Recurrent Nontuberculous Mycobacterial Tenosynovitis

Extrapulmonary Comparisons Between Mycobacterium Tuberculosis and Non-Tuberculous Mycobacteria: From Manifestations and Diagnosis to Treatment

The incidence of tuberculosis (TB) and non-tuberculous mycobacteria (NTM) diseases and the number of deaths from these diseases are steadily increasing worldwide. However, the pathologic diagnosis of NTM disease is similar to that of tuberculosis, and it is often difficult to distinguish between the two, which can lead to misdiagnosis and treatment aversion. Therefore, differentiation between the two can help in accurate diagnosis and treatment planning. This review compares the presentation, diagnosis, and treatment of common extrapulmonary sites of involvement in tuberculosis and non-tuberculous mycobacterial disease.

Granulomatous Tenosynovitis of the Volar Wrist from Mycobacterium Avium Complex - A Case Report

Introduction

Mycobacterium avium complex (MAC) musculoskeletal (MSK) involvement is a rare clinical presentation of the upper extremity. When MSK involvement does occur, hand and wrist involvement are the most often reported due to the rich synovial fluid environment in these regions. This report describes an unusual case of tenosynovitis of the hand, in which a patient presented with a prolonged course of wrist pain due to MAC.

Case Report

An 87-year-old Caucasian, right-handed female presented with a 2-year history of right wrist pain and swelling. There had been no previous trauma or immunocompromised state. The patient was hospitalized for severe pneumonia 2 years ago, with wrist pain developing in the months after discharge. The treatment course included radical synovectomy and subsequent triple antibiotic therapy upon confirmation of MAC rice bodies. Due to advanced age and worsening dementia, the patient did not follow-up until 2 years post-operatively. Upon return at 2 years postoperatively, the patient had concerns of recurrent tenosynovitis. Treatment was declined by the family at this time and the patient did not return again until 5 years postoperatively with continued worsening tenosynovitis. Repeat synovectomy was suggested; however, additional treatment was held by the family due to the patient's cognitive decline.

Conclusion

The aim of this report is to describe an atypical presentation of MAC-induced tenosynovitis. Patients diagnosed with a MAC infection should be treated promptly and informed of the possibility of recurrence. The goal of this report is to encourage practitioners to keep MAC infection on their list of differentials when evaluating abnormal wrist swelling.

Chronic intractable nontuberculous mycobacterial-infected wound after acupuncture therapy in the elbow joint: A case report

BACKGROUND

Musculoskeletal nontuberculous Mycobacterium (NTM) infections are rare, particularly post-acupuncture therapy, and present diagnostic challenges due to their infrequency and potential severity. Prompt recognition and appropriate management are crucial for optimal outcomes. NTM-infected wounds involving the joints are difficult to treat, and only a few cases have been reported.

CASE SUMMARY

We present a case of a chronic intractable NTM-infected wound on the elbow joint that completely healed with conservative wound care and antibiotic treatment. An 81-year-old woman presented with a chronic, ulcerative wound on the right elbow joint where she had undergone repeated acupuncture therapy for chronic intolerable pain. Magnetic resonance imaging revealed synovial thickening, effusion, and subcutaneous cystic lesions. An orthopedic surgeon performed open synovectomy and serial debridement. However, 1 month postoperatively, the wound had not healed and became chronic. A wound culture revealed NTM (Mycobacterium abscessus), and the patient was referred to the Department of Plastic and Reconstructive Surgery. Instead of surgical intervention, conservative wound care with intravenous antibiotics was provided, considering the wound status and the patient's poor general condition. Complete wound healing was achieved in 12 months, with no impact on the range of motion of the elbow joint.

CONCLUSION

With clinical awareness, musculoskeletal NTM infection can be treated with conservative wound care and appropriate antimicrobial agents.

Trigger Finger: An Unusual Clue to Hashimoto's Thyroiditis

Stenosing flexor tenosynovitis, commonly known as trigger finger (TF), is characterized by thickening and inflammation of the flexor tendon sheath (A1 pulley), leading to painful catching or locking of the finger in a flexed position. While often associated with conditions like diabetes and hypothyroidism, this case report presents a unique instance where surgical intervention for pharmacologically resistant TF ultimately led to the diagnosis of Hashimoto's thyroiditis. This case highlights the potential for underlying systemic conditions to manifest as TF and emphasizes the importance of a comprehensive diagnostic approach in patients with persistent or atypical presentations.

Nontuberculous Mycobacterial Flexor Tenosynovitis of the Wrist and Hand

Nontuberculous mycobacteria (NTM) are uncommon causes of cutaneous and musculoskeletal infections. Here, we present an immunocompromised patient with persistent swelling in the left hand, wrist, and distal forearm. MRI findings revealed flexor tenosynovitis with synovial hypertrophy of the left hand and wrist and loculated fluid containing rice bodies along the distal flexor digitorum muscles in the volar aspect of the left wrist. The patient underwent flexor tenosynovectomy, and histological examination of the excised tenosynovium and mass revealed noncaseating granulomas. Mycobacterium intracellulare was identified in microbiological cultures. Antimycobacterial therapy was administered postoperatively to manage the infection. This report underscores the significance of maintaining a high index of suspicion for NTM infection when assessing chronic hand swelling, particularly in individuals with compromised immune systems.

Difficulty in Diagnosis and Management of Musculoskeletal Nontuberculous Mycobacterial Infections

We describe two cases of musculoskeletal nontuberculous mycobacterial (NTM) infection resulting in undesirable outcomes. These organisms can be difficult to identify and treat, potentially leading to significant morbidity. NTM should remain on the differential for culture negative bone and joint infections, especially with a prior surgical history or environmentally-acquired injuries.

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There is considerable difficulty in diagnosing NTM orthopedic infections.

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These infections can be prolonged and progressive.

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Consider NTM infection with negative cultures and failure of routine antibacterials.

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Surgical debridement is essential in combination with antimycobacterials.

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Treatment should be determined after culture results yield drug susceptibilities.

Non-tuberculous Mycobacterial Infection of the Musculoskeletal System Detected at Two Tertiary Medical Centres in Henan, China, 2016-2020

Non-tuberculous mycobacterial (NTM) infection of the musculoskeletal system is rare but poses a grave threat to public health. These infections yield non-specific symptoms that remain undetected until the development of the later stages of the disease. In this study, we performed a retrospective review of 25 cases of musculoskeletal NTM infection at two tertiary medical centres over a 5-year period to determine the clinical features and improve the current clinical diagnosis and treatment. The most common mycobacterial species detected were Mycobacterium fortuitum in eleven patients, Mycobacterium abscessus in eight patients, Mycobacterium houstonense in three patients, Mycobacterium avium in two patients, and Mycobacterium smegmatis in one patient. The sites of infection included the limbs and joints, most commonly the knee (ten patients) and foot (six patients). The median duration from the onset of symptoms to diagnosis was 2.5 months (0.8-13.5 months). Deep sinus tracts extending to the surgical site were observed in 60% of the patients (15/25), and granulomatous inflammation and granulomatous inflammation with necrosis occurred in 60% of the patients (15/25). All patients underwent surgical treatment for infection control, and all patients, except one, received antimycobacterial therapy based on drug sensitivity assays. The median duration of the antimicrobial chemotherapy was 5 months (range: 3-20 months). At the final follow-up, 24 patients presented with absence of recurrence and one patient succumbed owing to heart failure after debridement. Our findings highlight the importance of vigilance and improvements in the diagnostic methods for musculoskeletal NTM infection. Aggressive surgical treatment and antimycobacterial drug treatment can help achieve satisfactory results.

Atypical Mycobacterial Tenosynovitis in the Setting of Adalimumab Use

Tumor necrosis factor-alpha (TNF-α) inhibitors indicated in the management of psoriasis, rheumatoid arthritis, ulcerative colitis, Crohn's disease, and other autoimmune diseases have been associated with the development of mycobacterial and other opportunistic infections. The majority of mycobacterial infections diagnosed in patients taking TNF-α inhibitors are secondary to Mycobacterium tuberculosis. Atypical mycobacteria have also been identified in this patient population, most commonly manifested by pulmonary or disseminated infections. Extra-pulmonary manifestations such as bone and joint infections are rare. We describe a case of atypical mycobacterial tenosynovitis in the setting of adalimumab use in a patient with psoriasis. This is a rarely reported complication that one should be aware of when prescribing these medications.