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.

Lumbrical muscle enhancement on MRI and its association with rheumatoid arthritis

OBJECTIVE

To investigate the significance of lumbrical muscle enhancement (LME) on magnetic resonance imaging (MRI) in rheumatoid arthritis (RA).

MATERIALS AND METHODS

Blinded to the diagnoses, contrast-enhanced bilateral hand MRIs of patients with suspected early RA between 2014 and 2019 were reviewed by two observers for the presence and degree (weak/strong) of LME. The presence of other inflammatory findings was also noted. The patients were then stratified into RA (n = 41), control (n = 31), and other arthritides groups(n = 28) based on their final diagnoses in the hospital records within the following 12 months. Categorical variables were compared by chi-square test or Fisher's exact test. Differences among the groups were evaluated by one-way ANOVA or Kruskal-Wallis tests. When the p-value from the Kruskal-Wallis test was statistically significant, multiple comparison test was used to identify group differences. Correlations between LME and flexor tenosynovitis were evaluated by Spearman rank correlation test. The agreement between two observers was assessed by Cohen's Kappa (κ) statistic. P-value < 0.05 was considered as statistically significant.

RESULTS

There were 100 patients (88 females) with mean age of 47.2 ± 11.2. There were no significant differences for age or sex between groups (p = 0.17, p = 0.84, respectively). RA patients showed significantly more frequent (p < 0.001) and stronger LME (p = 0.001). There were no correlations between LME and flexor tenosynovitis (p > 0.05). Interrater agreement for the degree of LME on right and left sides was substantial (κ = 0.74, κ = 0.67, respectively).

CONCLUSION

RA patients demonstrated significantly more frequent and stronger LME with substantial interrater agreement. LME could constitute a subtle radiological clue for early RA.

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.

Implementation of the OMERACT Psoriatic Arthritis Magnetic Resonance Imaging Scoring System in a randomized phase IIb study of abatacept in psoriatic arthritis

OBJECTIVES

To investigate if the OMERACT PsA MRI Scoring System (PsAMRIS), including a novel total inflammation score, shows sensitivity to change with an agent (abatacept) known to impact clinical outcomes in PsA.

METHODS

We performed a post hoc analysis of a randomized phase IIb study of abatacept in patients with PsA and inadequate DMARD response. Participants received one of three abatacept dosing regimens [ABA3, ABA10 or ABA30/10 mg/kg (30 mg/kg switched to 10 mg/kg after two doses)] or placebo until day 169, then ABA10 through day 365. MRIs at baseline and days 85, 169 and 365 were centrally evaluated by two readers blinded to chronological order and treatment arm. Synovitis, osteitis, tenosynovitis, periarticular inflammation, bone erosions, joint space narrowing and bone proliferation were assessed using the PsAMRIS. A novel total inflammation score was tested.

RESULTS

MRIs for 123 patients were included. On day 169, ABA10 and ABA30/10 significantly reduced MRI synovitis and tenosynovitis, respectively, vs placebo [differences -0.966 (P = 0.039) and -1.652 (P = 0.014), respectively]. Synovitis in the placebo group increased non-significantly from baseline to day 169, total inflammation and tenosynovitis decreased non-significantly and all measures improved significantly after a switch to ABA10 [-1.019, -0.940, -2.275 (P < 0.05), respectively, day 365 vs day 169]. Structural outcomes changed minimally across groups.

CONCLUSION

Adults with PsA receiving ABA10 and ABA30/10 demonstrated significant resolution of inflammatory components of disease, confirmed by MRI, with synovitis and tenosynovitis improvements consistent with previously reported clinical responses for these doses. Results indicate that a reduction in OMERACT PsAMRIS inflammation scores may provide proof of tissue-level efficacy in PsA clinical trials.

REGISTRATION

ClinicalTrials.gov (https://clinicaltrials.gov), NCT00534313.

Evidence for the presence of synovial sheaths surrounding the extensor tendons at the metacarpophalangeal joints: a microscopy study

MRI-detected inflammation around the extensor tendons of metacarpophalangeal (MCP-) joints is prevalent in RA and poses a markedly increased risk of RA development when present in arthralgia patients. Such inflammation is called 'peritendinitis' since anatomy literature reports no presence of a tenosynovial sheath at these tendons. However, the presence or absence of tenosynovium at these extensor tendons has never been studied. Therefore, an anatomical and histological study of extensor tendons at the MCP-joints of three embalmed human hands was performed. Immunohistochemical staining showed the presence of markers for synovial macrophages and fibroblast-like synoviocytes bordering a natural dorsal space next to the extensor tendon, suggesting the presence of a synovial lining. This implies that contrast-enhancement on MRI around extensor tendons at MCP-joints observed in early RA and pre-RA likely represents tenosynovitis and that inflammation of this synovial tissue is an early feature of RA.

MR and ultrasound of the hands and wrists in rheumatoid arthritis. Part II. Added clinical value

Advanced imaging has become just as vital for diagnosing, staging, and monitoring disease in rheumatoid arthritis (RA) patients as it is for cancer patients. Part 1 of this review discussed synovitis, tenosynovitis, erosions, and osteitis-key imaging findings that occur in patients with RA. Part 2 will now show how these features, in combination with clinical and serologic data, can assist clinical decision-making at various stages of a patient's disease course. Specifically, assessing current disease activity and prognosticating future aggressiveness inform treatment decisions at initial presentation, during medical treatment, and at clinical remission. In addition to summarizing the current literature on advanced imaging in RA, clinical examples from different stages throughout the disease course will illustrate practical approaches for applying these research results. Last, this review will describe potential future roles of imaging in RA patients.

Right Ring Finger Volar Mass in a 14-Year-Old Boy

A trigger digit is relatively uncommon in adolescents and often has a different etiology in that age group vs adults. In the pediatric population, trigger digits frequently arise from a variety of underlying anatomic situations, including thickening of the flexor digitorum superficialis or flexor digitorum profundus tendons, an abnormal relationship between the flexor digitorum superficialis and flexor digitorum profundus tendons, a proximal flexor digitorum superficialis decussation, or constriction of the pulleys. In addition, underlying conditions such as mucopolysaccharidosis, juvenile rheumatoid arthritis, Ehlers-Danlos syndrome, and central nervous system disorders such as delayed motor development have been associated with triggering. Less commonly, triggering secondary to intratendinous or peritendinous calcifications or granulations has been described, which is what occurred in the current case. This report describes a case of tenosynovitis with psammomatous calcification treated with excision of the mass from the flexor digitorum superficialis tendon and release of both the A1 and palmar aponeurosis pulleys in an adolescent patient. [Orthopedics. 2017; 40(5):e918-e920.].

The frondiform ligament and pseudotenosynovitis of the extensor digitorum longus tendon: MRI evaluation with cadaveric correlation

OBJECTIVE

Fluid along the frondiform ligament, the sinus tarsi stem of the inferior extensor retinaculum (IER), can approximate the extensor digitorum longus (EDL), at times simulating tenosynovitis. Our purpose, based on MRI and cadaveric studies, was to further evaluate this scantly described phenomenon, to identify associated findings and to alert the radiologists to the potential pitfall of over diagnosing EDL tenosynovitis.

MATERIALS AND METHODS

Two musculoskeletal radiologists retrospectively reviewed the radiology reports and MRI studies of 258 ankle MRI exams, performed at our institution, for fluid along the frondiform ligament extending toward the EDL. No patient had EDL pathology clinically. MRI was performed in two cadaveric ankles following injection of the sinus tarsi and EDL tendon sheath, under ultrasound guidance.

RESULTS

Altogether, 31 MRIs demonstrated fluid extending from the sinus tarsi along the frondiform ligament toward the EDL. In 30 cases (97 %), the fluid partially surrounded the tendon, without tendon sheath distension. Based on the radiology reports, in 11 of the 31 cases (35 %), the fluid was misinterpreted as abnormal. Most common associated findings included ligamentous injury, posterior tibial tendon (PTT) tear, flat-foot, and osteoarthrosis. In the cadavers, fluid extended along the frondiform ligament toward the EDL after sinus tarsi injection; there was no communication between EDL tendon sheath and the sinus tarsi.

CONCLUSION

Fluid within the sinus tarsi can extend along the frondiform ligament and partially surround the EDL, manifesting as pseudotenosynovitis. This phenomenon, often seen with ligamentous tears or PTT dysfunction, should not be misdiagnosed as true pathology of the EDL.

Tenosynovitis: a rare presentation of tuberculosis better known by hand surgeons than infectious diseases specialists

PURPOSE

Clinical presentation of tuberculosis is pleomorphic. Some forms are rare and better known by surgeons than infectious disease specialists.

METHODS

We describe a rare case of isolated chronic tenosynovitis of the wrist due to Mycobacterium tuberculosis in a 66-year-old man and review similar cases in the literature.

RESULTS

On literature search, only 23 other cases of tuberculous tenosynovitis were retrieved. Our case is similar, with an insidious classical presentation. The diagnosis was suggested at the surgical presentation by the presence of rice body masses.

CONCLUSION

The diagnosis of tuberculous tenosynovitis should be considered in chronic tenosynovitis. Functional prognosis may be committed without adequate treatment.

[Ultrasonography for carpal tunnel syndrome]

Ultrasonography in cases of carpal tunnel syndrome is described with respect to the following aspects: (1) imaging technique; (2) image characteristics; (3) detection of pathophysiology; (4) diagnosis of idiopathic cases; (5) screening of local pathologies (space-occupying lesions, tenosynovitis, and bone and joint abnormalities), incomplete release, and anatomic variations; and (6) role in facilitating minimally-invasive surgery.

Aseptic tenosynovitis of the carpal flexor sheath caused by rupture of the accessory ligament of the deep digital flexor tendon

A mare was evaluated for acute left forelimb lameness with effusion of the carpal flexor sheath. No osseous abnormalities were noted during radiographic examination. Significant disruption of the accessory ligament of the deep digital flexor tendon was seen during ultrasonographic examination. Carpal sheath effusion and lameness resolved after medical treatment.

MRI assessment of tenosynovitis in children with juvenile idiopathic arthritis: inter- and intra-observer variability

BACKGROUND

There is sparse knowledge about grading tenosynovitis using MRI.

OBJECTIVE

The purpose of this study was to assess the reliability of a tenosynovitis MRI scoring system in juvenile idiopathic arthritis.

MATERIALS AND METHODS

Children with juvenile idiopathic arthritis and wrist involvement were enrolled in two paediatric centres, from October 2006 to January 2010. The extensor (compartments II, IV and VI) and flexor tendons were assessed for the presence of tenosynovitis on T1-weighted postcontrast fat-saturated MR images and were scored from 0 (normal) to 2 (moderate to severe) by two observers independently. Intra- and interobserver agreement was assessed.

RESULTS

Ninety children (age range: 5-18.5 years) were included, of whom 34 had tenosynovitis involving extensors and 28 had tenosynovitis involving flexors. A total of 360 tendon areas were analysed, of which 114 had tenosynovitis (86/270 extensors and 28/90 flexors). Intra-reader 1 agreement was excellent for the extensors (k = 0.82-0.91) and for the flexors (k = 0.85); intra-reader 2 agreement was moderate to good for the extensors (k = 0.51-0.72) and good for the flexors (k = 0.64). Inter-reader agreement was good for the extensors (k = 0.69-0.73) and moderate for the flexors (k = 0.49).

CONCLUSION

The proposed MRI scoring system for the assessment of wrist tenosynovitis in juvenile idiopathic arthritis appears feasible with an observer agreement sufficient for clinical use.

Late spontaneous rupture of the extensor pollicis longus tendon after corticosteroid injection for flexor tenosynovitis

INTRODUCTION

Spontaneous rupture of the extensor pollicis longus (EPL) tendon has been reported after trauma, rheumatoid arthritis and sports. Rupture may also occur as a consequence of the use of anabolic steroids for recreational purposes, or systemic steroids for the treatment of a variety of medical conditions.

CASE REPORT

We present a case report of a woman affected with a spontaneous EPL tendon rupture resulted 14 months after a corticosteroid injection for flexor tenosynovitis, "trigger finger," of the thumb. The edges of the tendon were debrided and sutured using figure of eight stitch and a running locked stitch. In addition multiple specimens were sent to Pathology.

DISCUSSION

Duplay in 1876 described spontaneous rupture as a problem of mechanical and pressure phenomena. Another cause of EPL rupture is related to the development and persistence of inflammatory processes seen in patients with medical illnesses such as rheumatoid arthritis. There have been no reports in the literature to date of spontaneous EPL tendon rupture in the late period after steroid injection. Tendon ruptures in the hand usually occur one or two weeks after a corticosteroid injection, and the affected tendons are usually in neighbouring areas.

Extracorporeal shockwave therapy in a dog with chronic bicipital tenosynovitis

A 15-month-old, spayed female, Bernese mountain dog was presented to the Institute of Small Animal Surgery at the University of Zurich because of chronic left forelimb lameness. The referring veterinarian diagnosed pain in the left shoulder region and had treated the dog with systemic non-steroidal anti-inflammatory drugs and restricted exercise for a two-week period. The follow-up examination revealed only minimal improvement and therefore, the dog was referred for further diagnostic evaluation. Chronic bicipital tenosynovitis and tendinitis of the infraspinatus muscle was diagnosed based on survey radiographs, arthrography, ultrasound, computed tomography (CT), and synovial fluid cytology. The dog underwent three sessions of extracorporeal shockwave therapy and substantial clinical improvement was observed. On follow-up examinations, only mild left forelimb lameness was evident following exercise, and changes in the intertubercular groove and at the supraglenoid tuberosity appeared less active on radiographs and CT. However, six months following treatment, mild degenerative joint disease was apparent.

[Ultrasound in complex of radiological studies in diagnosis of ankle joint medial aspect pathologies]

The aim of the research is to study sonosemiotics of ankle joint pathology by means of ultrasound in order to optimize the diagnostic process and improve the treatment. 130 patients (age ranges from 5 to 70 years) underwent the radiological study of ankle joint medial aspect. Pathology types: degenerative-dystrophic diseases - 39 (30%), inflammatory pathology - 21 (16.2%), traumatic injuries - 20 (15.2%), vascular pathologies - 26 (20%), neurogenic problems -7 (5.4%), soft tissue neoplasms - 5 (3.8%), congenital anomalies - 7 (5.4%) and vertebral pathology - 5 (4.0%). The diagnostic studies include: a) Ultrasound, performed on digital ultrasound system using high frequency (7.5-12.0 MHz) linear probe with Doppler capability (all patients); b) X-Ray filming in antero-posterior and lateral projections (6 patients- 4.5%); c) MRI - T1 and T2 weighted images in saggital and transverse planes 10 patients (10.0%) and d) CT - 2 patients (1.5%); To 2 (1.5%) patient biopsy has been performed. This study showed that ultrasound was successful in ankle joint medial aspect pathology diagnosis in 108 cases (84.0%); It was ineffective in osseous pathology definition. In final diagnosis of impingment syndrom MRI was required in 4 (3.6%) cases. It is concluded that ultrasound should be used as a Gold Standard in diagnosis of localized pain and swelling in the ankle joint.

Clinical presentation of psoriatic arthritis

Psoriatic arthritis is a spondyloarthropathy which occurs in patients with skin and/or nail psoriasis. Basing its characterization on morphological purposes, several types of arthritis have been described. Alternatively, we propose a simplified classification into three subsets, focusing on the levels of expression of cutaneous and articular elements which devise this syndrome. The first is established psoriatic arthritis which occurs in patients with evident or remittent skin and/or nail psoriasis. Its clinical spectrum consists of the five subsets classically described by Moll and Wright in 1973. The second is psoriatic arthritis "sine psoriasis" which occurs in subjects without psoriasis but with a family history of the disease in first or second-degree relatives. The third is early psoriatic arthritis which consists of an articular involvement of recent onset, occurring in subjects belonging to established or sine psoriasis subsets.

Magnetic resonance imaging of inflammatory arthropathies of peripheral joints

As the treatment of inflammatory arthropathies has advanced with new therapies that can slow or even halt the development of disabling disease, early and accurate diagnosis has become imperative. Magnetic resonance (MR) imaging has proved to be very sensitive in the detection of erosions, but more importantly, it can demonstrate pre-erosive changes. Detection of synovitis and edema-like bone marrow lesions for initial diagnosis and as an indicator of disease progression can provide crucial information leading to therapeutic interventions before permanent joint damage occurs. Understanding the characteristic intra-articular and extra-articular MR imaging findings of the inflammatory arthritides allows the radiologist to provide appropriate consultations in the care of these patients. The MR appearances of both intra-articular and extra-articular findings of inflammatory arthritis are presented. Despite the advances in imaging, however, many of the MR findings remain nonspecific, and radiologists must avoid overdiagnosis by synthesizing all of the clinical information available into their interpretations.

[Magnetic resonance imaging of the hand as an early diagnostic method for rheumatoid arthritis]

AIM

To provide the qualitative and quantitative characteristics of changes revealed by the data of magnetic resonance imaging (MRI) of the hand and by those of X-ray study of the hand and foot in patients with early rheumatoid arthritis (ERA).

SUBJECTS AND METHODS

The study enrolled 110 patients (90 females, 20 males; age 49.6 +/- 12.2 years) examined in the framework of the RADICAL program at the Research Institute of Rheumatology, Russian Academy of Medical Sciences. The mean duration of the disease was 5.61 +/- 3.17 months. The diagnosis of rheumatoid arthritis was established by the 1987 ARA criteria in all the patients on primary standard examination comprising X-ray study of the hand and feet and evaluation by the modified Sharp method. MRI of the hand was performed in all the patients, by assessing the result by the OMERACT-RAMRIS procedure.

RESULTS

Destructive changes (cysts and erosions) evidenced by X-ray study were found in the wrists, metacarpophalangeal articulations (MPA), and foot in 7.27, 8.2, and 13.64%, respectively. MRI revealed destructions in the wrist, MPA, and metacarpal bone base in 50, 60, and 16.36%, respectively. Overall, erosions could be seen on X-ray films and MRI scans in 20.91 and 67.27%, respectively (p < 0.0001). MRI revealed bone edema (osteitis) in 46.4% of the patients; there was no difference in the detection rate between the extremities. MRI synovitis was found in 99% of the patients, the right hand being significantly more commonly affected. Detailed characterization of the changes revealed by MRI and Xray was obtained in patients with ERA.

CONCLUSION

MRI detected erosions significantly more frequently than did X-ray (p < 0.001), which confirms the high value of low-field MRI diagnosis on primary examination of patients with ERA and supports the opinion that the results of this study should be included into the diagnostic criteria of ERA.

Tenosynovitis with rice body formation in a non-tuberculosis patient: a case report

In this report, we present a 68-year-old man with rice body formation in the flexor tendon sheath of the fingers without any inflammatory diseases such as tuberculosis or rheumatoid arthritis. The patient visited our institute in March 2004 with a one-month history of swelling and pain of the right distal forearm. Laboratory data were within normal limits, and the rheumatoid factor was negative. He had no history of tuberculosis, and the tuberculin reaction was weakly positive. Magnetic resonance (MR) images showed a mass measuring 6 cm x 4 cm around the flexor tendons of the forearm. Many rice bodies had been erupted from a small hole of the fibrous wall of the mass at the time of incisional biopsy performed in June 2004. Histological diagnosis was synovitis with fibrous loose bodies. In July 2004, spontaneous ruptures of the right fourth and fifth flexor tendons occurred. Open repair was performed in August 2004. The patient regained good function of the operated fingers with no evidence of recurrence at the latest follow-up in March 2009.

Case report: protothecal tenosynovitis

Protothecosis is a rare infection caused by achlorophyllic algae called Prototheca. Approximately 117 cases have been described in the literature world wide, the majority caused by the species P. wickerhamii. Cutaneous infection is the most common and cases of tenosynovitis are very rare. A local or systemic immunosuppressive factor is seen in half of the cases of protothecosis. We report a case of protothecal tenosynovitis in a middle-aged, immunocompetent woman that developed after she received sclerosing therapy of varicose veins. Administration of itraconazole with surgical débridement produced a good response. We also review the published cases of protothecal tenosynovitis.

Co-occurrence of poststreptococcal reactive arthritis and acute glomerulonephritis

We report a 16-year-old patient who developed concurrent poststreptococcal reactive arthritis and acute glomerulonephritis. A high titer of antistreptolysin O antibody confirmed the preceding streptococcal infection. The patient presented with symmetric persistent tenosynovitis of hands and feet. Renal biopsy showed typical findings of acute glomerulonephritis with crescent formation. Physicians who treat patients with arthritis of acute onset, especially after throat infection, should be aware of possible urinary abnormalities or renal dysfunction.

[Ultrasonographic findings of disorders of the tarsal region in 97 cattle--arthritis, bursitis, tenosynovitis, periarticular abscess and vein thrombosis]

The clinical, radiographic, ultrasonographic and centesis findings of 97 cattle with disorders of the tarsal region (arthritis, bursitis, tenosynovitis, abscess, vein thrombosis) were reviewed (1994-2006), and the typical ultrasonographic findings of different tarsal disorders in cattle are presented. The following criteria were assessed: echogenicity, echopattern, size, shape, appearance of the borders of synovial or other cavities. Ultrasonographic findings were compared with the clinical, radiographic and arthrocentesis results and with intraoperative and/or necropsy findings. 50 cattle suffered from one tarsal disease only, in 47 cattle--up to three different--concurrent disorders in one tarsal region were identified. The afflicted synovial cavities and abscesses were definitely differentiated ultrasonographically in all cattle suffering from tarsal disorders a comprehensive diagnosis could be achieved due to the easy and rapid ultrasonographic differentiation of the incriminated soft tissues.

Tuberculous pyomyositis of the thigh masquerading as malignancy with concomitant tuberculous flexor tenosynovitis and dactylitis of the hand

Multifocal involvement of the skeleton is extremely rare, with tuberculous pyomyositis and tenosynovitis of the wrist being uncommon presentations of skeletal tuberculosis (TB). We present an immunocompetent 68-year-old woman with concomitant presentation of these uncommon forms of extrapulmonary TB heralded by tuberculous pyomyositis. Tuberculous pyomyositis can often masquerade as malignancy, leading to misdiagnosis and patients being mistakenly referred to oncologists for management. This delayed the institution of appropriate drug therapy. Similarly, because of its rarity, tuberculous tenosynovitis may be overlooked as a cause of chronic tenosynovitis. In the absence of pathognomonic imaging findings, the diagnosis ultimately rests on histopathological and microbiological confirmation. This case highlights the importance of maintaining a high index of suspicion of the protean manifestations of extrapulmonary TB, not only in high-risk populations, but in immunocompetent individuals as well. It also illustrates the advantage of a clinically-directed multidisciplinary approach in early recognition and treatment of this entity.

Sarcoidal granulomatous tenosynovitis of the hands occurring in an organ transplant patient

Six years after kidney-pancreas transplant, a 47-year-old white man developed multiple subcutaneous and tenosynovial nodules of hands and wrists, limiting mobility. Biopsy of multiple nodules showed fibrosing, sarcoidal granulomas, some of which contained pigmented material. Microbiology, immunohistochemistry, scanning electron microscopy with backscattered electron imaging and energy dispersive X-ray analysis and polymerase chain reaction assays failed to show any infectious agents or foreign material. There was no historical, clinical or laboratory evidence of systemic sarcoidosis. It is not known whether the donor had sarcoidosis. Despite empiric antimycobacterial therapy and ongoing immunosuppressive therapy (corticosteroids, mycophenolate, cyclosporine), the man has progressively developed more nodules, limiting hand function. Sarcoidosis occurring in non-donor tissue post-transplantation is an exceedingly rare complication of transplantation. We discuss this case and review the literature on sarcoidal tenosynovitis and sarcoidosis occurring post-transplantation.

[Isolated tuberculous tenosynovitis of the Achilles tendon: a report of two cases]

Tuberculous tenosynovitis involving the tendons of the feet is very rare. Isolated primary tuberculous tenosynovitis of the Achilles tendon was detected in two women aged 19 and 53 years, respectively. The younger patient had a swollen and painful Achilles tendon in the left foot. Complete excision of the lesion followed by antituberculous chemotherapy for six months resulted in complete improvement. Magnetic resonance imaging showed normal findings at the end of six months and no recurrence after 27 months of follow-up. The older patient had diabetes and was on cytostatic treatment for rheumatoid arthritis. She had difficulty in squatting and climbing stairs due to swelling and pain in the right ankle. She underwent abscess drainage and excision of the cystic mass. Despite disappearance of symptoms in the affected ankle in the course of antituberculous chemotherapy, she died due to miliary tuberculosis in the sixth month. Tuberculous tenosynovitis should be considered in the differential diagnosis of patients suffering from persistent swelling and pain in the hind foot.

Inflammatory and structural evaluation in spondyloarthritis: magnetic resonance imaging analysis of axial and peripheral involvement

OBJECTIVE

To determine the magnetic resonance imaging (MRI) criteria of most value in the assessment of patients with spondyloarthropathy (SpA) with axial or peripheral involvement.

METHODS

Fat suppressed (FS)-T2 and pre- and postinjection FS-T1 images were obtained in the most symptomatic region (axial or peripheral) of patients requiring tumor necrosis factor-a blockers. Thirty-eight MRI (21 axial and 17 peripheral) were blindly scored at synovial (S) and entheseal (E) sites by 2 experienced observers screening for 7 inflammatory and 7 structural predefined criteria, which were evaluated for frequency (N) and intra- and interobserver reproducibility.

RESULTS

In peripheral regions, synovitis (S; N = 69.4%), ligament inflammation (E; N = 39.7%), bone marrow edema (S; N = 22.1%; E; N = 15%), and tenosynovitis (S; N = 21%) were recorded with good to excellent intraobserver reproducibility [intraclass correlation coefficient (ICC) 0.49-0.93] and moderate to good interobserver reproducibility (ICC 0.49-0.66). With regard to structural criteria, erosions (S; N = 17.1%) and enthesophytes (E; N = 13.9%) exhibited good to excellent intraobserver (ICC 0.71-0.85) and moderate interobserver reproducibility (ICC 0.54-0.49); the reproducibility of fat inflation (N = 1.4%) was good (ICC 0.76-0.78). In axial regions, no inflammatory criteria achieved good interobserver reproducibility. However, fat inflation (S; N = 86%), chondral lesions (S; N = 85.8%), enthesophytes (E; N = 76.7%), fusion (S; N = 41.2%), and erosions (S; N = 25.1%) showed excellent intraobserver reproducibility (ICC 0.81-0.98), and moderate to excellent interobserver reproducibility (ICC 0.50-0.96).

CONCLUSION

In terms of intra- and interobserver reproducibility, MRI is a reliable tool with which to assess synovitis, bone edema, ligament inflammation, tenosynovitis, erosion, enthesophytes, and fat inflation in patients with peripheral involvement. In those with axial involvement, inflammatory criteria lack interobserver reproducibility, but chondral lesions, erosion, fat inflation, fusion, and enthesophytes are relevant.

Introduction of a novel magnetic resonance imaging tenosynovitis score for rheumatoid arthritis: reliability in a multireader longitudinal study

OBJECTIVES

To describe a novel scoring system for the assessment of tenosynovitis by magnetic resonance imaging (MRI) in patients with rheumatoid arthritis, and assess its intra- and inter-reader reliability in a multireader, longitudinal setting.

METHODS

Flexor and extensor tenosynovitis were evaluated at the level of the wrist in 10 different anatomical areas, graded semi-quantitatively from grade 0 to 3 (total score 0-30), based on the maximum width of post-contrast enhancement within each anatomical area on axial T1-weighted MR images. Ten sets of baseline and 1-year follow-up MR images of the wrists of patients with rheumatoid arthritis with early and established disease were scored independently by four readers twice on 2 consecutive days. Intra- and inter-reader agreements were evaluated.

RESULTS

The intrareader intraclass correlation coefficients (ICCs) were high for status scores (median ICCs 0.84-0.88) and slightly lower for change score (0.74). The smallest detectable difference (SDD) in % of the maximum score was 11.2-11.5% for status scores and 13.3% for change scores. Inter-reader single-measure ICCs were acceptable for both status scores (median 0.73-0.74) and change scores (0.67), while average-measures ICCs were very high for both status and change score (all > or =0.94). The median scoring time per patient (baseline and follow-up images) was 7 min (range 3-10).

CONCLUSIONS

The introduced tenosynovitis scoring system demonstrates a high degree of multireader reliability, is feasible, and may be used as an adjuvant to the existing OMERACT RAMRIS score, allowing improved quantification of inflammatory soft tissue changes in patients with rheumatoid arthritis.

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.

Volar dislocation of the extensor carpi ulnaris tendon on magnetic resonance imaging is associated with extensor digitorum communis tendon rupture in rheumatoid wrists

PURPOSE

Extensor tendon rupture in rheumatoid wrists is a common problem and causes immediate dysfunction of the digits. The best treatment for tendon rupture may be prophylactic management, although the factors associated with tendon rupture must first be identified. The purpose of this study was to evaluate structures around rheumatoid wrists using magnetic resonance imaging with forearm rotation and to identify factors associated with extensor tendon rupture as indications for prophylactic surgery.

METHODS

The subjects were 34 patients (40 wrists) with active rheumatoid arthritis. The extensor digitorum communis (EDC) tendons were ruptured in 15 wrists. Magnetic resonance imaging of the wrists was performed in maximally pronated and supinated positions of the forearm. Axial images of the distal radioulnar joints (DRUJs) were selected to evaluate DRUJ synovitis, dorsal tenosynovitis, volar dislocation of the extensor carpi ulnaris (ECU) tendon, sigmoid notch angle, and the radioulnar ratio (RUR) (ie, the degree of DRUJ subluxation).

RESULTS

No significant correlations were found between EDC tendon rupture and DRUJ synovitis, dorsal tenosynovitis, or RUR in pronation. Extensor digitorum communis tendon rupture correlated significantly with volar ECU tendon dislocation, sigmoid notch angle, and RUR in supination. Radioulnar ratio correlated significantly with volar ECU tendon dislocation only in supination and not in pronation. Thus, DRUJ subluxation was advanced even in the supinated wrist with volar ECU tendon dislocation. As a factor associated with EDC tendon rupture, volar ECU tendon dislocation had 87% sensitivity and 76% specificity.

CONCLUSIONS

Volar ECU tendon dislocation is associated with increased RUR in supination and EDC tendon rupture. Volar ECU tendon dislocation can thus be considered a factor associated with EDC tendon rupture, and its presence may indicate the need for prophylactic surgical intervention in a subset of rheumatoid arthritis patients.

Efficacy of a Percutaneous A1 Pulley Release Technique With Identification of Anatomic Differences Between Genders

BACKGROUND

This cadaver study investigates the efficacy and safety of the Biomet knife and technique for percutaneous A1 pulley release. We also evaluate the anatomic relationship between specific palmar surface landmarks and relevant underlying structures and identify differences between genders.

METHODS

Eighty percutaneous A1 pulley releases, excluding the thumb, were performed on 20 fresh human cadaver hands (10 male, 10 female).

RESULTS

Complete release was obtained in 60 of 80 fingers. Success rates for each surgeon improved markedly as the study progressed. There were no significant differences between males and females regarding the distance between a standardized incision site and the proximal edge of the A1 pulley.

CONCLUSIONS

A learning curve exists for percutaneous A1 pulley release using the Biomet knife and technique. The extended distal palmar crease is a reasonable incision site for percutaneous release of the index, middle, and ring A1 pulleys in both men and women as the A1 pulley begins just distal to this surface landmark.

[References to avoid complications in releases of the trigger thumb: a cadaveric study]

OBJECTIVES

The aim of this cadaveric study was to demonstrate the utility of some visible landmarks in the hand in avoiding probable complications during percutaneous or open releases performed for the trigger thumb associated with flexor tendon tenosynovitis.

METHODS

In this cadaveric study, we dissected 20 thumbs of 10 fresh cadavers (10 males; mean age 46 years; range 31 to 62 years) from the interphalangeal to the metacarpophalangeal creases to expose all digital arteries, nerves, the flexor tendon, and the A1 pulley. The following distances were measured: from the proximal edge of the A1 pulley to the digital arteries and nerves, and to the interphalangeal and metacarpophalangeal creases of the thumb.

RESULTS

The proximal edge of the A1 pulley lies at a mean distance of 3.5 mm distal to the metacarpophalangeal crease, and about 35 mm distal to the interphalangeal crease. These values may be helpful during percutaneous releases in avoiding any injury to the radial digital nerve, which crosses the flexor tendon proximal to the A1 pulley. On the other hand, care should be taken for the ulnar digital nerve during open releases, which is at a higher risk than the radial digital nerve due to its closer proximity to the A1 pulley, the mean distances being 1.95 mm and 3.40 mm, respectively.

CONCLUSION

These data are helpful in avoiding injuries to the digital nerves, which imply that the digital nerve on the ulnar side of the A1 pulley is more vulnerable during open releases, while the radial digital nerve proximal to the metacarpophalangeal crease is more vulnerable during percutaneous attempts. Complications can be avoided if the interphalangeal and palmar creases are taken into consideration.

[A case of isolated tuberculous tenosynovitis of the flexor tendon of the third finger of the hand]

A 55-year-old female patient presented with a painless swelling in the palm of the right hand, causing restriction of the third finger. Magnetic resonance imaging revealed a synovial lesion in the flexor tendon sheath of the third finger, showing heterogenous contrast. Open biopsy and histopathological studies showed a granulomatous infectious reaction of the synovial tissue. A diagnosis of tuberculosis was made, after which antituberculosis treatment was instituted. Total regression was achieved after nine months of medical treatment without further extensive surgical measures. At the end of nine months, the movements of the finger were found to be normal and painless.

[Treatment algorithm in synovial tuberculosis of the hand and wrist: a report of three cases]

Three patients with synovial tuberculosis are presented. Involvement was in the hand in one patient, and in the wrist in two patients. None of the patients had pulmonary tuberculosis or a family history of tuberculosis. Tuberculosis treatment was initiated only after histologic verification. The cultures remained negative. The patients received a 12-month course of multidrug chemotherapy for tuberculosis, resulting in symptomatic improvement and healing. There were no recurrences during a follow-up period of 16 to 26 months. Our clinical observations showed that tuberculosis tenosynovitis benefited well from antituberculosis chemotherapy.

Tenosynovitis and osteoclast formation as the initial preclinical changes in a murine model of inflammatory arthritis

OBJECTIVE

To determine the nature of the initial changes of joint inflammation occurring before, at the time of, and shortly after onset of clinically apparent arthritis.

METHODS

Human tumor necrosis factor (TNF)-transgenic mice were assessed for clinical, histologic, immunophenotypic, serologic, and molecular changes at the preclinical phase of arthritis, at the onset of disease, and at the stage of early clinical disease. In addition, the effects of a genetic osteoclast deficiency and pharmacologic inhibition of TNF were studied in these initial phases of disease.

RESULTS

Initial articular changes were observed even before the start of clinical symptoms. Infiltration of the tendon sheaths by granulocytes and macrophages as well as formation of osteoclasts next to the inflamed tendon sheaths were the first pathologic events. Tenosynovitis rapidly led to remodeling of the sheaths into pannus-like tissue, which formed osteoclasts that invaded the adjacent mineralized cartilage. Early lesions were associated with up-regulation of interleukin-1 (IL-1) and IL-6 as well as activation of p38 MAPK and ERK. In contrast, absence of osteoclasts led to uncoupling of tenosynovitis from invasion into cartilage and bone. TNF blockade also attenuated the pathologic changes associated with tenosynovitis.

CONCLUSION

Structural damage begins even before the onset of clinical symptoms of arthritis and involves the tendon sheaths as well as adjacent cartilage and bone. These results suggest that tenosynovitis is an initiating feature of arthritis and that joint destruction starts right from the onset of disease. Our findings thus underscore the importance of immediate initiation of an effective therapy in patients with rheumatoid arthritis.

Ulnar wrist pain in athletes caused by erosion of the floor of the sixth dorsal compartment: a case series

BACKGROUND

Ulnar-side wrist pain can be disabling for athletes because of limitation of pronation-supination during sports such as tennis and golf. Erosion of the floor of the sixth dorsal space should be considered for unresponsive ulnar-side wrist pain.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Four athletes with severe unresponsive ulnar-side wrist pain were identified. Because the usual treatment regimens were ineffective in all cases, surgery was indicated to attempt mitigation of symptoms. During surgical exploration, all patients had inflammatory tendon changes and erosions in the floor of the sixth dorsal space, deep to the extensor carpi ulnaris. A soft tissue interposition flap fashioned from the roof of the sixth compartment was used to cover the defect.

RESULTS

Patients were evaluated by reexamination for range of motion, ability to perform daily and sports activities, strength, and residual pain. All patients had relief of their symptoms, had normal range of motion with no residual pain, and returned to tennis and golf. Strength improved a mean of 15 lb after surgery. The follow-up was 19 to 40 months (mean, 33 months).

CONCLUSION

Erosion of the sixth compartment floor has been given very little attention in the literature. It should be suspected when severe ulnar-side pain persists in athletes after the usual methods of treatment. The interposition surgery described herein has been effective in 4 cases previously unresponsive to the usual methods of treatment for chronic tendinitis of the extensor carpi ulnaris or triangular fibrocartilage rupture.

[Recurrences of carpal tunnel syndrome in long-term haemodialysis patients]

BACKGROUND

Multiple recurrences of carpal tunnel syndrome and increased malfunction of the hand caused by tendopathies and arthropathies occur in long-term (20 - 30 years) haemodialysis and are mainly influenced by beta2-microglobulin amyloidosis.

METHOD AND CLINICAL MATERIAL

18 patients undergoing haemodialysis for an average of 29 years had been operated on 96 times for bilateral CTS and recurrent CTS during a mean observation period of 12.6 years. In nine patients (12 hands), removal of the thickened flexor digitorum superficialis tendons III and IV had been performed. All but two patients suffered from amyloidosis, 17 of them suffered from additional tendo- and 13 from additional arthropathies. All procedures were performed under local anaesthesia, and in half of them a tourniquet was used. The outcome was evaluated both clinically and with nerve conduction studies.

RESULTS

77 procedures for CTS-recurrences were performed. The first recurrence was observed after an average of 6.1 years (SD 2.8), the second after 4.6 (SD 3.1) and the third after 3.8 (SD 1.9) years. Whereas in case of a first (occasionally second or extremely seldom in a third) recurrence, another re-opening of the carpal tunnel with or without synovectomy, was sufficient to improve symptoms in the majority of patients, this was occasionally the case with a second but rarely with the third recurrence. In these latter patients, only resection of thickened superficial flexor tendon bundles, showing marked amyloid-deposits histologically, resulted in improvement of pain, as well as finger mobility in one third of the patients. The distal motor latency of the median nerve recovered after the primary operation in 86 %, and after the second (first recurrence) only in 53 %. After the third operation (second recurrence), the results after tendon removal were better than in cases after synovectomy alone.

CONCLUSION

In long-term (more than 20 - 30 years) haemodialysis patients suffering from arthropathies, tendopathies and recurrent carpal tunnel syndrome, removal of the flexor digitorum superficial tendons should be considered for the second recurrence to improve pain and finger mobility.

Familial hypercholesterolaemia commonly presents with Achilles tenosynovitis

BACKGROUND

Patients with heterozygous familial hypercholesterolaemia (HeFH) develop tendon xanthomata (TX), most commonly in their Achilles tendons. Even before tendons are chronically enlarged, tenosynovitis may occur and medical advice be sought. Untreated HeFH carries a high risk of premature coronary heart disease, which can be ameliorated by early diagnosis.

OBJECTIVE

To determine the prevalence of episodes of Achilles tendon pain in HeFH before its diagnosis.

METHODS

Patients with definite HeFH (Simon Broome criteria) attending a lipid clinic were identified. They completed a questionnaire asking about symptoms relating to their Achilles tendons. Unaffected spouses or cohabiting partners served as controls.

RESULTS

133 patients (47% men) and 87 controls (51% men) participated. TX had been recognised by the referring physicians in <5% of cases. However, 62 (46.6% (95% confidence interval (CI) 38.1 to 55.1)) patients had experienced one or more episodes of pain in one or both Achilles tendons lasting >3 days, whereas only 6 (6.9% (1.6 to 12.2)) controls had done so (difference p<0.001; likelihood ratio 6.75). Typically, in the patients with HeFH the pain lasted 4 days (median). It was described as severe or very severe in 24/62 (38.7% (30.4 to 47.0)) patients with HeFH, but never more than moderate in controls. 35 (26.3% (18.8 to 33.8)) patients with HeFH had consulted a doctor about Achilles tendon pain, but in no case had this led to a diagnosis of HeFH. None of the controls had consulted a doctor.

CONCLUSIONS

Measurement of serum cholesterol in patients presenting with painful Achilles tendon could lead to early diagnosis of HeFH.

Anatomical variations of the extensor pollicis brevis tendon and abductor pollicis longus tendon--relation to tenosynovectomy

Sufficient improvement in De Quervain disease, is not always archieved even by tenosynovectomy, and the reason for this appears to be anatomical variation in the first extensor compartment of the hand. In this study we examined the first extensor compartment of 159 hands of 80 human cadavers. Hiranuma and colleagues documented four anatomical types of first compartment, and in this study type A was observed in 76 (47.8%) of the 159 hands, type B in 49 (30.8%), and type C in 21 (13.2%). No type D compartments in which the extensor pollicis brevis tendon is absent, were observed. There were 13 hands that did not fit any of Hiranuma's categories, and we classified them into three new types: E, F, and G. The numbers of extensor pollicis brevis tendons in the first compartment varied from one to three, and the number of abductor pollicis longus tendons varied from one to seven. Successful tenosynovectomy in the treatment of De Quervain disease requires to pay close attention to accessory tendons of the extensor pollicis brevis tendon and abductor pollicis longus tendon, branching of the tendons, and the presence of an atypical septum in the first compartment.

Molecular cytogenetic characterization of tenosynovial giant cell tumors

Tenosynovial giant cell tumor (TSGCT) is a disease of disputed etiology and pathogenesis. Some investigations indicate a neoplastic origin of the tumors; others indicate that they are polyclonal and inflammatory. The cytogenetic and molecular genetic features of TSGCTs are largely unknown, as only some 20 localized and 30 diffuse tumors with cytogenetic aberrations have been reported. The most common karyotypic aberrations have been trisomy for chromosomes 5 and 7 and translocations involving chromosomal area 1p11-13. We decided to screen the genomes of TSGCTs by comparative genomic hybridization (CGH) to perform interphase fluorescence in situ hybridization (IP-FISH), looking for numerical aberrations of chromosomes 1, 5, and 7, and to analyze the tumors for microsatellite instability. Except for two diffuse TSGCTs that came fresh to us, and which, by karyotyping, exhibited t(1;22)(p13;q12) and a t(1;1)(q21;p11) and +7, respectively, all studies had to be performed on formalin-fixed, paraffin-embedded material. DNA was extracted from 51 localized and nine diffuse TSGCTs. CGH was successful for 24 tumors, but none of them showed copy number changes. The IP-FISH studies showed trisomy 7 in 56% of the tumors (15/27), whereas chromosomes 1 and 5 seemed to be disomic in all TSGCTs. All informative tumors were wild-type by microsatellite instability analysis.