A typically atypical tenosynovitis

Abstract

A 68-year-old woman developed tenosynovitis of the right second digit without a history of injury or animal bites. Apart from high titer anti-nuclear antibodies, serological studies were unremarkable. Tuberculin test and interferon gamma release assay were both negative. Several immunosuppressive therapies led only to partial relief of symptoms. Of note, clinical symptoms worsened significantly after introduction of adalimumab therapy. Tenosynovectomy was performed revealing a granulomatous inflammatory process. Seven weeks later, Mycobacterium malmoense could be cultured from the surgical specimen. A four drug antibiotic regimen was started and immunosuppressive therapy discontinued resulting in complete clinical remission. Our case highlights non-tuberculous mycobacterial (NTM) tenosynovitis as an important differential diagnosis of atypical arthritis. A negative tuberculin skin test as well as negative Ziehl-Neelsen stain does not argue against NTM infection. In fact, mycobacterial culture for extended periods remains the gold standard for diagnosis.

Tenosynovitis caused by Mycobacterium malmoense in two kidney transplant recipients and review of the literature

“…Besides our two cases, nine previous cases of M. malmoense tenosynovitis have been reported in literature (Table ) . Infections were reported in immunocompetent as well as in immunocompromised patients, and six cases had no history of previous trauma.…”

“…Clinical suspicion is essential for diagnosis of an NTM infection, as histological and microbiological examinations require specific handling, which is not routinely performed . Owing to lack of clinical suspicion, diagnosis is often delayed, as was also the case in both our patients, resulting in significant morbidity . Moreover, a negative history of trauma, surgical procedure, or corticosteroid injection should not distract from the possibility of an NTM infection, as demonstrated in Table .…”

“…9 Besides our two cases, nine previous cases of M. malmoense tenosynovitis have been reported in literature (Table 1). [10][11][12][13][14][15][16][17][18] Infections were reported in immunocompetent as well as in immunocompromised patients, and six cases had no history of previous trauma. Eight cases were treated with a combination of surgical debridement and variable antibiotic regimens (Table 1).…”

“…2 Owing to lack of clinical suspicion, diagnosis is often delayed, as was also the case in both our patients, resulting in significant morbidity. [10][11][12][13][14][15][16][17][18] Moreover, a negative history of trauma, surgical procedure, or corticosteroid injection should not distract from the possibility of an NTM infection, as demonstrated in No consensus exists about the optimal therapy for NTM tenosynovitis. Based on current knowledge, surgical debridement in combination with an adequate antibiotic regimen seems to be the best treatment.…”

Tenosynovitis with Rice Body Formation Due to Mycobacterium Intracellulare Infection After Initiation of Infliximab Therapy

“…The risk of infectious tenosynovitis is increased among patients with RA, mixed connective tissue disorders, diabetes mellitus, solid organ transplants, steroid medication, cancer, previous trauma, surgical procedure, and non-apparent inoculation (e.g., water contamination) [ 9 , 10 ]. To the best of our knowledge, only 4 reports/7 cases of infectious tenosynovitis after the initiation of TNFi have been described [ 11 – 14 ] ( Table 1 ).…”