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CASE REPORT
Year : 2023 | Volume
: 12
| Issue : 1 | Page : 100-102
Flexor tenosynovitis of the wrist with carpal tunnel syndrome
Ravi Kumar, Maheshwar Lakkireddy, Deepak Maley, Srikanth Eppakayala, Sreedhar Sathu, Adinarayana Kashyap
Department of Orthopaedics, All India Institute of Medical Sciences, Hyderabad, Telangana, India
Correspondence Address:
Srikanth Eppakayala
Department of Orthopaedics, All India Institute of Medical Sciences, Bibinagar, Hyderabad, Telangana
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijmy.ijmy_201_22
Tubercular tenosynovitis of the wrist with carpal tunnel syndrome (CTS) is a rare occurrence. The authors present a case of tubercular flexor tenosynovitis of the wrist with CTS. A 60-year-old female presented with complaints of swelling in the volar aspect of the right wrist with numbness of the first three fingers for the past 6 months. Clinical and radiological diagnosis of chronic flexor tenosynovitis with median nerve compression neuropathy was made. The patient was operated with carpal tunnel release and total tenosynovectomy. Histopathology showed features suggestive of Koch's etiology. The patient was started with antitubercular therapy (ATT) and followed up regularly. Carpal tunnel symptoms subsided immediately after surgery and there was no recurrence of swelling at the last follow-up. Carpal tunnel release and tenosynovectomy should be performed at the earliest possible and followed up with ATT for better outcomes in tubercular tenosynovitis of the wrist with CTS.
Keywords: Carpal tunnel syndrome, extrapulmonary tuberculosis, tenosynovitis of wrist, tuberculosis of wrist
Tuberculosis (TB) is an endemic disease in India and contributes to more than 33% of the world's TB burden.[1] Extrapulmonary TB accounts for 15%–20% of all TB cases.[2] Musculoskeletal TB accounts for 1%–3% of all TB cases, and the wrist joint is rarely affected.[3] Due to the nonspecific symptoms and signs, tuberculous tenosynovitis of the wrist is frequently misdiagnosed or detected too late. The authors present a case of tubercular tenosynovitis of flexor tendons of the wrist with carpal tunnel syndrome (CTS) masquerading as a ganglion cyst preoperatively.
Case ReportA 60-year-old female patient presented to us with complaints of swelling in the volar and radial aspect of the right wrist with tingling sensation of the thumb, index, and middle fingers of the right hand for the past 6 months. The swelling was associated with pain and stiffness of the wrist. The patient did not give any history suggestive of diabetes mellitus, TB, or any other known comorbidities. The patient visited a private general surgeon 4 months ago where the swelling was diagnosed as a ganglion cyst and an excision of swelling was performed but it recurred within 2 to 3 weeks with aggravation of carpal tunnel symptoms.
On examination, there was a well-healed surgical scar of size 6 cm × 1 cm over the swelling on the volar and radial aspect of the right wrist. The swelling was oval in shape, mobile, nontender, noncompressible, and nonfluctuant. The skin over the swelling was pinchable. Her complete blood picture was within normal limits, erythrocyte sedimentation rate (ESR) was 32 mm/1sth, C-reactive protein was 12 mg/l, and rheumatoid factor and anti-cyclic citrullinated peptides antibodies were negative. Radiographs of the wrist showed a generalized decrease in bone density and a sclerotic lesion of 7 mm × 5 mm in size in the distal and posterior aspects of the radial metaphysis [Figure 1]. Ultrasonography of the wrist over the swelling showed diffuse thickening of the flexor retinaculum, multiple flexor tendon sheaths, and thickening of the perineurium of the median nerve at the carpal tunnel. Magnetic resonance imaging (MRI) of the wrist showed 8 mm × 7 mm × 7 mm T1 hypointense collection within the synovial sheath between the first and second flexor digitorum superficialis (FDS) tendons with diffuse thickening of the flexor retinaculum and multiple flexor tendon sheaths as described in ultrasonography [Figure 2]. The median nerve was compressed in the carpal tunnel, and the sclerotic bony lesion seen on the radiograph was reported as enchondroma on MRI. Both ultrasonography and MRI features were in favor of chronic flexor tenosynovitis with medial nerve compression neuropathy.
Figure 1: Anteroposterior and lateral view radiographs of the wrist showing generalized decrease in bone density, a sclerotic lesion in the distal radius, and soft-tissue swelling
Figure 2: Coronal and axial sections of magnetic resonance imaging of the wrist showing focal collection and thickening of the tenosynovium of flexor digitorum superficialis tendon to index finger compressing the median nerve(Red arrow)The patient was taken up for median nerve decompression with carpal tunnel release and excision biopsy of the tenosynovium. Intraoperatively, there was a spindle-shaped thickened synovial sheath completely engulfing the FDS tendon to the index finger and compressing the median nerve [Figure 3]. The thickened synovium was excised completely and FDS tendon to the index finger and median nerve were released [Figure 4]. Excised tissue was subjected to histopathology, and microbiological investigations such as Gram stain, aerobic bacterial culture and sensitivity, Ziehl–Neelsen acid-fast staining, fungal culture, and tissue were subjected to polymerase chain reaction for TB (TB PCR). Histopathology showed epithelioid granuloma with multinucleate giant cells, synovial tissue with hyalinization, and fibrosis suggestive of granulomatous tenosynovitis. Likely, Koch's etiology was opined. All the microbiological investigations including PCR for TB were negative.
Figure 3: Intraoperative picture showing spindle-shaped thickened synovium involving the flexor digitorum superficialis tendon to index finger(lower blue arrow) adjacent to median nerve(upper blue arrow)The patient was started with four drugs antitubercular therapy (ATT) based on weight and followed up regularly. Carpal tunnel symptoms subsided immediately after surgery and there was no recurrence of swelling or carpal tunnel symptoms at the last follow-up (10 months till date). Pain and stiffness in the wrist have subsided significantly.
Figure 4: Picture showing engulfed tendon (above) and freed tendon (below) Discussion At times, diagnosis of the tubercular tenosynovitis of the wrist causing CTS is challenging as it mimics more common conditions around the wrist such as ganglion, rheumatoid arthritis, nonspecific tenosynovitis, and gouty synovitis.[4],[5] Tubercular tenosynovitis is associated with several risk factors, such as elderly age, male gender, low socioeconomic status, poor nutrition, history of exposure to TB, immunocompromise, residence in a TB endemic area, and corticosteroid infiltration.[6] Diagnosis is usually delayed by 16–19 months from the onset of CTS.[7] Our patient had few of the described risk factors such as old age, low socioeconomic status, poor nutrition, and living in an endemic region. In countries like India where TB is endemic, tubercular tenosynovitis should be suspected in all patients presenting with chronic wrist pain and nonspecific swelling.
Routine laboratory investigations such as complete blood picture, ESR, C-reactive protein, and Mantoux test are not specific tests for tubercular tenosynovitis and can be normal in these cases. Radiography of the involved region may be normal. High-resolution ultrasonography and MRI helps to know the amount of synovial thickening, pus, or fluid collection and the extent of the lesion. TBPCR has a low sensitivity rate of 62.5% and a false positivity rate of 23.07% in nonspinal musculoskeletal TB and was attributed it to the paucibacillary state of extrapulmonary tubercular lesions and the dilution of tubercle bacilli in synovial fluid and synovial tissues.[8] For similar reasons, culture is positive in only 10% to 30% of cases in Indian studies.[9] Histopathology remains the gold standard investigation to establish the diagnosis. Histopathology of synovial tissue reveals granulomatous lesions with central caseation surrounded by multiple giant cells and epithelioid cells. However, approximately 27% of the cases show noncaseous granulomas and 12% of cases do not show any granulomas.[10] In our case, histopathology showed epithelioid granuloma with multinucleate giant cells and synovial tissue with hyalinization and fibrosis but there was no evidence of caseating granulomas.
“Rice bodies” or “Melon seed bodies” found inside the synovial sheaths of infected tendons are composed of amorphous material surrounded by collagen and fibrin. The “Rice bodies” may be “characteristic” but not “pathognomonic” of tubercular tenosynovitis and are seen in some other conditions such as rheumatoid arthritis, systemic lupus erythematosus, seronegative arthritis, and nonspecific arthritis.[11] “Rice bodies” or “Melon seed bodies” are present in approximately 50% of the diagnosed tubercular tenosynovitis cases and in our case, we could not find rice bodies intraoperatively.[12]
When there are no signs or symptoms of CTS, tubercular tenosynovitis can be treated with ATT alone without the need for surgery.[4] It is already known that diagnosis of tubercular tenosynovitis is delayed on average of 16–19 months from the onset of carpal tunnel symptoms, so total tenosynovectomy and carpal tunnel decompression are recommended at the earliest possible for the best recovery of median nerve and symptoms of CTS.[7]
ConclusionHigh index of suspicion is required for the diagnosis of tubercular tenosynovitis of the wrist as radiological, histopathological, and microbiological studies are not always positive. When the condition is associated with CTS, carpal tunnel release and total tenosynovectomy should be performed at the earliest possible and followed up with ATT for a better outcome.
Limitation of study
Follow-up is 10 months which is relatively short. Longer follow-ups would be needed to comment on the complete resolution of the disease and no recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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