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Atypical presentation of tuberculous tenosynovitis of the hand

Atypical presentation of tuberculous tenosynovitis of
the hand
Dear Sir,
Tuberculosis (TB) may affect almost any body tissue.
Musculoskeletal TB, which may affect bones, tendons
and bursa, is a rare form of extrapulmonary disease and
occurs in about 1.3% of cases (Lakhanpal et al., 1987).
The diagnosis of TB tenosynovitis is often delayed.
Typically, patients with TB synovitis describe local pain
and have a swelling on the hand with limitation in the
range of motion of the fingers (Lakhanpal et al., 1987;
Sueyoshi et al., 1996).
We report a case with atypical involvement of the hand.
A 27-year-old butcher was referred to our clinic complaining
of a painless swelling on the right hand for more than a
year. Physical examination revealed hyperaemic palpable
masses on the palmar surface of the thumb, the small
finger and the ulnar region of the wrist. The limitations in
the ranges of motion in the interphalangeal joint of the
thumb and distal and proximal interphalangeal joints of
the small finger were 10, 20 and 25, respectively.
Soft tissue masses only were seen on radiographs, with
no sign of bone destruction. MRI (post-contrast study)
revealed heterogenous synovial lesions extending to the
wrist around the flexor sheaths of the thumb and the
small finger (Fig 1). Because of these findings, an open
biopsy of the tenosynovium from the wrist was done.
Macroscopically there was thickening of synovium
accompanied by numerous rice-like particles. Histology
showed granulomatous lesions containing multinuclear
giant cells with occasional central necrosis, epitheloid
fibroblasts and mononuclear inflammatory cells. These
findings were characteristic of tuberculosis (Fig 2).
Africanum and Bovinum types of tuberculosis were
isolated by BACTEC. The patient was treated with
antitubercular drugs (isoniazid, rifampin, pyrazinamide
and ethambutol) for 9 months. The lesions regressed
dramatically 6 weeks after starting these drugs. A nearly
complete recovery of range of motion was observed at a
1 year follow-up.
Further assessment of the patient and his family did
not reveal any other physical or radiological evidence of
the disease. Expect for a positive tuberculin test, all his
routine biochemical tests were normal.
There have been a few cases of flexor tenosynovitis
caused by Mycobacterium bovis (Cooke et al., 2002).
Most of them were related to occupation. In the light of
our findings, we believe that the most likely source of
contagion was an animal. To the best of the authors’
knowledge, this is the first case in which tuberculous
tenosynovitis occurred in two different locations on the
same hand.