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Basnayake O, Jayarajah U, Beneragama T. Tuberculosis of the wrist causing carpal tunnel syndrome in a patient with rheumatoid arthritis: A case report. SAGE Open Med Case Rep 2024; 12:2050313X231225871. [PMID: 38222941 PMCID: PMC10787524 DOI: 10.1177/2050313x231225871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/20/2023] [Indexed: 01/16/2024] Open
Abstract
Among extrapulmonary tuberculosis, osteoarticular tuberculosis is a rare manifestation, and cases related to osteoarticular tuberculosis of large joints have been reported previously. However, tuberculous tenosynovitis causing carpal tunnel syndrome is a rare manifestation, especially in the background of rheumatoid arthritis. A 67-year-old Sri Lankan male with a background of rheumatoid arthritis presented with progressively enlarging left wrist swelling associated with pain and numbness for 2 months. He was on Methotrexate and Hydroxychloroquine as disease-modifying agents, and his symptoms related to arthritis were well controlled. On examination, lobulated subcutaneous swelling was noted in distal forearm extending to the palmar region with evidence of carpal tunnel syndrome which was confirmed by nerve conduction studies. There was no pre-operative evidence to suggest tuberculosis both clinically and biochemically. Synovial thickening due to rheumatoid arthritis was considered as the probable diagnosis and surgical decompression of the carpal tunnel was performed. Intraoperatively, synovial thickening was noted around the flexor tendons with evidence of median nerve compression in the carpal tunnel. Thickened synovial mass was completely excised. Histology and culture were positive for tuberculosis. Following excision and 9 months of anti-tuberculosis treatment, he was asymptomatic with good range of motion of fingers. In conclusion, a combination of surgical excision and anti-tuberculosis treatment was successful to achieve good functional outcomes. In a country like Sri Lanka, where tuberculosis is still prevalent, uncommon musculoskeletal manifestations may not be infrequent. Therefore, clinicians should have a high degree of suspicion when treating such patients.
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Affiliation(s)
- Oshan Basnayake
- Department of Anatomy, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- Department of Plastic and Reconstructive Surgery, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Umesh Jayarajah
- Department of Plastic and Reconstructive Surgery, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Thushan Beneragama
- Department of Plastic and Reconstructive Surgery, National Hospital of Sri Lanka, Colombo, Sri Lanka
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2
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Giri SK, Suba S, Bandyopadhyay A, R P. Tuberculous flexor tenosynovitis of wrist and hand. BMJ Case Rep 2023; 16:e252286. [PMID: 36944442 PMCID: PMC10032381 DOI: 10.1136/bcr-2022-252286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
A woman in her 40s presented with a swelling over her left distal forearm and hand since 7 months, progressively increasing in size. She had history of difficulty in moving her wrist and fingers with no associated pain. She had no immune or chronic conditions except for hypothyroidism for which she was on regular medication. On examination, there was an 8×7 cm swelling on the radial side of the volar surface of her left distal forearm extending till the thenar eminence. MRI of the left upper limb was suggestive of a soft tissue swelling arising from the flexor tendon.The patient was planned for surgical excision of the swelling. Intraoperatively, there was a mass arising from the flexor tendons of flexor digitorum superficialis, flexor digitorum profundus (FDP) and flexor pollicis longus (FPL), extending distally up to the mid palm region. On incising the flexor tendon sheath, it was observed that multiple yellowish rice like granules extended across the tendons. The lesion was excised completely and sent for histopathology examination. The lax FDP of little and ring fingers were plicated following proper tension adjustment and defect in FPL was primarily repaired. Postoperatively, the patient recovered well with no local wound complications. The biopsy report was suggestive of tuberculosis. The patient completed a course of antituberculosis treatment in 6 months.
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Affiliation(s)
- Sanjay Kumar Giri
- Burns and Plastic Surgery, AIIMS Bhubaneswar, Bhubaneswar, Odisha, India
| | - Santanu Suba
- Burns and Plastic Surgery, AIIMS Bhubaneswar, Bhubaneswar, Odisha, India
| | | | - Pavithra R
- Burns and Plastic Surgery, AIIMS Bhubaneswar, Bhubaneswar, Odisha, India
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3
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Kefi A, Ben Abdelghani K, Ben Jemaa I, Elleuch M, Sassi C, Jrad M, Turki S, Abderrahim E. Tuberculous tenosynovitis of the hand: A challenging diagnosis. Clin Case Rep 2023; 11:e6872. [PMID: 36721682 PMCID: PMC9880383 DOI: 10.1002/ccr3.6872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/23/2022] [Accepted: 01/03/2023] [Indexed: 01/28/2023] Open
Abstract
Tuberculous tenosynovitis of the hand is a very rare condition. Herein, we report the case of tuberculous tenosynovitis of the hand in a 32-year-old woman. We highlight the success of anti tuberculosis drugs alone without resort to surgical treatment.
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Affiliation(s)
- Asma Kefi
- Department of Internal Medicine ACharles Nicolle HospitalTunisTunisia,Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia
| | - Khaoula Ben Abdelghani
- Department of Internal Medicine ACharles Nicolle HospitalTunisTunisia,Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia
| | - Ilef Ben Jemaa
- Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia,Department of RadiologyCharles Nicolle HospitalTunisTunisia
| | - Mounira Elleuch
- Department of Internal Medicine ACharles Nicolle HospitalTunisTunisia,Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia
| | - Cyrine Sassi
- Department of Internal Medicine ACharles Nicolle HospitalTunisTunisia,Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia
| | - Myriam Jrad
- Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia,Department of RadiologyCharles Nicolle HospitalTunisTunisia
| | - Sami Turki
- Department of Internal Medicine ACharles Nicolle HospitalTunisTunisia,Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia
| | - Ezzeddine Abderrahim
- Department of Internal Medicine ACharles Nicolle HospitalTunisTunisia,Faculty of Medicine of TunisTunis El Manar UniversityTunisTunisia
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Wu M, Lan X, Lin S, Lai T, Lin W, Wu H. Synovial tuberculosis in wrist diagnosed based on metagenomic next-generation sequencing: A case report. EUR J INFLAMM 2022. [DOI: 10.1177/20587392221075507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Meimei Wu
- Department of Digestive System, Fuzhou Second Hospital, Fuzhou, China
| | - Xianfeng Lan
- Department of Hand Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Shibei Lin
- Department of Hand Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Tian Lai
- Department of Hand Surgery, Fuzhou Second Hospital, Fuzhou, China
| | - Weiguo Lin
- Department of Digestive System, Fuzhou Second Hospital, Fuzhou, China
| | - Hao Wu
- Department of Hand Surgery, Fuzhou Second Hospital, Fuzhou, China
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Goravey W, Al Maslamani M, Petkar M, Ammar A, Ali GA. Sausage digit: Isolated tuberculous tenosynovitis of the middle finger. IDCases 2022; 27:e01438. [PMID: 35169542 PMCID: PMC8829555 DOI: 10.1016/j.idcr.2022.e01438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 12/02/2022] Open
Abstract
Isolated tuberculous tenosynovitis is a rare form of extra-pulmonary tuberculosis that frequently eludes assessment and constitutes diagnostic challenges
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Zheng S, Wang J, Ji Z. A diffuse granulomatous inflammation secondary to a trauma of hand: a case report. Radiol Case Rep 2021; 16:2256-2260. [PMID: 34178200 PMCID: PMC8214190 DOI: 10.1016/j.radcr.2021.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/15/2021] [Accepted: 05/15/2021] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Sui Zheng
- Department of Ultrasound, Shantou Central Hospital, Shantou, Guangdong, China
| | - Jiagang Wang
- Department of Ultrasound, Shantou Central Hospital, Shantou, Guangdong, China
| | - Zhongyuan Ji
- Department of Ultrasound, Shantou Central Hospital, Shantou, Guangdong, China
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Suwannaphisit S, Ranong NN. Tuberculous tenosynovitis of the Flexor Tendons of the hand and wrist: A case report and mini-review. Ann Med Surg (Lond) 2020; 57:249-252. [PMID: 32817788 PMCID: PMC7426482 DOI: 10.1016/j.amsu.2020.07.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 11/24/2022] Open
Abstract
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. Chronic painless swelling of the hand and wrist in TB endemic area should include TB tenosynovitis. Tissue pathology is the mainstays for diagnosis. The treatment mainstay is an anti-tuberculosis drugs regimen.
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Affiliation(s)
- Sitthiphong Suwannaphisit
- Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University. 15 Karnjanavanich Road, Hat Yai, Songkhla, 90112, Thailand
| | - Nakares Na Ranong
- Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University. 15 Karnjanavanich Road, Hat Yai, Songkhla, 90112, Thailand
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Abstract
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.
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Affiliation(s)
- Abdo Bachoura
- The Philadelphia Hand to Shoulder Center, Thomas Jefferson University Hospital, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107, USA
| | - David S Zelouf
- The Philadelphia Hand to Shoulder Center, Thomas Jefferson University Hospital, 834 Chestnut Street, Suite G114, Philadelphia, PA 19107, USA.
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9
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Flexor Tenosynovitis of the Hand Caused by Mycobacterium tuberculosis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e083. [PMID: 30211389 PMCID: PMC6132321 DOI: 10.5435/jaaosglobal-d-17-00083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Infectious tenosynovitis of the hand is a serious condition with a high risk of morbidity. Mycobacterium tuberculosis is a rare cause of tenosynovitis, especially in regions where tuberculosis is no longer endemic, and presents significant diagnostic challenges. We present the case of a 42-year-old woman with no known history of or exposure to tuberculosis and a medical history of systemic lupus erythematosus on chronic immunosuppressive therapy who presented with swelling and erythema in the fifth finger of the left hand of 1-month duration. She underwent tenosynovectomy, and intraoperative cultures grew M tuberculosis. The patient completed an appropriate antibiotic regimen, and systemic workup revealed ring-enhancing lesions on brain MRI consistent with tuberculoma. We review the literature and current trends in the management of mycobacterial tenosynovitis, as well as the important teaching points of the case.
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11
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Lopes MJ, Furtado I, Brandão M, Farinha F. Tuberculous osteomyelitis of the wrist presenting as a monoarthritis syndrome. BMJ Case Rep 2018; 2018:bcr-2017-222136. [PMID: 29437679 DOI: 10.1136/bcr-2017-222136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
| | - Inês Furtado
- Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Mariana Brandão
- Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Fátima Farinha
- Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
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12
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Abstract
For patients with suspected flexor tenosynovitis, the mainstay of diagnosis is a thorough history and physical examination. The examination is guided by evaluating the patient for Kanavel's four cardinal signs. Empiric antibiotics should be started immediately on diagnosis covering skin flora and gram-negative bacteria. Typically, surgery is required. Appropriate exposure is required for adequate treatment and incisions should be tailored to preserve areas of skin compromised from draining sinuses and abscess pressure. Diabetes mellitus and peripheral vascular disease place patients at higher risk of poor outcomes including stiffness and amputation; early administration of antibiotics is the intervention that correlates most closely with good outcomes.
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Affiliation(s)
- Brad T Hyatt
- The Hand Center of San Antonio, 21 Spurs Lane, San Antonio, TX 78240, USA.
| | - Mark R Bagg
- The Hand Center of San Antonio, 21 Spurs Lane, San Antonio, TX 78240, USA
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Karakaplan M, Köroğlu M, Ergen E, Aslantürk O, Özdemir ZM, Ertem K. Isolated Tuberculosis of Capitate and Triquetrum. J Wrist Surg 2017; 6:70-73. [PMID: 28119799 PMCID: PMC5258124 DOI: 10.1055/s-0036-1584312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Mustafa Karakaplan
- Department of Orthopaedics and Traumatology, Turgut Özal Medical Center, İnönü University Medical School, Malatya, Turkey
| | - Muhammed Köroğlu
- Department of Orthopaedics and Traumatology, Turgut Özal Medical Center, İnönü University Medical School, Malatya, Turkey
| | - Emre Ergen
- Department of Orthopaedics and Traumatology, Turgut Özal Medical Center, İnönü University Medical School, Malatya, Turkey
| | - Okan Aslantürk
- Department of Orthopaedics and Traumatology, Turgut Özal Medical Center, İnönü University Medical School, Malatya, Turkey
| | - Zeynep Maraş Özdemir
- Department of Radiology, Turgut Özal Medical Center, İnönü University Medical School, Malatya, Turkey
| | - Kadir Ertem
- Department of Orthopaedics and Traumatology, Turgut Özal Medical Center, İnönü University Medical School, Malatya, Turkey
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