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.

First report of Mycobacterium virginiense-induced synovitis and tenosynovitis of flexor digitorum superficialis and profundus muscles in Japan

Mycobacterium virginiense, a species of the Mycobacterium terrae complex, was first identified in 2016. Although M. virginiense has only been reported to cause tenosynovitis, there have been only a few reports. Moreover, there is no established standard treatment, and no cases of M. virginiense infection have been reported in Japan. A 70-year-old Japanese man with a history of hand injury and wound contamination was diagnosed with synovitis and tenosynovitis of the left flexor digitorum superficialis and profundus muscles. M. virginiense was detected in perisynovial reservoirs and surgically removed synovium and was identified by hsp65 and rpoB sequencing. Postoperative chemotherapy with clarithromycin, rifabutin, and ethambutol was administered. Infection with M. virginiense can occur in patients with synovitis and tenosynovitis who have experienced injury or wound contamination, requiring surgery and long-term treatment with multiple antibiotics.

Combined administration of rifampicin, ethambutol, and clarithromycin for the treatment of tenosynovitis of the hand caused by Mycobacterium avium complex: Case series and literature review

ABSTRACT

We report the clinical results and problems of combined administration of rifampicin, ethambutol, and clarithromycin (REC) for the treatment of Mycobacterium avium complex (MAC) infection of the hand (hand MAC).Participants included 7 patients with hand MAC. After resection of the infected lesion, REC was prescribed for 12 months. For these patients, the site of infection, clinical course after initiation of REC, adverse drug effects (ADEs), and incidence of recurrence were evaluated.Sites of infection were the flexor tenosynovium in 5 patients, extensor tenosynovium in 1 patient, and both flexor and extensor tenosynovium in 1 patient. ADEs of REC occurred in 5 patients, and included visual disturbance caused by ethambutol in 2 patients, liver function abnormality caused by rifampicin in 2 patients, and fever with diarrhea caused by rifampicin in 1 patient. For 2 of these 5 patients, desensitization therapy was applied and REC was able to be reinstated. In the remaining 3 patients, the causative drugs were discontinued and levofloxacin, a new quinolone, was administered. Complete healing was achieved in 5 patients, and recurrence was observed in 2 patients. These 2 patients with recurrence included 1 patient in whom REC was completed and 1 patient in whom REC therapy was modified due to ADE.REC provided relatively good clinical results as a treatment for hand MAC. However, recurrences were observed even after the completion of REC and the use of an alternative drug. Optimal duration of REC and appropriate alternative drugs need to be identified in the future.

Non-tuberculosis Mycobacterium Tenosynovitis with Rice Bodies in a Patient with Systemic Lupus Erythematosus

Infectious disease with various presentations in systemic lupus erythematosus often resembles lupus flare. A 37-year-old woman presented with a swollen left index finger that had not resolved, despite 7 years of immunosuppressive treatment. MRI showed rice-body formation in the flexor tendon sheath and tenosynovectomy demonstrated chronic synovitis with epithelioid granuloma. A mycobacterial culture confirmed invasive mycobacterial tenosynovitis due to Mycobacterium chelonae. The patient was treated with moxifloxacin and clarithromycin and completely recovered.

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.

Pyogenic tenosynovitis of the wrist due to Corynebacterium striatum in a patient with dermatomyositis: A case report

INTRODUCTION

Corynebacterium striatum is common contaminant in clinical specimens. Here, we report a rare case of pyogenic tenosynovitis of the wrist caused by C striatum in a dermatomyositis patient taking oral immunosuppressants.

PATIENT CONCERNS

A 67-year-old Japanese woman with dermatomyositis had a history of multiple intraarticular injections of corticosteroids to the right wrist joint for the treatment of osteoarthritis. She was admitted to our hospital with a painful lump on the right dorsal wrist lasting for three months. MRI revealed cellulitis of the dorsum of the right wrist and hand and fluid collection in the extensor tendon sheath. C striatum was detected in the cultures of three samples of synovial fluid taken from the dorsal hand.

DIAGNOSIS

Pyogenic tenosynovitis of the wrist due to C striatum.

INTERVENTIONS

The infection was successfully controlled with synovectomy and adjuvant antibiotic therapy.

OUTCOMES

There has been no sign of recurrence for 12-months after the surgical treatment.

LESSONS

This is the first reported case of pyogenic tenosynovitis due to C striatum in a patient with dermatomyositis. Clinicians should be aware that patients undergoing immunosuppressive therapy have a risk of C striatum infection.

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.

Mycobacterial skin and soft tissue infections: TB or not TB?

Non-tuberculous mycobacteria are a known cause of skin and soft tissue infections. However, only too often it takes inordinately long to arrive at the appropriate diagnosis and start treatment. Actively searching for predilection factors, exposure risks and specific clinical clues may speed up the diagnostic process. Deep tissue biopsy cultures are indispensable to determine the species and strain of mycobacterium, with important consequences for treatment. Less well known as a causative agent of prolonged tenosynovitis is Mycobacterium tuberculosis. We present a case series and performed a literature search concerning mycobacterial tenosynovitis.

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.].

Closed Continuous Irrigation With Lidocaine and Immediate Mobilization for Treatment of Pyogenic Tenosynovitis

Pyogenic flexor tenosynovitis treatment consists of either closed continuous irrigation with sterile saline or antibiotic solution, or open debridement and irrigation. These treatment approaches serve to resolve the infection, but are extremely painful and residual stiffness can be devastating to the patient. We describe herein our approach to managing pyogenic flexor tenosynovitis. To provide continuous irrigation, a butterfly catheter with needle removed is utilized with irrigation holes cut into the tubing. The catheter is inserted into the tendon sheath at the level of the Al pulley and brought out at the level of the A5 pulley. A knot is tied in the end of the catheter for retention, eliminating the need for sutures. Immediately postoperative, continuous irrigation with sterile saline mixed with lidocaine is initiated and is titrated to achieve pain-free motion in the finger. Occupational therapy begins an aggressive course of active and passive range of motion exercises immediate postoperatively, which is continued for the remainder of hospitalization. Our approach of continuous infusion of a lidocaine solution allows for pain-free movement immediately postoperatively to mechanically debride tissue, as well as allow for early active range of motion. We have obtained excelleepaknt results with this technique in all of our cases.

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.

Pyogenic Flexor Tenosynovitis Caused by Shewanella algae

Pyogenic flexor tenosynovitis is an orthopedic emergency most commonly caused by Staphylococcus aureus and streptococci and occasionally, when associated with water exposure, Mycobacterium marinum. Shewanella algae, a gram-negative bacillus found in warm saltwater environments, has infrequently been reported to cause serious soft tissue infections and necrosis. In this case, S. algae caused complicated flexor tenosynovitis requiring open surgical irrigation and debridement. Flexor tenosynovitis caused by S. algae rapidly presented with all 4 Kanavel cardinal signs as well as subcutaneous purulence, ischemia, and necrosis, thus meeting the requirements for Pang et al group III classification of worst prognosis. Because of its rarity and virulence, S. algae should always be considered in cases of flexor tenosynovitis associated with traumatic water exposure to treat and minimize morbidity appropriately.

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.

Bilateral endogenous endophthalmitis associated with methicillin sensitive Staphylococcus aureus (MSSA) related tenosynovitis: case report

Endogenous endophthalmitis is a rare, devastating intraocular infection associated with poor outcome often from late diagnosis. We present a case report of acute onset bilateral endogenous endophthalmitis caused by Methicillin Sensitive Staphylococcus Aureus causing tenosynovitis of carpometacarpal joint in a 64 year old man with Type II Diabetes Mellitus. To the best of our knowledge, this is the first case report of endogenous endophthalmitis following tenosynovitis. This case also highlights the fact that prompt diagnosis and treatment is the key for good outcome.

Disseminated gonococcal infection in Japan: a case report and literature review

Disseminated gonococcal infection (DGI) is quite a rare condition, especially in the Japanese population; only 10 cases have been reported in case notes and minutes. We describe a man in which Neisseria gonorrhoeae was suspected to have infected the patient through his pharynx. He developed chills, fever, tonsillitis, papules, tenosynovitis and migratory polyarthralgia without genitourinary symptoms. After conducting a literature review, we suggest that being male is a possible risk factor and that blood culture can be used for diagnosing DGI in Japan. DGI should be considered as a diagnosis for patients with fever, dermatitis and joint pain in Japan.

Isolated tuberculous tenosynovitis of the forearm in an immunocompetent patient

Primary tuberculous tenosynovitis is a rare manifestation of extraspinal musculoskeletal tuberculosis. The diagnosis may be easily delayed because of its nonspecific clinical signs. We report a case of culture-proven tuberculous tenosynovitis of the extensor carpi ulnaris tendon and common extensor tendon in a 68-year-old female without concomitant pulmonary tuberculosis, nor documented immunodeficiency. The diagnosis was initially overlooked due to the lack of appropriate histological and bacteriological analyses and the lesion recurred after surgery. MR imaging represents the most accurate method in making the diagnosis, but has no diagnostic specificity in regard to tuberculosis, therefore surgical biopsy is strongly recommended. The patient had a favorable clinical response after a combination of excision and appropriate antituberculous therapy for sensitive Mycobacterium tuberculosis. We emphasize the need for an increased awareness and high index of suspicion of tuberculosis in all cases of a chronic orrecurrent abscess in the extremities, not only in patients living in endemic areas but also in those who have emigrated from regions with a high prevalence of tuberculosis.

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.

Infectious tenosynovitis and osteomyelitis caused by Mycobacterium nonchromogenicum

Infections due to Mycobacterium terrae complex are rare. We report a severe case of chronic tenosynovitis and osteomyelitis of the hand caused by Mycobacterium nonchromogenicum requiring second ray finger amputation.

Mycobacterium heckeshornense tenosynovitis

We describe the first case of tenosynovitis due to Mycobacterium heckeshornense, a mycobacterium characterized in 2000 and only incriminated in a few previous cases of infections. Molecular identification of this pathogen included 16S rRNA and hsp65 gene sequencing. M. heckeshornense may cause a wide spectrum of human infectious diseases and may be underestimated due to its phenotypic relatedness with Mycobacterium xenopi.

[Acute infections of the hand]

Hand infections can result in significant morbidity if not appropriately diagnosed and treated. Host factors, location and circumstances of the infection are important guides to initial treatment strategies. Many hand infections improve with early splinting, elevation and appropriate antibiotics based on bacterial culture. The basic principles for deep infections are bridement of necrotic and infected tissue and healing by second area intension and antibiotics. Hand therapy is important.

A mass lesion of the wrist: a rare manifestation of tuberculosis

The worldwide reemergence of tuberculosis is significant. In particular, the incidence of extrapulmonary tuberculosis is increasing. But tuberculous tenosynovitis is rare and may be overlooked as a cause of chronic tenosynovitis. Here, we present a case of a 24 year-old man with a mass lesion on the flexor side of the right wrist. Laboratory findings were generally negative, except for the acceleration of the erythrocyte sedimentation rate, and the tuberculosis skin test was strongly positive. Magnetic resonance imaging (MRI) of the mass lesion of the wrist revealed tenosynovitis. We performed open biopsy and mycobacterial cultures. Thus, we diagnosed the patient with tuberculous tenosynovitis. Tuberculous tenosynovitis is uncommon but should be kept in mind in cases of chronic tenosynovitis.

Factors affecting the prognosis of pyogenic flexor tenosynovitis

BACKGROUND

Pyogenic flexor tenosynovitis is a closed space infection involving the digital flexor tendon sheaths of the upper extremity that can cause considerable morbidity. The purpose of the present report is to describe the various risk factors leading to poor outcomes and to recommend a clinical classification system for this condition.

METHODS

We studied seventy-five patients with pyogenic flexor tenosynovitis over a six-year period. The amputation rate and total active motion were used as outcomes measures. The clinical factors influencing outcomes were identified and analyzed.

RESULTS

The five risk factors associated with poor outcomes were (1) an age of more than forty-three years, (2) the presence of diabetes mellitus, peripheral vascular disease, or renal failure, (3) the presence of subcutaneous purulence, (4) digital ischemia, and (5) polymicrobial infection. On the basis of the clinical findings and outcomes, three distinct groups of patients could be identified, each with a progressively worse outcome. Patients in Group I had no subcutaneous purulence or digital ischemia; these patients had the best prognosis, with no amputations and a mean 80% return of total active motion. Patients in Group II demonstrated the presence of subcutaneous purulence but no ischemic changes; these patients had an amputation rate of 8% and a mean 72% recovery of total active motion. Patients in Group III had both extensive subcutaneous purulence and ischemic changes; these patients had the worst prognosis, with an amputation rate of 59% and a mean 49% return of total active motion.

CONCLUSIONS

We propose a three-tier clinical classification system that can aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity.

Q fever osteoarticular infection: four new cases and a review of the literature

Q fever is a worldwide-occurring zoonosis caused by Coxiella burnetii. Better knowledge of the disease and of evolving diagnostics can enable recognition of unusual manifestations. Reported here are four cases of Q fever osteoarticular infections in adults: two cases of Q fever tenosynovitis, which represent the first two reports of this infection, and two cases of Q fever spondylodiscitis complicated by paravertebral abscess. In addition, the literature is reviewed on the 15 previously reported cases of Q fever osteoarticular infection, six of which were vertebral infections. Osteomyelitis is the usual manifestation Q fever osteoarticular infection. Because its onset is frequently insidious, diagnosis is usually delayed. The main differential diagnosis is mycobacterial infection, based on the histological granulomatous presentation of lesions. Whereas serology is the reference diagnostic method for Q fever, detection of C. burnetii in tissue specimens by PCR and cell culture provides useful additional evidence of infection. Culture-negative osteoarticular samples with granulomatous presentation upon histological examination should raise suspicion of Q fever.

Fish gambler's tenosynovitis caused by Mycobacterium marinum: environmental investigation of a fishing pond in Southern Taiwan

We describe a patient with Mycobacterium marinum tenosynovitis associated with a fish spine injury acquired at a gambling fishing pond in southern Taiwan and identify the source of the infection. M. marinum was isolated from fishing ponds and underground water and wastewater at the site. The isolates shared the same pulsed-field gel electrophoresis pattern as the patient. M. marinum was not detected in 54 samples obtained from 27 fish. Mycobacterium gordonae was isolated from 24 samples collected from the fish. Mycobacterium abscessus was isolated from 3 fish samples (Lateolabrax japonicus 1 and Sciaenops ocellatus 2). M. abscessus and M. gordonae were isolated from all water samples. This investigation provides strong evidence that the predisposing factor for the M. marinum infection was with a fish spine injury acquired at a gambling fishing pond. The source of the infection was the contaminated pond water.

Disseminated gonococcal infection presenting as vasculitis: a case report

A 50-year-old man with alcoholic liver disease presented with fever, tenosynovitis, polyarthritis and a vasculitic rash on the hands and feet for 4 days. He had neutrophilia and raised inflammatory markers. He had no history of sore throat, urethral discharge or travel abroad. His initial blood cultures were negative, and he was treated for vasculitis with steroids. The rash and arthritis seemed to improve initially, but he had another episode of fever. Repeat blood cultures grew Neisseria gonorrhoeae,and he received intravenous ceftriaxone followed by oral ciprofloxacin. He had marked improvement in rash, tenosynovitis and arthritis, and the fever dropped. He also had chlamydial urethritis and received azithromycin. The presentation of disseminated gonococcal infection after a presumptive episode of asymptomatic urethral gonorrhoea is highlighted.