Successfully treating hand primary tuberculous synovitis by synovectomy combined antituberculous therapy

Abstract

Rationale:Primary tuberculous infection in hand and wrist is a rare disease. Few articles reported on hand primary tuberculous synovitis.Patient concerns:A 68-year-old Chinese male, without history of tuberculosis (TB), had complained of pain and swelling in right palm and little finger for 3 months. Patient came to our hospital on 9th Oct 2016. X-ray just showed soft tissue swelling in little finger. Magnetic resonance imaging (MRI) showed synovitis around flexor tendon of little finger, volar palm, and carpal tunnel. Notably, it also implied nodular images in little finger sizing 5 mm × 11 mm. Laboratory tests revealed C-reactive protein (CRP): 22 mg/L, erythrocyte sedimentation rate (ESR): 49 mm/h, and white blood cells (WBC): 11.8 × 109/L.Diagnoses:He was diagnosed with primary hand tuberculous synovitis.Interventions:The patient received aspiration biopsy in right palm guided by ultrasound on 13rd Oct and pathological examination indicated Mycobacterium tuberculosis (MTB) infection. We performed radical synovetomy and collected abnormal tissue for pathological examination on 18th Oct. Finally, result showed MTB infection, which was the same with the result of first pathological examination. Then, this patient received antituberculous treatment.Outcomes:One year after operation, pain and swelling relieve and no recurrence of the clinical symptoms happened.Lessons:Primary tuberculous synovitis of hand and wrist is rare, MTB infection should be considered as an infectious agent, especially in developing countries. Radical synovectomy and antituberculous treatment regain a satisfactory outcome.

A rare presentation of tuberculosis

“…There were studies comparing anti-tuberculin drugs versus surgery combined with anti-tuberculin medication; in which both methods were found to be equally effective [1]. In our case, we did a radical synovectomy followed by antituber-culous medication.…”

“…However, the ESR level can be high in other causes of monoarthritis. X-ray findings of swelling in the soft tissues and sometimes periarticular osteoporosis were also seen in tuberculous joint involvement [1,4]. Synovitis due to tuberculosis is seen in Magnetic Resonance Imaging as thickening of the adjacent tendons, osteomyelitis, joint effusions erosions into bones and nerve entrapment [2].…”

“…The surgical and histopathological findings were also suggestive of a tuberculous disease. A high ESR value is seen in most cases of tuberculous synovitis [1,3]. However, the ESR level can be high in other causes of monoarthritis.…”

“…The disease burden of tuberculosis in developing countries is catastrophic. Among patients with tuberculosis, less than 1% was reported to have lesions on hand [1].…”

Ultrasound Findings in Less Frequent Causes of Carpal Tunnel Syndrome

“…Tuberculous infection of the hand is rare and accounts for less than 1% of extrapulmonary involvement. 40 The tenosynovium is the most common location for upper extremity infections 41 and can lead to CTS if the tuberculous tenosynovitis involves the FDTs in the CT. 5,42 Although MR imaging has been the primary imaging modality used to diagnose tenosynovitis of the upper extremity due to tuberculous tenosynovitis, 5,[43][44][45] US can also assess for the presence of tenosynovitis and can guide needle aspiration biopsy for presurgical diagnosis and treatment optimization. 43 The US appearance of Mycobacterium tenosynovitis is nonspecific ( Figure 6) and shows extensive thickening of the FDT sheaths associated with fluid and hypervascular changes.…”