Significance of early diagnosis and surgical management in treating Mycobacterium immunogenum-related pyogenic extensor tenosynovitis: a case report

BACKGROUND

Non-tuberculous mycobacteria (NTM) are environmental organisms that are increasingly contributing to human infections. Mycobacterium immunogenum, a variant of NTM discovered in 2001, is a rapidly growing mycobacterium that exhibits multidrug resistance. Reports of infections caused by this organism, particularly tenosynovitis in the musculoskeletal system, are limited.

CASE PRESENTATION

A 71-year-old female with vesicular pemphigus, undergoing immunosuppressive therapy, presented with a progressively enlarging tumour on the dorsum of her right hand, along with erythematous papules that extended across her right forearm. The specimens of skin tissues and blood cultures revealed the presence of M. immunogenum. Magnetic resonance imaging evaluation led to the diagnosis of pyogenic extensor tenosynovitis. A multidrug regimen, comprising amikacin and clarithromycin, was initiated, followed by synovectomy. The patient underwent a course of 180 days of antimicrobial therapy and demonstrated no signs of disease recurrence one year after treatment completion.

CONCLUSION

Early diagnosis and surgical intervention are crucial to prevent the adverse prognostic implications of pyogenic extensor tenosynovitis caused by M. immunogenum. Effective management requires precise microbial identification and susceptibility testing, necessitating collaborative engagement with microbiological laboratories.

High risk and low prevalence diseases: Flexor tenosynovitis

INTRODUCTION

Flexor tenosynovitis (FTS) is a deep space infection of an upper extremity digit which carries a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of FTS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

FTS typically occurs after direct penetrating trauma to the volar aspect of an upper extremity digit. Development of a deep space infection that quickly propagates through the flexor tendon sheath of a digit can result in serious structural damage to the hand and place the patient at risk for significant morbidity such as finger amputation or even result in death. Signs of FTS include symmetrical swelling of the affected finger, the affected finger being held in a flexed position, pain on any attempt of passive finger extension, and tenderness along the course of flexor tendon sheath, known as the Kanavel signs. Systemic symptoms such as fevers and chills may occur. Recognition of these signs and symptoms is paramount in diagnosis of FTS, as laboratory and imaging assessment is not typically diagnostic. ED management involves intravenous antibiotics and emergent surgical specialist consultation.

CONCLUSION

An understanding of the presentation and risk factors for development of FTS can assist emergency clinicians in diagnosing and managing this disease in an expedited fashion.

Nontuberculous mycobacteriosis oligoarthritis of the right hand misdiagnosed as rheumatoid arthritis: A case report

Infection with Mycobacterium marinum has several different clinical presentations. Most commonly, it appears as a solitary papulonodular lesion on an extremity. A rare presentation of osteoarticular M. marinum involving multiple small joints and tenosynovitis of the hand, which was misdiagnosed as rheumatoid arthritis, is reported. The patient was initially treated for seronegative rheumatoid arthritis but failed to respond to methotrexate. Magnetic resonance imaging showed arthritis and tenosynovitis. Subsequently, synovial biopsy led to histological and microbiological diagnosis. Antimycobacterial treatment should be started promptly in such cases. The combined use of rifampicin, ethambutol, and clarithromycin appears to be effective, and debridement is indicated in patients with deep-seated infections.

Proliferative tenosynovitis in Brazilian Mangalarga Marchador horses

Proliferative tenosynovitis (PT) is an inflammatory and proliferative disorder of the synovial membrane of the tendon sheath that is rare in animals. The histological alterations are characterized by multinodular neovascularization, with infiltration of histiocytic and multinucleated giant cells and haemosiderin deposition. We reviewed necropsy and biopsy records of horses submitted to the Setor de Anatomia Patológica of the Universidade Federal Rural do Rio de Janeiro from January 2017 to December 2020 to select cases of PT. We identified PT in three adult Brazilian Mangalarga Marchador horses with nodular lesions on the metacarpophalangeal, metatarsophalangeal or carpal joints. The three horses were under 6 years of age and presented with lameness and pain on palpation. There were recurrences in two horses after surgical removal. Radiographic and ultrasound examinations detected masses in the flexor or extensor tendons and subtendinous bursa. Histological study of synovial membrane and tendon sheath revealed an increased number of vessels, fibroplasia, osseous metaplasia and infiltration of lymphocytes, plasma cells and siderophages. This is the first description of PT in horses, which should be included as an orthopaedic differential diagnosis, especially in Mangalarga Marchador horses with lameness.

Synovitis due to Histoplasma capsulatum: a case series and literature review

Musculoskeletal manifestations of Histoplasma capsulatum infection are uncommon but can mimic inflammatory arthritis. Early diagnosis of this complication is of critical importance in the era of potent immunosuppression for rheumatologic diseases. We conducted a retrospective chart review for patients with histoplasmosis and tenosynovitis, synovitis, or arthritis, diagnosed and treated at our institution between January 1, 2000, and December 31, 2019. We also reviewed the relevant literature. Four patients with biopsy-proven, culture-proven histoplasma tenosynovitis were identified at our institution. All four patients had wrist or hand involvement in an asymmetric pattern, and one patient had lower extremity involvement as well. Two patients were not immunocompromised at baseline. One patient underwent a lengthy evaluation and received immunosuppression for 4 years without improvement prior to the diagnosis of histoplasmosis. Histoplasma serologic tests varied among patients with localized infection. Pathologic findings revealed non-caseating granulomatous inflammation. Three patients recovered after 6-12 months of antifungal treatment. One patient still had recurrent infection despite 20 months of treatment. Histoplasma tenosynovitis and synovitis are rare causes of inflammatory arthritis. Infectious causes should be considered and carefully evaluated when patients present with asymmetric oligoarthritis. Early recognition is crucial for successful treatment, especially in patients with concomitant rheumatologic diseases receiving immunosuppressive treatment.

Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis

BACKGROUND

Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment.

METHODS

A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach.

RESULTS

Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores.

CONCLUSIONS

Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.

The value of ultrasound-defined tenosynovitis and synovitis in the prediction of persistent arthritis

OBJECTIVES

The value of US-defined tenosynovitis in predicting the persistence of inflammatory arthritis is not well described. In particular, the predictive utility of US-defined tenosynovitis of larger tendons is yet to be reported. We assessed the value of US-defined tenosynovitis alongside US-defined synovitis and clinical and serological variables in predicting persistent arthritis in an inception cohort of DMARD-naïve patients with early arthritis.

METHODS

One hundred and fifty DMARD-naïve patients with clinically apparent synovitis of one or more joints and a symptom duration of ≤3 months underwent baseline clinical, laboratory and US (of 19 bilateral joints and 16 bilateral tendon compartments) assessments. Outcomes were classified as persistent or resolving arthritis after 18 months' follow-up. The predictive value of US-defined tenosynovitis for persistent arthritis was compared with those of US-defined synovitis, and clinical and serological variables.

RESULTS

At 18 months, 99 patients (66%) had developed persistent arthritis and 51 patients (34%) had resolving disease. Multivariate logistic regression analysis showed that US-detected digit flexor tenosynovitis [odds ratio (OR): 6.6, 95% CI: 2.0 , 22.1, P = 0.002] provided independent predictive data for persistence over and above the presence of US-detected joint synovitis and RF antibodies. In the RF/ACPA-negative subcohort, US-defined digit flexor tenosynovitis remained a significant predictive variable (OR: 4.7, 95% CI: 1.4, 15.8, P = 0.012), even after adjusting for US-defined joint synovitis.

CONCLUSION

US-defined tenosynovitis provided independent predictive data for the development of persistent arthritis. The predictive role of US-defined digit flexor tenosynovitis should be further assessed; investigators should consider including this tendon site as a candidate variable when designing imaging-based predictive algorithms for persistent inflammatory arthritis development.

The Radial Synergy Test: An Aid to Diagnose de Quervain's Tenosynovitis

BACKGROUND

Diagnosis of de Quervain's tenosynovitis is made clinically. Finkelstein's and Eichoff's tests are commonly utilized examination maneuvers. Their specificity has been questioned due to a propensity to provoke pain in asymptomatic patients. Using the principle of synergism, the novel radial synergy test takes advantage of isometric contraction of the first dorsal compartment with resisted abduction of the small finger.

METHODS

Electromyography was performed on 3 authors and the first dorsal compartment sampled during the maneuver. Sensitivity evaluation was performed via retrospective chart review for patients diagnosed with de Quervain's from 2013 to 2018. Inclusion criteria were documented radial synergy test, Eichoff's test, and ≥90% pain relief after lidocaine/corticosteroid injection. We enrolled 222 patients with 254 affected extremities. Specificity evaluation was performed via a prospective cohort of volunteers undergoing radial synergy and Eichoff's tests. Inclusion criterion was lack of preexisting wrist pain. Score > 0 on Visual Analog Scale was considered positive. We enrolled 48 volunteers with 93 tested extremities.

RESULTS

Electromyography revealed positive recruitment of the first dorsal compartment. Sensitivity of the radial synergy test was inferior to Eichoff's test (97% vs 91%, relative risk [RR] = 0.93 [95% confidence interval [CI] = 0.89-0.97], P < .01). Specificity of the radial synergy test was superior to Eichoff's test (99% vs 74%, RR = 1.33 [95% CI = 1.18-1.51], P < .001).

CONCLUSIONS

We describe and evaluate the radial synergy test, a novel examination maneuver to aid the diagnosis of de Quervain's. This serves as an adjunct for future diagnostic evaluations with its high specificity.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Common Hand Conditions: A Review

Importance

Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and basilar (carpometacarpal) joint arthritis of the thumb can be associated with significant disability.

Observations

Carpal tunnel syndrome is characterized by numbness and tingling in the thumb and the index, middle, and radial ring fingers and by weakness of thumb opposition when severe. It is more common in women and people who are obese, have diabetes, and work in occupations involving use of keyboards, computer mouse, heavy machinery, or vibrating manual tools. The Durkan physical examination maneuver, consisting of firm digital pressure across the carpal tunnel to reproduce symptoms, is 64% sensitive and 83% specific for carpal tunnel syndrome. People with suspected proximal compression or other compressive neuropathies should undergo electrodiagnostic testing, which is approximately more than 80% sensitive and 95% specific for carpal tunnel syndrome. Splinting or steroid injection may temporarily relieve symptoms. Patients who do not respond to conservative therapies may undergo open or endoscopic carpal tunnel release for definitive treatment. Trigger finger, which involves abnormal resistance to smooth flexion and extension ("triggering") of the affected finger, affects up to 20% of adults with diabetes and approximately 2% of the general population. Steroid injection is the first-line therapy but is less efficacious in people with insulin-dependent diabetes. People with diabetes and those with recurrent symptoms may benefit from early surgical release. de Quervain tenosynovitis, consisting of swelling of the extensor tendons at the wrist, is more common in women than in men. People with frequent mobile phone use are at increased risk. The median age of onset is 40 to 59 years. Steroid injections relieve symptoms in approximately 72% of patients, particularly when combined with immobilization. People with recurrent symptoms may be considered for surgical release of the first dorsal extensor compartment. Thumb carpometacarpal joint arthritis affects approximately 33% of postmenopausal women, according to radiographic evidence of carpometacarpal arthritis. Approximately 20% of patients require treatment for pain and disability. Nonsurgical interventions (immobilization, steroid injection, and pain medication) relieve pain but do not alter disease progression. Surgery may be appropriate for patients unresponsive to conservative treatments.

Conclusions and Relevance

Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and thumb carpometacarpal joint arthritis can be associated with significant disability. First-line treatment for each condition consists of steroid injection, immobilization, or both. For patients who do not respond to noninvasive therapy or for progressive disease despite conservative therapy, surgical treatment is safe and effective.

Recurrent Carpal Tunnel Syndrome Associated with Mycobacterium szulgai Infection: A Case Report

CASE

We present the case of an otherwise healthy 77-year-old male retired firefighter and recreational pheasant hunter who presented with recurrent symptoms of carpal tunnel syndrome and tenosynovitis because of Mycobacterium szulgai. He was initially treated unsuccessfully for a presumed seronegative rheumatologic flare, followed by surgical diagnosis and treatment including revision carpal tunnel release with tenosynovectomy, and a secondary debridement and wound closure. His symptoms resolved after several months of multidrug antibiotic therapy with only mild residual median nerve deficit.

CONCLUSION

Nontuberculous Mycobacterium infections of the upper extremity are extremely rare and challenging to diagnose/treat. This report highlights diagnostic and surgical challenges in this rarely reported infection.

[De Quervain's tenosynovitis: Clinical aspects and diagnostic techniques]

De Quervain's tenosynovitis is a tendon sheath inflammation of the musculus abductor pollicis longus (APL) and the musculus extensor pollicis brevis (EPB) in the first extensor compartment of the wrist. Typically, patients present with pain symptoms on the radial side of the wrist as a result of repetitive moments and consequent overload of the tendons. During physical examination, De Quervain's tenosynovitis is easily distinguishable from other wrist injuries. Early recognition is of utmost importance for treatment decisions due to the fact that it is very well treatable, especially in the acute phase. A multimodal approach with conservative management is the most effective. Surgical intervention is usually not necessary.

Rare case of Mycobacterium marinum in a patient presenting with tenosynovitis

A 72-year-old man presented with tenosynovitis of the left hand's extensor tendons that had been present for several months. He was initially treated with corticosteroids, first by local injection then systemically, but with no effect. When re-evaluated, the patient had developed a rash, and the symptoms had spread locally to surrounding structures. At this point, the patient added to the medical history that he had been stung by a sculpin a month before the debut of symptoms. Based on this, the patient's involved area was biopsied, and subsequent microbiology findings proved consistent with Mycobacterium marinum infection. By the time of diagnosis, the patient had soft tissue involvement, arthritis and osteomyelitis with an overlying rash. This case emphasises the need for reassessment when treatment is not effective and for further investigations of the medical history to establish the correct diagnosis and treatment.

Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND

Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition.

QUESTION/PURPOSE

What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics?

METHODS

This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively.

RESULTS

After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively.

CONCLUSION

Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A Rare Case of Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: a Case Report

Tuberculosis (TB) is still a worldwide problem. We present a case of flexor tenosynovitis due to tuberculosis in the hand and wrist. A 42-year-old man presented to the outpatient clinic with a 2-year history of a slowly growing mass over the volar aspect of the left wrist. His MRI showed multiple rice bodies in the wrist and hand. An open biopsy was performed. Pathology specimens showed granulomatous lesions with central necrosis. The purified protein derivative (PPD) test was positive. In this case, granulomatous lesions with central necrosis, rice bodies, and positive PPD test confirmed the diagnosis of TB in the wrist and hand. There was no other concurrent evidence of TB elsewhere. Antituberculosis chemotherapy was commenced. Tuberculous tenosynovitis of the wrist and hand is very rare. The tuberculous tenosynovitis should be kept in mind as an infectious agent when patients are presenting with atypical clinical. Key words: tuberculosis, rice bodies, flexor tenosynovitis, wrist, hand.

Pyogenic Flexor Tenosynovitis: Evaluation and Management

Pyogenic flexor tenosynovitis is a closed-space infection that can lead to a devastating loss of finger and hand function. It can spread rapidly into the palm, distal forearm, other digits, and nearby joints. Healthy individuals may present with no signs of systemic illness and often deny any penetrating trauma or inoculation. Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. Many treatment options have been described, although all share 2 common principles: evacuation of the infection and tailored postoperative antibiotic treatment with close monitoring to ensure clinical improvement.

How best to approach these acute hand infections

Antimicrobial therapy is not straightforward with the 4 infectious conditions reviewed here. Combination therapy at the start must usually be tailored once an organism is known.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT)is a potentially devastating closed-space infection of the flexor tendon sheath of the hand that can result in considerable morbidity. Management of PFT, regardless of the pathogen, includes prompt administration of empirical intravenous antibiotics and often surgical treatment. However, currently, there is no standardized treatment algorithm for PFT in regards to the need for, timing, or type of surgical treatment. Many utilize a combination of surgical decompression and sheath irrigation. However, despite prompt treatment, and regardless of the protocol used, complication rates can be high, leading to impaired function and even amputation of the affected digit. Further research is needed to elucidate the role of local antibiotics and corticosteroids in treating this condition and potentially preventing the morbid outcomes that are currently seen. This paper reviews the background, microbiology, and treatment options and controversies surrounding PFT.

Tenosynovitis Induced by an Immune Checkpoint Inhibitor: A Case Report and Literature Review

A 51-year-old man underwent second-line treatment for non-small-cell lung cancer (NSCLC) with the immune checkpoint inhibitor (ICI) pembrolizumab. On day 2 after two cycles of pembrolizumab, he presented with edema limited to the left third, fourth, and fifth fingers. Based on symptoms, laboratory results, and contrast-enhanced magnetic resonance imaging (MRI) findings, we diagnosed him with tenosynovitis. We prescribed oral prednisolone (0.5 mg/kg/day), and pembrolizumab was continued. Prednisolone immediately relieved the symptoms, and the tumor was still shrinking on day 21 after eight cycles of pembrolizumab. ICI-induced tenosynovitis was managed while continuing ICI usage, suggesting that 0.5 mg/kg/day prednisone might be effective for tenosynovitis without ICI cessation.

Automatic quantification of tenosynovitis on MRI of the wrist in patients with early arthritis: a feasibility study

OBJECTIVES

Tenosynovitis (inflammation of the synovial lining of the sheath surrounding tendons) is frequently observed on MRI of early arthritis patients. Since visual assessment of tenosynovitis is a laborious task, we investigated the feasibility of automatic quantification of tenosynovitis on MRI of the wrist in a large cohort of early arthritis patients.

METHODS

For 563 consecutive early arthritis patients (clinically confirmed arthritis ≥ 1 joint, symptoms < 2 years), MR scans of the wrist were processed in three automatic stages. First, super-resolution reconstruction was applied to fuse coronal and axial scans into a single high-resolution three-dimensional image. Next, 10 extensor/flexor tendon regions were segmented using atlas-based segmentation and marker-based watershed. A measurement region of interest (ROI) was defined around the tendons. Finally, tenosynovitis was quantified by identifying image intensity values associated with tenosynovial inflammation using fuzzy clustering and measuring the fraction of voxels with these characteristic intensities within the measurement ROI. A subset of 60 patients was used for training and the remaining 503 patients for validation. Correlation between quantitative measurements and visual scores was assessed through Pearson correlation coefficient.

RESULTS

Pearson correlation between quantitative measurements and visual scores across 503 patients was r = 0.90, p < 0.001. False detections due to blood vessels and synovitis present within the measurement ROI contributed to a median offset from zero equivalent to 13.8% of the largest measurement value.

CONCLUSION

Quantitative measurement of tenosynovitis on MRI of the wrist is feasible and largely consistent with visual scores. Further improvements in segmentation and exclusion of false detections are warranted.

KEY POINTS

• Automatic measurement of tenosynovitis on MRI of the wrist is feasible and largely consistent with visual scores. • Blood vessels and synovitis in the vicinity of evaluated tendons can contribute to false detections in automatic measurements. • Further improvements in segmentation and exclusion of false detections are important directions of future work on the path to a robust quantification framework.

Hand Infections

Infections are common in hand surgery and proper management is important to achieve optimal outcomes. Although most cases are not urgent, less common, severe infections such as flexor tenosynovitis and necrotizing fasciitis require urgent identification with both medical and surgical management. It is common for diagnoses to be missed or delayed because clinical and laboratory indicators are often variably present. Delayed identification and management can result in poor outcomes with permanent deficits. This article will provide a review of hand infections with a focus on identifying serious hand infections requiring urgent or emergent treatment, and distinguishing these from less urgent scenarios.

[Intersection syndrome in a tetraplegic hand cyclist]

Wrist tendinopathies are common overuse injuries in athletes and often associated with activities such as rowing, riding or racket sports. Correctly diagnosing the various tendinopathies is essential for management of cases refractory to initial treatment. Easily mistaken for de Quervain's tenosynovitis, the intersection syndrome may be effectively managed by simple taping negating the need for corticosteroid injection and tendon release surgery. We present an unusual case report of intersection syndrome in a tetraplegic hand cyclist following a 24-hour endurance race.

Atypical Mycobacterial Infections of the Upper Extremity

Atypical mycobacterial infections of upper extremity synovial-lined structures are often misdiagnosed and unrecognized. Despite an increasing incidence, lack of physician awareness of these pathogens may result in considerable delay in diagnosis and management, potentially leading to permanent disability. The authors conducted a literature review and analyzed 31 cases of penetrating atypical mycobacterial infection to better understand the clinical characteristics and to evaluate their posttreatment complication rate compared with available literature. Medical records for culture-positive cases of tenosynovial or intra-articular atypical mycobacterial infections of the upper extremity that were treated were retrospectively reviewed. Treatment outcomes were analyzed against published case reviews and case series. Thirty-one cases of penetrating atypical mycobacterial infection were identified. Mycobacterium marinum (n=11) was the most common organism and was associated with aquatic exposure. Twenty-eight cases received empiric treatment, 17 of which received contraindicated treatment. Patients saw an average of 5 physicians prior to receiving an accurate diagnosis, and the mean time to diagnosis was 10 months. All cases received antibiotic treatment in addition to surgical management. Twenty cases (68%) failed treatment outcomes. Delay in diagnosis and inappropriate management of atypical mycobacterial infections may lead to a treatment failure rate that is higher than what has been reported in the literature. Mycobacterium avium and M fortuitum had significantly higher failure rates than other organisms. A high index of suspicion is required to make a diagnosis and prevent residual disability. [Orthopedics. 2018; 41(3):e383-e388.].

Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound

BACKGROUND

Gonorrhea is the second most common sexually transmitted infection. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Diagnosis in the emergency department (ED) must be suspected clinically, as confirmatory tests are often not available. Point-of-care ultrasound (POCUS) can aid in diagnosis and appropriate management by identifying tenosynovitis and excluding arthritis.

CASE REPORT

A 26-year-old man with multiple recent sex partners presented to the ED with slowly progressing right wrist pain and swelling over 5 days. His dorsal right wrist was swollen, with slightly decreased range of motion owing to mild pain, and no warmth, tenderness, erythema, or drainage. Multiple hemorrhagic, gray-purple blisters were noted over both hands. Serum white blood cell count was 12 × 10³/μL; C-reactive protein was 30.3 mg/L. POCUS of the dorsal right wrist found no joint effusion; the extensor tendon sheath contained a large anechoic space with clear separation of the extensor tendons, suggesting a tendon sheath effusion/tenosynovitis. DGI was suspected, without septic arthritis. The patient was admitted and treated with ceftriaxone and azithromycin. Gonococcus grew from blood cultures and pharyngeal swabs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DGI must be suspected clinically, as confirmatory tests are often not available in the ED. Not all patients present with arthritis, tenosynovitis, and dermatitis. It is often difficult to differentiate tenosynovitis from arthritis. POCUS can aid in diagnosis by identifying tenosynovitis (vs. arthritis or simple soft-tissue swelling), allowing timely appropriate DGI diagnosis and management, and, importantly, averting unnecessary arthrocentesis.

[Diagnosis and treatment of rheumatoid arthritis:toward the best practice. The utility of MRI for clinical practice in rheumatoid arthritis.]

Imaging is important and essential for clinical practice in rheumatoid arthritis(RA). MRI and musculoskeletal ultrasonography(MSUS)are helpful to detect early as well as accurate joint injury of RA patients, and thus, potentially useful in early diagnosis, evaluating disease activity, therapeutic outcome and prediction of joint outcome. Articular synovitis, tenosynovitis and bone marrow edema are useful to predict RA progression. Bone marrow edema is closely associated with radiographic bone erosion. In addition, we are necessary to pay attention to the influence of aging that increases of MRI-detected joint changes, especially in hand and foot joints.

Mycobacterium marinum and Carpal Tunnel Syndrome: Three Case Reports

Infection with Mycobacterium marinum is often difficult to diagnose. Infection with M. marinum in the upper extremity may involve the tendon sheaths, producing clinical manifestations such as tenosynovitis and symptoms of carpal tunnel syndrome. We report 3 cases of M. marinum infection of the hand associated with carpal tunnel syndrome during an outbreak in New York City's Chinatown. A combination of carpal tunnel release, flexor tenosynovectomy, and appropriate antibiotics yielded complete resolution of symptoms in all cases.

Ultrasound characterization of ankle involvement in Löfgren syndrome

BACKGROUND

Bilateral ankle arthritis is a classic diagnostic criterion for Löfgren syndrome. The objective of this study was to use ultrasonography to characterize the articular and periarticular involvement of the ankles in patients with Löfgren syndrome.

METHODS

Multicenter descriptive cohort study of patients with Löfgren syndrome who underwent ultrasonography of the ankles. We collected clinical data, imaging study findings, blood test results, and joint fluid properties in patients who underwent joint aspiration.

RESULTS

Findings from ultrasonography of the ankles in 40 patients were analyzed. The most common B-mode abnormality was subcutaneous edema (26/40), followed by tenosynovitis (22/40), with no differences in frequency across compartments. Joint involvement manifested as synovitis in 7 patients and effusion in 10 patients. Synovitis with increased vascularity by power Doppler was found in 3 patients. No statistically significant associations were found linking synovitis or tenosynovitis to clinical features (age and gender), laboratory tests, or imaging study findings.

CONCLUSION

Contrary to the classical view, our results indicate that ankle involvement in Löfgren syndrome is more often abarticular than articular. The inclusion of bilateral ankle arthritis among the diagnostic criteria for Löfgren syndrome deserves reappraisal.

Tenosynovitis caused by Scedosporium apiospermum infection misdiagnosed as an Alternaria species: a case report

BACKGROUND

Scedosporium apiospermum, which can usually be isolated from soil, polluted stream water and decaying vegetation, is increasingly recognized as an opportunistic dematiaceous fungus. The mortality rate of infection in immunocompromised hosts is over 50%. S. apiospermum is commonly responsible for dermal and epidermal infections (i.e., mycetoma) after traumatic penetration.

CASE PRESENTATION

A 73-year-old woman was admitted to our hospital complaining of painful swelling and tenderness on the dorsum of the proximal left wrist and hand. The symptoms had persisted for approximately 2 months. A physical examination revealed a 4 x 3 cm, poorly defined, erythematous papule, which was fluctuant, with pustules and crusts on the dorsum of the left hand.

CONCLUSIONS

We report a very rare case of tenosynovitis caused by S. apiospermum infection. We identified the infectious agent via molecular DNA sequencing. The infectious agent was initially misidentified as an Alternaria species by microscopic examination with lactophenol cotton blue (LPCB) staining. The infection was successfully treated with debridement and adjuvant fluconazole therapy.

Sporotrichal Tenosynovitis Diagnosed Helpfully by Musculoskeletal Ultrasonography

A 72-year-old man presented with persistent oligoarthritis and positive results for rheumatoid factor and was suspected of having rheumatoid arthritis (RA). However, the musculoskeletal ultrasonography (MSUS) findings were not consistent with those of typical RA. He had undergone surgery for carpal tunnel syndrome, which allowed both histopathological and microbiological examinations to be performed. A synovial tissue culture was positive for Sporothrix schenckii, and he was diagnosed with sporotrichal tenosynovitis. He received anti-fungal therapy, and the sporotrichal tenosynovitis resolved. This case suggests that MSUS is a useful modality, and sporotrichal tenosynovitis, though rare, should be considered in the differential diagnosis of RA.

Tenosynovitis due to pseudogout

A 93-year-old woman acutely developed fever associated with pain and swelling around her left wrist. Physical examination revealed fusiform symmetric swelling of the entire digits, digits held in partial flexion, tenderness along the flexor tendon sheath and pain along the tendon with passive digits extension. Gram stain of collected fluid showed the presence of calcium pyrophosphate dihydrate crystals.

[STENOSING FLEXOR TENOSYNOVITIS - COMMON PRACTICE OF FAMILY PHYSICIANS, ORTHOPEDIC AND HAND SURGEONS]

BACKGROUND

The trigger finger is a common condition of the hand that is treated by family physicians, orthopedic and hand surgeons. The patients suffer from pain, triggering of the finger and may develop a flexion contracture of the finger, causing significant functional limitations.

AIM

The objectives of this study were to evaluate factors involved in the diagnosis and treatment of this condition, as well as the differences in treatment between specialists.

METHODS

The different specialists were asked to rate the importance of symptoms, examination and imaging studies regarding the decision to refer a patient for surgery as well as suggest the treatment of a hypothetical patient complaining of typical symptoms.

RESULTS

In the 158 questionnaires collected, the complaint of limited finger range of motion and previous treatment were rated most important. Family physicians stated that age, occupation and rate of recent triggering were considered to be additional important factors (p=.0003). In comparison with hand surgeons, family physicians reported localized tenderness as important, and the need for passive release of the finger locked in flexion as less important (p=.0003). Family physicians were more likely to treat with NSAID [p= 0.0002), orthopedic surgeons with steroid injections (p=0.0004 and hand surgeons with surgery (p=0.0001).

CONCLUSIONS

According to this survey, we found differences in the acquaintance of physicians of different backgrounds with the clinical staging of trigger finger, specifically, the significance of finger contracture and indications for surgery. This information may guide training of physicians in all fields.

Brucellosis as a primary cause of tenosynovitis of the extensor muscle of the arm

Osteoarticular involvement is the most frequently observed complication of brucellosis. Brucellosis tenosynovitis of the extensor tendon sheath is an extremely rare manifestation of musculoskeletal brucellosis. A 36-year-old male patient presented with described pain in his right wrist that had started six days earlier. There was also a diffuse swelling in the first finger of his right hand. The patient described fever, night sweats, widespread muscle pain and fatigue that had been going on for the last six days. Standard tube agglutination for Brucella was positive at a titre of 1/320. At diagnosis, the patient showed radiographic abnormalities. Doxycycline 200 mg/d and rifampicin 600 mg/d were given for six weeks. Complete resolution was achieved with medical treatment.

Gonococcal tenosynovitis in two HIV-infected heterosexual men: delayed diagnoses following negative urine nucleic acid amplification testing

With recent increases in annual gonorrhoea incidence and disproportionately high infection rates amongst men who have sex with men, the clinical picture of disseminated gonococcal infection is changing. We present two cases where consideration of, and investigation for, disseminated Neisseria gonorrhoeae infection provided the answer when routine inpatient diagnostics had been unsuccessful.

Hyperparathyroidism-related extensor tenosynovitis at the wrist: a general review of the literature

Extensor tenosynovitis often occurs accompanying with rheumatoid arthritis, gout, trauma, mycobacterium and dialysis-related amyloidosis. However, there is no recognition of extensor tenosynovitis accompanying with hyperparathyroidism. The purpose of this general review was to describe the clinical condition and to report the results of surgical intervention in the extensor tenosynovitis at the wrist related to hyperparathyroidism. Hyperparathyroidism is thought to be a rare disease in adult. Although renal symptoms are the commonest symptom, musculoskeletal complaints also occur in hyperparathyroidism. From our general review, hyperparathyroidism deserves consideration in the differential diagnosis of extensor tenosynovitis at the wrist.

[Tenosynovitis confirmed by MRI during anti-tuberculous treatment suspected due to isoniazid--2 case reports and literature review]

The adverse effects of anti-tuberculosis agents is an important problem for treatment of tuberculosis. We report 2 possible cases of isoniazid-induced tenosynovitis. Case 1: A 49-year-old man with untreated diabetic mellitus presented with hypesthesia and difficulty grasping with his right hand 1 month after starting treatment of tuberculosis of the lung and pleuritis using isoniazid, rifampicin, ethambutol, and pyrazinamide. His symptoms were due to tenosynovitis, which was detected by magnetic resonance imaging. The clinical course and isoniazid challenge test revealed that the condition was related to isoniazid. After discontinuing isoniazid treatment, his symptoms gradually improved. Case 2: An 78-year-old man operated on for rectal cancer 3 weeks previously presented with edema and arthralgia of both hands 1 month after starting anti-tuberculosis treatment. His tuberculosis was diagnosed at preoperative screening tests for rectal cancer. Owing to a medical history of gout, pyrazinamide was discontinued. However, his symptoms did not improve. Magnetic resonance imaging revealed findings indicative of tenosynovitis. At the end of anti-tuberculosis treatment, his symptoms improved slightly within 6 months. Isoniazid-induced tenosynovitis and arthritis are rare adverse effects. However, they may be underestimated because the severity is variable. We suggest further investigations of the side effects of isoniazid using imaging techniques such as magnetic resonance imaging.

Approach to traumatic hand injuries for primary care physicians

OBJECTIVE

To review the initial management of common traumatic hand injuries seen by primary care physicians.

SOURCES OF INFORMATION

Current clinical evidence and literature identified through MEDLINE electronic database searches was reviewed. Expert opinion was used to supplement recommendations for areas with little evidence.

MAIN MESSAGE

Primary care physicians must routinely manage patients with acute traumatic hand injuries. In the context of a clinical case, we review the assessment, diagnosis, and initial management of common traumatic hand injuries. The presentation and management of nail bed injuries, fingertip amputations, mallet fingers, hand fractures, tendon lacerations, bite injuries, and infectious tenosynovitis will also be discussed. The principles of managing traumatic hand injuries involve the reduction and immobilization of fractures, obtaining post-reduction x-ray scans, obtaining soft tissue coverage, preventing and treating infection, and ensuring tetanus prophylaxis.

CONCLUSION

Proper assessment and management of traumatic hand injuries is essential to prevent substantial long-term morbidity in this generally otherwise healthy population. Early recognition of injuries that require urgent or emergent referral to a hand surgeon is critical.

[Update in Current Care guidelines: repetitive strain injuries of the hand and forearm]

Repetitive strain injuriesof the upper extremities refer to pain in the forearm, wrist and hand, caused by excessive strain. Diagnoses include tenosynovitis, epicondylitis and carpal tunnel syndrome. Treatment is aimed at alleviating pain, restoring normal physical functioning and maintain ability to work. Preventive interventions have shown some attenuation of discomfort but no effects on disease prevalance or sick leave days. Return to work interventions seem to decrease length of sickness absences. Part time work has hastened return to work and decreased sickness absences in musculoskeletal disorders.

Low-field MRI versus ultrasound: which is more sensitive in detecting inflammation and bone damage in MCP and MTP joints in mild or moderate rheumatoid arthritis?

OBJECTIVES

The aim of the present paper is to determine if the ultrasound of hands and feet is comparable to the MRI of the dominant hand to detect erosive disease and inflammation in mild or moderate rheumatoid arthritis (RA).

METHODS

Twenty-six patients (14 females; mean age, 48 years) with active mild or moderate RA (mean DAS28, 3.9; mean disease duration, 19 months) were examined clinically, by ultrasound and by gadolinium-enhanced low-field MRI at baseline, after 6 and 12 months (78 examinations). Radiographs from hands and forefeet were taken at baseline and after 12 months. MRI was performed at the clinically most active (dominant) hand or forefoot evaluating the MCP 1-5 or MTP 1-5 joints. Ultrasound examination additionally included all other 2nd, 5th MCP and 5th MTP joints.

RESULTS

MRI and ultrasound detected erosive disease in 67 and 56 of 78 examinations, respectively (p<0.01); radiography only in 8 of 52 examinations (p<0.001). MRI and ultrasound were equally sensitive to detect synovitis (in 64 and 66 examinations). Synovial power Doppler signals were present in 38 ultrasound examinations. Bone marrow oedema was present in 37 MRI examinations. Ultrasound was more sensitive than MRI to detect tenosynovitis (in 30 vs. 15 examinations; p=0.001).

CONCLUSIONS

MRI of the dominant hand and bilateral ultrasound of MCP and MTP joints are superior to x-ray to detect erosive disease in mild and moderate RA. MRI is slightly, but significantly more sensitive than ultrasound for erosive disease, while ultrasound is more sensitive to detect tenosynovitis. Ultrasound and MRI are comparably sensitive to detect synovitis.