Tenosynovitis and carpal tunnel syndrome from mycobacterium tuberculosis - a rare manifestation of extrapulmonary tuberculosis

Tenosynovitis caused by tuberculosis (TB) is a rare presentation of this disease usually reported in immunocompromised patients. We describe a patient diagnosed with TB tenosynovitis of the left upper limb with no history of immunodeficiency. Although appearing in an endemic area the time to diagnosis was 6 years due to the absence of acid-fast stained bacilli in the first cultures despite histopathology showing a granulomatous lesion. Institution of pharmacological treatment and surgical debridément led to improvement within one month. The authors emphasize the need for early intervention in order to halt disease progression and avoid sequelae.

Mycobacterium tuberculosis-induced carpal tunnel syndrome: management and follow-up evaluation

PURPOSE

To determine the clinical characteristics of 12 patients with Mycobacterium tuberculosis-induced carpal tunnel syndrome. This article also presents our intraoperative findings and surgical treatment results.

METHODS

Twelve patients with tuberculosis-induced carpal tunnel syndrome who had surgery during a 10-year period that began in March 1991 were reviewed. The entrance criterion was a positive histologic report of tuberculosis for surgical specimens. The preoperative evaluation leading to diagnosis was reviewed for all patients. Transection of the transverse carpal ligament and complete synovectomy were performed for all patients. After surgery the patients were given an antituberculosis regimen for 1 year and were followed up for an average of 6 years.

RESULTS

Twelve cases from a total of 1,180 patients with carpal tunnel syndrome were traced to M tuberculosis involvement of synovial tissue of the flexor tendons. Ten patients had large rice bodies in thick synovial membranes, and in the other 2 patients thick synovial tissue with yellow exudates were observed during surgery. In contrast to tendon involvement with rupture, no direct median nerve involvement was noted. Histopathologic study results of surgical specimens were positive for tuberculosis in all patients. Eight of 10 initial smears showed acid-fast bacillus and all 10 cultures of the specimens were positive for tubercle bacilli. Surgery and antituberculosis therapy were associated with a desirable outcome and sensory disturbance in the median nerve distribution resolved in all patients. Anterior wrist swelling disappeared and there has been no clinical or laboratory evidence of recurrence in all treated patients.

CONCLUSIONS

Early diagnosis and surgical treatment combined with antituberculosis medical treatment are important in treating this condition. All patients treated were relieved of symptoms of synovial proliferation at the wrist, with no recurrence of the condition during the follow-up period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Tuberculous tenosynovitis: a cause of Carpal Tunnel Syndrome

OBJECTIVE

To highlight the presentation of tuberculous tenosynovitis as Carpal Tunnel Syndrome (CTS).

METHODS

A descriptive study conducted with purposive sampling on the patients presenting between April 2004 to January 2005 to the department of Plastic Surgery, CMH Rawalpindi, with the clinical picture of CTS. Symptoms and signs were recorded. The carpal tunnels were explored under nerve blocks. Where tenosynovitis was observed per-operatively, specimen of excised synovium were sent for histo-pathological examination, acid fast stains and bacterial cultures, to ascertain or rule out the presence of tuberculosis.

RESULTS

A total of 53 patients predominantly males were included in the study. The median age was 43 years and average duration of symptoms was 9 months. Tenosynovitis was observed in three patients (6%) per-operatively, with histopathology suggestive of Tuberculous tenosynovitis. Point Prevalence of tuberculous tenosynovitis as a cause of CTS was 6%. These patients reported clinical improvement with anti-tuberculosis treatment. NCS/EMG co-related well with clinical relief.

CONCLUSION

Tuberculous tenosynovitis is an uncommon cause of median nerve compression at the wrist. As symptoms are usually typical of CTS, diagnosis is frequently missed. Consideration of the possibility, examination of the opened canal at surgery and proper treatment can result in a successful outcome.

Acute progressive bilateral carpal tunnel syndrome after upper respiratory tract infection

This report describes the case of a 32-year-old male presenting with acute progressive bilateral carpal tunnel syndrome after a benign upper respiratory tract infection. Serial nerve conduction studies confirmed progressive entrapment of the median nerves in the carpal tunnel to the point of axonal damage. Surgical decompression relieved the entrapment, and nerve conduction studies improved.

Mild leptospirosis with three-year persistence of IgG- and IgM-antibodies, initially manifesting as carpal tunnel syndrome

Long-term persistence of IgG- and IgM-antibodies against leptospira after mild leptospirosis has not been reported. In a 45-year-old female pet-shop worker with carpal tunnel syndrome, accompanied by arthralgias, coughing, repeatedly elevated temperature, followed by easy fatigability, personality change, memory and speech disturbance, blurred vision, myalgia and swollen lymph nodes, leptospirosis was diagnosed, based upon history, clinical findings, and serological investigations. After the described symptoms had disappeared following doxycyclin for 2 weeks, IgG- and IgM-antibodies against leptospira remained positive during the next three years. This case illustrates that leptospirosis may start as carpal tunnel syndrome and that the severity of leptospirosis does not seem to be related to the intensity of the humoral immune response against the causative agent.

Lyme borreliosis in Portugal caused by Borrelia lusitaniae? Clinical report on the first patient with a positive skin isolate

BACKGROUND

Borrelia lusitaniae was isolated from an Ixodes ricinus tick in Portugal in 1993 for the first time. Further, this borrelia genospecies has been found in ixodid ticks collected around the coasts of southern Portugal and North Africa. Its reservoir has not been defined yet. B. lusitaniae was isolated once until now from a patient with a long standing and expanding skin disorder.

PATIENT AND METHODS

A 46-year-old Portuguese woman presented with a skin lesion on the left thigh which had evolved slowly over ten years. The patient reported limb paraesthesias, cramps, chronic headaches, and cardiac rhythm disturbances. History of tick bites was negative nor had the patient ever noticed a skin lesion comparable with erythema chronicum migrans. Skin biopsies were taken for histological evaluation, culture and DNA detection. Antibodies to borrelia were searched by indirect immunofluorescence assay and Western-blot.

RESULTS

A bilateral carpal tunnel syndrome and local synovitis was diagnosed. Dermato-histology was normal, serology was negative. Spirochaetal organisms were cultured from a skin biopsy and identified as B. lusitaniae. The patient improved after a 2-week course of intravenous ceftriaxone; the skin lesions did not expand further.

CONCLUSIONS

This culture confirmed skin infection by B. lusitaniae in a patient from Portugal suggests an additional human pathogen out of the B. burgdorferi sensu lato complex in Europe, particularly in Portugal.

[Association of carpal tunnel syndrome and tuberculosis]

Extrapulmonary tuberculosis, and especially articular, is less frequent than their pulmonary form. We report a 59 year-old men that requests medical attention for suggestive symptoms of carpal tunnel syndrome, of which is operated, being demonstrated in the carpo a granulomatous tissue including the median nerve suggestive of sarcoidosis or tuberculosis. In sputum the presence of Micobacterium tuberculosis was demonstrated. The respiratory symptoms of pulmonary tuberculosis were for the patient less excellent symptoms in relation to those produced by compression of the median nerve. The relationship between the tuberculosis and the carpal tunnel syndrome is demonstrated.

Mycobacterium kansasii causing carpal tunnel syndrome with concomitant pulmonary Mycobacterium tuberculosis infection

Mycobacterium kansasii is an uncommon cause of infection of the hand. Other atypical mycobacteria that cause hand infections are M marinium, M avium, M intracellularis, and M chelonei. Such infections usually occur around aquatic areas, though sometimes the source of infection is elusive. Inoculation of the atypical mycobacterium into the host occurs usually from a traumatic break in the skin. Patients commonly report a history of fish tank cleaning, oyster shucking, swinuning, or other aquatic activities. Several drug regimenshave been suggested and used successfully. Surgical intervention is occasionally required for unresponsive or symptomatic cases. Concomitant hand infection and pulmonary tuberculosis is extremely rare. We present a case report of M kansasii infection of the hand and forearm, with carpal tunnel syndrome complicated by concomitant pulmonary M tuberculosis.

Mycobacterium kansaii flexor tenosynovitis presenting as carpal tunnel syndrome

We present a case in which Mycobacterium kansasii flexor tenosynovitis caused the development of carpal tunnel syndrome. The diagnosis was made from synovial tissue specimens taken at the time of operation.

Carpal tunnel syndrome caused by Mycobacterium szulgai

We describe 2 cases of infection due to Mycobacterium szulgai revealed by a carpal tunnel syndrome (CTS) that was the only clinical manifestation. Both patients regularly cleaned their fish tank with bare hands. The diagnosis was made by isolation of M. szulgai from synovium. The cause of the CTS was a synovitis. Previous synovectomies were ineffective. Improvement was observed with antibiotic treatment. The only way to diagnose this unusual infection is to perform histology of synovium and to isolate the mycobacteria from synovium culture.

Mycobacterial tenosynovitis of the flexor tendons of the hand. A report of five cases

We present five cases of mycobacterial tenosynovitis of the flexor tendons of the fingers. These cases were observed during the last 12 years and treated by the same surgeon. This pathology is uncommon now, but it is becoming more frequent, especially in patients with diminished immunity. The diagnosis was most commonly made after synovectomy in patients presenting with carpal tunnel syndrome associated with slightly painful swelling at the wrist. Histological and bacteriological examinations are very important and revealed tuberculosis in four of our patients and mycobacterium in one, and the treatment consists of synovectomy and appropriate antibiotics. The functional result is usually good, but recurrence is not uncommon. Long-term follow-up is necessary. Local corticosteroid therapy could have a part in the causation of this condition.

Carpal tunnel syndrome associated with histoplasmosis: a case report and literature review

A case of localized Histoplasma capsulatum flexor tenosynovitis causing a carpal tunnel syndrome is presented. Carpal tunnel release, with tenosynovectomy, was performed followed by antifungal therapy. The symptoms did not recur. Tenosynovectomy followed by antifungal treatment is recommended.

[Mycobacterium malmoense infection of the flexor tendon sheath]

Infections of the tendon sheath caused by non-tuberculous mycobacteria are well known. So far, only one case involving Mycobacterium malmoense has been reported. The authors report of a 73-year old patient having undergone carpal tunnel release. In spite of granulomatous inflammation of the flexor tendon sheaths, there was no biopsy cultured for acid-fast bacteria. One year later, symptoms recurred and synovialectomy was repeated. In spite of macroscopic appearance of the synovialis and histological studies, a specific diagnosis was not yet made. Two weeks later, acid-fast bacteria, identified as M. malmoense were cultured in the BACTEC vial. Because specific treatment was not initiated, a further recurrence developed five months later, necessitating further surgery with synovialectomy. Properly treated with Rifampin and Ethambutal for twelve months, the patient has remained asymptomatic for the following two years.