|Year : 2020 | Volume
| Issue : 2 | Page : 167-171
Tuberculous involvement of multiple flexor and extensor tendon sheaths of hand and wrist
Ashwani Jain1, Ayushi Chhabra1, Ankur Malhotra1, Deepti Arora2, Sarika Goel1, Satish Pathak1
1 Department of Radiodiagnosis, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
2 Department of Pathology, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
|Date of Submission||27-May-2020|
|Date of Decision||27-Jun-2020|
|Date of Acceptance||22-Jul-2020|
|Date of Web Publication||19-Aug-2020|
Department of Radiodiagnosis, Teerthanker Mahaveer Medical College and Research Centre, Moradabad - 244 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Tuberculosis (TB) continues to be a major health burden in developing countries. It can be pulmonary or extrapulmonary, but involvement of tendon sheaths is extremely uncommon. Due to nonspecific clinical features and wide differentials, diagnosis is often delayed. Here, we report one such rare case, where a male patient presented with multiple, painless swellings over the wrist and hand and posed a diagnostic challenge on radiological investigations (ultrasonography and magnetic resonance imaging). The final diagnosis of TB tenosynovitis was confirmed only on histopathological examination. Tubercular tenosynovitis of hand is a rare entity, which mimics a variety of clinical conditions, often leading to delay in diagnosis and appropriate timely treatment. Thorough clinico-radiological and pathological examinations are thus necessary to diagnose this condition.
Keywords: Hand, magnetic resonance imaging, tendon, tenosynovitis, tuberculosis, wrist
|How to cite this article:|
Jain A, Chhabra A, Malhotra A, Arora D, Goel S, Pathak S. Tuberculous involvement of multiple flexor and extensor tendon sheaths of hand and wrist. Saudi J Health Sci 2020;9:167-71
|How to cite this URL:|
Jain A, Chhabra A, Malhotra A, Arora D, Goel S, Pathak S. Tuberculous involvement of multiple flexor and extensor tendon sheaths of hand and wrist. Saudi J Health Sci [serial online] 2020 [cited 2020 Sep 27];9:167-71. Available from: http://www.saudijhealthsci.org/text.asp?2020/9/2/167/292641
| Introduction|| |
Tuberculosis (TB) is one of the highly prevalent diseases in India. Pulmonary involvement is far more common than extrapulmonary TB. Tuberculous involvement of the musculoskeletal system is quite uncommon (~10%). Even in the musculoskeletal system, the TB has affliction for axial skeleton (spine), and the involvement of wrist/hand is the rarest.,
Tenosynovitis is quite a common cause of wrist pain, but owing to the varied etiologies, attaining an exact diagnosis is always a challenge for clinicians. Mycobacterium TB (MTB) is one of the infectious causes of tenosynovitis and always poses a diagnostic dilemma due to nonspecific presentation and misleading features, which may simulate a number of other diseases such as pigmented villonodular synovitis (PVNS), hemophilia, gout, and synovial tumors.,
We report one such case of tubercular tenosynovitis of the left hand and wrist in a 65-year-old male patient. The aim of this report is to highlight the significance of radiological and pathological investigations in such cases where onset of the symptoms is insidious and presentation is often nonspecific, making clinical diagnosis difficult and thereby delaying the treatment, which poses an increased risk of serious complications.,
| Case Report|| |
A 65-year-old male patient, a farmer by occupation, presented to the routine outpatient department with the complaint of multiple swellings over the left hand and wrist for 1 year. The swellings were painless, were gradually progressive in nature, and were increasing in size. There was no past history of any trauma, pulmonary TB, diabetes mellitus, or hypertension.
On physical examination, the multiple swellings were noted involving both the volar and dorsal aspects of the wrist and hand [Figure 1]. The swellings were nontender and nonmobile, and there was mild reduction of range of movement at the wrist joint.
|Figure 1: Clinical photograph showing a swelling along the proximal aspect of the dorsum of the left hand (arrow in a) and a similar swelling along the mid part of the volar aspect (arrow in b)|
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Laboratory investigations were within normal limits only except erythrocyte sedimentation rate, which had marginally increased (21 mm/h, normal range: 0–20 mm/h).
The patient was referred to the radiology department for ultrasonography (USG) of the left wrist and hand. On USG, all the lesions were seen to have their origin from the synovial sheath of the tendons of the flexor and extensor muscles of the wrist and hand. The lesions were smooth, were well defined, and showed variable internal consistency and minimal internal vascularity. The largest size lesion along the palmar aspect showed purely cystic consistency with densely moving internal echoes [Figure 2]. The lesions along the dorsum of the hand showed solid area of frond-like synovial proliferation, completely encasing the underlying tendon, which otherwise appeared intact [Figure 3].
|Figure 2: Ultrasonography of the volar aspect of the left hand showing a smooth, well-defined, purely cystic lesion with dense internal echoes surrounding the flexor tendon (arrow) with a thickened synovium|
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|Figure 3: Ultrasonography of the dorsum of the left wrist and hand showing multiple solid areas of frond-like nodular synovial proliferation (straight arrow in a) completely encasing the underlying tendon which otherwise appears intact (curved arrow in b)|
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The patient was further evaluated on magnetic resonance imaging (MRI) for better characterization of the lesions. The lesions appeared isointense to muscle on T1-weighted image (WI) T1WI, hyperintense on T2WI, and very hyperintense on short TAU inversion recovery/fat-saturation sequences with internal dot-like hypointensities and showed minimal postcontrast peripheral enhancement [Figure 4]. Diffusion-weighted sequence revealed facilitated diffusion with T2 shine through effect on apparent diffusion coefficient. No blooming was seen on gradient echo (GRE) images [Figure 5]. The lesion in the dorsum of the hand measured approximately 3.4 cm × 1.6 cm and involved the tendon sheaths of extensor digitorum (3rd and 4th tendon slips), extending from the level of the carpometacarpal joint up to the proximal half of the metacarpal with overlying subcutaneous edema. The lesions along the flexor aspect appeared dumbbell shaped extending from the level of the distal radio-ulnar joint, crossing the carpal tunnel and reaching the volar aspect of the hand. At the level of the wrist, two separate lesions were seen involving the flexor digitorum profundus tendon of the 2nd digit and the 3rd to 5th digits measuring approximately 1.9 cm × 1.7 cm and 2.1 cm × 1.6 cm, respectively. Within the carpal tunnel, the lesions caused radial displacement of the median nerve without any flattening. In the hand just distal to the carpal tunnel, a small lesion (approx. size 11 cm × 8 mm) was identified arising from the sheath of the flexor pollicis longus tendon. Another lesion measuring approximately 3.1 cm × 3 cm was also seen arising from the sheath of the flexor digitorum superficialis tendon of the 4th and 5th digits, which extended from the level just distal to the carpal tunnel up to the distal half of the metacarpals. The fluid was seen distending the common flexor tendon sheath of the 2nd digit. Based on the findings of USG and MRI, a provisional diagnosis of chronic tenosynovitis was kept.
|Figure 4: (a) Axial T1-weighted magnetic resonance images of the left wrist at the level of the distal radio-ulnar joint showing two separate well-defined isointense lesions involving the flexor digitorum profundus tendon sheath of the 2nd digit (long arrow) and the 3rd to 5th digits (short arrow). (b-d) Axial T2 short ti inversion recovery magnetic resonance images of the left hand at the level of carpal tunnel (b), just distal to the tunnel (c) and farther from the tunnel (d) showing hyperintense lesions along the sheath of flexor pollicus longus tendon (thick arrow) and flexor digitorum superficialis tendon of the 4th and 5th digits (thin arrow). Along the dorsum, a similar hyperintense lesion with internal dot-like hypointensities representing synovial proliferation can be seen along the sheaths of extensor digitorum tendon involving the 3rd and 4th tendon slips (striped arrow)|
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|Figure 5: (a and b) Axial diffusion-weighted images and apparent diffusion coefficient of the left hand showing facilitated diffusion with T2 shine in both flexor (thick arrow) and extensor (thin arrow) lesions. (c) Sagittal oblique gradient echo images of the wrist and hand at the level of the radio-lunate joint (striped arrow) showing no evidence of any blooming in the palmar and dorsal lesions. (d) Coronal TI postcontrast image revealing faint peripheral enhancement in the dumbbell-shaped lesion (arrow) along the flexor tendon in the wrist extending across the carpal tunnel into the volar aspect of the left hand|
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Intraoperatively, multiple, ganglion-like lesions were identified along the flexor and extensor tendons. On puncturing, a cheesy material was aspirated. On histopathological examination, multiple synovial tissue bits showed numerous well-formed, epithelioid cell granulomas; Langhans giant cells along with scattered epithelioid cells with areas of fibrin clot and necrosis admixed with chronic inflammatory infiltrate; and congested blood vessels suggestive of tubercular synovitis [Figure 6].
|Figure 6: Photomicrograph showing well-formed epithelioid cell granuloma and Langhans giant cell along with chronic inflammatory infiltrate|
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| Discussion|| |
Joint, bone, muscle, tendon sheath, and synovial bursa involvement or a combination of these may be seen in cases of extra-axial musculoskeletal TB. MTB is the most common infective agent. It is known to involve the synovium and tendon sheaths more often than the bones and joints. The wrist and volar aspects of the hand are the selective targets in tuberculous tenosynovitis, where it accounts for 5% of cases of osteoarticular TB. Radioulnar bursae and flexor tendon sheath are the most common sites of involvement. It is also known to affect the digital flexor sheaths and the dorsal wrist compartment, although less often.
The tubercular infection of the tendon sheaths could be a result of direct inoculation from the adjacent bone or joint infection or seeding from a tuberculous lesion elsewhere in the body such as pleuro-pulmonary or genito-urinary system. Trauma, joint overuse, old age, low socioeconomic status, malnutrition, and immune-compromised state of the individual are the precipitating factors. The mechanism in our case may be direct inoculation as there is no history of any pulmonary TB.
Clinical presentation in TB tenosynovitis may differ depending on the duration of illness, the varying cell-mediated immunity of the patient, and variable virulence of the causative agent. Patients with tubercular tenosynovitis mostly present with an insidious-onset, slow-growing, sausage-like swelling along the involved tendon sheaths associated with local pain that worsens with movement of the fingers. Our patient also had a very long duration of illness and presented with multiple, slow-growing swellings, although painless but with associated restriction of movement at the wrist.
Pathologically, in the early stages, there is vascular granulation tissue formation followed by obliteration of tendon sheath by fibrous tissue fluid accumulation and formation of rice bodies or sago seeds (which are fibrinous masses or tubercle, made by caseation). In the final stage, there occur rupture of tendon sheath, extensive caseation, and granulation.
Patel et al. have described three disease patterns in tendon sheath involvement, which include (a) distension of tendon sheath with normal-appearing tendon within due to accumulation of the synovial fluid; (b) synovial thickening with tendon involvement; and (c) peritendinous soft-tissue masses.
Plain radiographs may show soft-tissue radio-opacity and osteoporotic changes around the wrist. USG may be undertaken to describe the extent of involvement of the tendon and tendon sheath. In acute suppurative tenosynovitis, synovial sheath effusion is the main feature, whereas in chronic tenosynovitis, thickening of tendon and synovium is predominantly noted with relatively little synovial sheath effusion.
MRI is the preferred modality for evaluating the extent of disease involving the soft tissue and any adjacent osseous or joint. Three stages have been described on MRI: hygromatous, sero-fibrinous, and fungoid stages. The hygromatous stage distinctively shows the presence of fluid inside the tendon sheath without associated sheath thickening. The sero-fibrinous stage characteristically causes flexor tendon and synovial thickening, with numerous tiny hypointense nodules within the hyperintense synovial fluid on T2WIs. These tiny nodules represent the rice bodies. The fungoid stage characteristically presents as a soft-tissue mass involving the tendon and tendon sheath.,
The common differentials of tubercular tenosynovitis include PVNS, hemophilia, gouty arthritis, and synovial tumors.,, PVNS of the tendon sheath which is also known as giant cell tumor of tendon sheath presents on USG with joint effusion and nodular synovial thickening with hypervascularity. The key differentiating feature on MRI is the presence of enhancing villous or nodular proliferation of the synovium with low signal intensity areas of blooming within, seen on GRE images due to hemosiderin deposition. In hemophilic arthropathy, USG findings include joint effusions, synovitis, and hemarthrosis. MRI assesses early soft-tissue findings, bony changes, and cartilage damage. Intra-articular hemosiderin results in blooming artifacts on GRE images. However, no postcontrast enhancement is seen. The absence of blooming on GRE helped us rule out both of these conditions in this patient.
The characteristic radiographic findings in gout include dense nodular soft-tissue masses; bony proliferation; and well-defined, punched-out bony erosions with sclerotic margins and overhanging edges (rat bite erosions), which were missing in the present case. On MRI, joint effusion and para-articular edema may be seen. The pathognomonic tophaceous deposits in soft tissues are seen as low-to-intermediate signal intensity on T1WIs and low-to-high signal intensity on T2WIs depending on the amount of hydration of the tophi.
The synovial proliferation in tubercular tenosynovitis (like in our case) may mimic other synovial lesions such as synovial chondromatosis and synovial sarcoma. Synovial chondromatosis is typically characterized by synovial metaplasia and proliferation, resulting in multiple, uniform-sized cartilaginous loose bodies, which eventually calcify/ossify. On MRI, unmineralized nodules demonstrate chondroid signal intensity (intermediate to low signal on T1WIs and high signal on T2WIs), whereas calcified nodules appear as focal areas of signal void (on GRE).,, A slow-growing, soft-tissue lesion in the juxta-articular location with areas of dystrophic calcification is highly suggestive of synovial sarcoma. USG reveals a nonspecific heterogeneous hypoechoic vascular mass. An MRI finding which favors the diagnosis of synovial sarcoma includes a large, ill-defined heterogeneous lesion with internal necrosis, bleed, and dystrophic calcifications with marked postcontrast enhancement. At times, direct invasion of the underlying bone may also be seen (~30% of cases).,
The diagnosis of tuberculous tenosynovitis is made by histological examination and culture of the infected material. Nucleic acid amplification tests such as Xpert MTB/RIF test allow rapid identification of the amplified specific RNA or DNA sequence via a nucleic acid molecule within 24–48 h. Another advantage is the ability to detect rifampicin resistance of the organism.
Anti-TB drugs are the mainstay treatment of TB. Surgical treatment may be useful in sero-fibrinous and fungoid stages to provide symptomatic relief. In the present case, surgical debridement was done for symptomatic relief and anti-tuberculous drugs were instigated.
| Conclusion|| |
TB is a rare cause of chronic inflammatory swelling of the hand, but it should be considered in the list of differentials, irrespective of how indolent a mass appears, especially in developing countries. Due to slow progression of the disease and numerous differentials, delayed diagnosis is common which may lead to dreaded complications. Careful clinical evaluation and radio-pathological examinations are key to early diagnosis of tuberculous tenosynovitis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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