bacterial therapy in the early post-surgical period could be effective.

Mass of the thenar eminence hiding idiopathic massive rice bodies formation with a compression of the median nerve: Case report and review of the literature

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Rice bodies are highly suggestive of tuberculous tenosynovitis and rarely found among non-tuberculosis patients.

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Synovial chondromatosis and pigmented Villonodular synovitis are differential diagnosis.

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MRI and routine histopathological examination are useful to establish the diagnosis.

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In our case, the key problem was the etiology of these rices bodies.

Introduction

Rice bodies are described as fibrin bodies usually found among patients with inflammatory joint diseases, tuberculous arthritis, and tuberculous tenosynovitis, but they are rarely found among non-tuberculosis patients.

Case presentation

We report a case of a 69-year-old with a 2-year history of swelling and pain of the thenar eminence of the left hand with paresthesia in the territory of the median nerve. Surgical exploration revealed multiple rice bodies.

Discussion

Several authors have speculated on the nature of rice bodies. Their presence is highly suggestive of tuberculous tenosynovitis. One case of a primary brucellar tenosynovitis has been reported. In Morocco, brucellosis and tuberculosis remain a significant problem, with synovial chondromatosis and pigmented villonodular synovitis as differential diagnoses.

Conclusion

The patient had no history of tuberculosis, rheumatic disease, joint trauma, or infectious disease. Despite extensive evaluation, the etiology of the rice bodies could not be identified, and no underlying pathology was found.

Tenosynovitis with Rice Body Formation Due to Mycobacterium Intracellulare Infection After Initiation of Infliximab Therapy

Patient: Female, 74

Final Diagnosis: Tenosynovitis

Symptoms: Arthralgia • pain

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

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.

Rice Bodies and a Partial Flexor Tendon Rupture in a Patient with Juvenile Idiopathic Arthritis: A Case Report and Review of the Literature

CASE

We present a case of rice-body formation and partial flexor tendon rupture in a 3-year-old child with seronegative juvenile idiopathic arthritis (JIA), which presented as a painless soft-tissue mass of the volar aspect of the hand. The diagnosis was not confirmed until histologic examination. The patient was managed with a tenosynovectomy and oral medication; he made a full recovery.

CONCLUSION

JIA is one of the most common rheumatologic conditions of childhood. Establishing the diagnosis can be challenging in very young children, particularly when clinical presentation is atypical and serology is negative. Surgical intervention may be warranted in the appropriately selected patient with JIA.

Dorsalis pedis psuedoaneurysm: A complication followed extensor tendoscopy of the ankle in a non-tuberculosis patient with tenosynovitis with rice body formation

Tenosynovitis with rice body formation is very rare in the ankle region. A case of this condition in a non-tuberculosis patient was presented. He was treated by extensor tendoscopy of the ankle. The tenosynovitis subsided after the procedure. However, it was complicated by formation of a dorsalis pedis pseudoaneurysm.

Arthroscopic treatment of bony loose bodies in the subacromial space

INTRODUCTION

Multiple bony loose bodies in the subacromial space caused form cartilage or bone cells and continue to grow.

PRESENTATION OF CASE

A 58-year-old man with two-year history of swelling and pain of the right shoulder. He had no history of tuberculosis and rheumatoid arthritis. Magnetic resonance (MR) images showed some bony loose bodies in the subacromial space. The removal of loose bodies and bursa debridement were performed arthroscopically. Histological diagnosis of them was synovitis with fibrous bodies.

DISCUSSION

Extra-articular loose bodies is extremely rare, especially in the subacromial space, which maybe originated in the proliferative synovial bursa. Most authors recommend open removal to relive the pain, but there were choice to apply arthroscopy to remove them.

CONCLUSION

The mechanism of formation of bony loose bodies is not clear, may be associated with synovial cartilage metaplasia. Arthroscopic removal of loose bodies and bursa debridement is a good option for treatment of the loose body in the subacromial space, which can receive good function.

Subdeltoid Bursa Tuberculosis with Rice Bodies Formation: Case Report and Review of Literature

Introduction:

We describe a rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as bursitis of the left shoulder with rice bodies, without coexisting active tuberculosis or tuberculosis in the previous history.

Case Report:

A 21 year old patient was examined, who complained of pain and swelling in the left shoulder for 2 years. MRI showed a large amount of rice bodies with joint effusion in the left shoulder with intact rotator cuff. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas. Arthroscopic debridement and removal of the loose bodies was done. A brief summary of the literature is given.

Conclusion:

We report a unique case of tuberculous subdeltoid bursitis with rice bodies formation in absence of any other concomitant focus of tuberculous infection, managed with arthroscopic debridement and anti -tuberculous regimen with a long follow up of twelve months.

Tenosynovitis with rice body formation presenting as a cutaneous abscess

A 62-year-old woman with a past medical history of rheumatoid arthritis was referred to the Department of Dermatology because of an enlarging cutaneous lesion on the right thumb which resembled a soft tissue infection. She had received antibiotics without significant improvement. Clinical examination revealed an erythematous nodule involving almost the whole surface of the distal phalanx with spontaneous drainage of countless of small yellowish ovoid granules. Histopathologic study of these structures showed an inner core of amorphous acidophilic material with some interspersed chronic inflammatory cells and a surrounding thin fibrin layer. Special stains and cultures were negative for parasites, bacterium and mycobacterium. Magnetic resonance imaging (MRI) revealed distension of the first and fifth finger flexor sheaths and common finger flexor sheath. These areas were filled by fluid and multiple small nodular lesions. A diagnosis of non-infectious rice body tenosynovitis was rendered and surgical removal was performed. Total recovery was observed with no evidence of recurrence after 6 months of follow-up. To our knowledge, this is the first report of rice body tenosynovitis presenting as a pseudoinflammatory cutaneous lesion with evolution to a cutaneous fistula with drainage of rice grain-like structures. The description of this impressive and peculiar clinical and histopathologic picture is important to further recognize similar cases.

Bilateral recurrent wrist flexor tenosynovitis and rice body formation in a patient with sero-negative rheumatoid arthritis: A case report and review of literature

INTRODUCTION

Rice body formation has been traditionally observed in the joint and tendon sheaths of patients with tuberculosis. Few case reports exist that describe rice body formation in patients with rheumatoid arthritis. We describe a case report of bilateral recurrent wrist flexor tenosynovitis with rice body formation in a patient with sero-negative rheumatoid arthritis.

PRESENTATION OF CASE

This case report describes a 72 year old lady presenting with severe bilateral, flexor tenosynovitis of the wrists. Ultrasonography revealed significant echogenic fluid on the palmer aspect of wrist joint surrounding flexor tendons with intact neurovascular bundles and no bony erosion. Laboratory tests demonstrated elevated erythrocyte sedimentation rate (50 mm/h) and negative rheumatoid factor. A sequential subtotal flexor tenosynovectomy was carried out with decompression of the carpal tunnel. During the operation, multiple rice bodies among the flexor tendons with adherent synovitis were found. Histology revealed disrupted synovial tissue containing several areas of fibrinoid necrosis, bounded by a layer of vaguely pallisaded histiocytes but no epitheloid granulomata or germinal centre. A revision surgery with debulking of the fibro-osseous canal was undertaken following recurrence. The patient presently has complete resolution of symptoms at one year follow-up.

DISCUSSION

The combined clinical, laboratory, ultrasound and histology findings of the patient indicated that the cause of the rice body formation was due to a sero-negative arthritis rather than tuberculosis.

CONCLUSION

Rice body formation can be caused by sero-negative arthritis. Bilateral wrist flexor tensosynovitis can recur within five months of a previous synovectomy in a patient with sero-negative arthritis.