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Case Number 23: Tuberculous tenosynovitis
  1. U A Walker,
  2. J Gutfleisch,
  3. H H Peter
  1. Albert-Ludwigs University Medical School, Department of Rheumatology and Clinical Immunology, Freiburg, Germany
  1. Correspondence to:
    Dr U A Walker, Albert-Ludwigs University Medical School, Department of Rheumatology and Clinical Immunology, Hugstetterstr 55, D-79106 Freiburg, Germany;
    walkerul{at}uni-freiburg.de

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A 58 year old woman presented with a several month history of painful swelling of the second and fifth fingers of her left hand (fig 1). The flexor tendon sheath of the index finger had been excised six months before. Median nerve entrapment led to surgical release of the transverse carpal ligament three months ago. In both instances histopathological examination disclosed necrotising granulomas with Langerhans'cells. The swelling progressed to affect the subcutis of the forearm and the fascia of the superficial and deep flexor muscles. Diagnosis was delayed until there was spontaneous perforation of the index finger and Mycobacterium tuberculosis was cultured. The patient had had pulmonary tuberculosis at the age of 16 years, but there were no other signs of current reactivation. She improved rapidly with tuberculostatic treatment.

Even before the era of effective antituberculous chemotherapy, tuberculous tenosynovitis was a rare condition. Nevertheless, tuberculosis was reported to be the most common cause of chronic infections of the tendon sheaths of the hand.1,2 For the past 30 years, reports of the disease have been rare. Almost any long tendon may be affected, but the wrist is the most common site.3 It has been suggested that trauma and increased use may foster this form of secondary tuberculosis.3 This is based on the observation that the tendons on the right side of the body were affected twice as often as were those on the left.3

Because granulomatous inflammation alone may also occur with foreign bodies, sarcoidosis, or other infectious agents (non-tuberculous mycobacteria, fungi), the definite diagnosis has to rely on culture or on polymerase chain reaction based assays, but stains for acid-fast bacilli are helpful in obtaining a provisional diagnosis.

Because about one half of patients are cured by complete surgical extirpation, an operative approach was suggested as the best treatment.3 There are no data, however, to suggest that additional antituberculous combination treatment according to the current guidelines should be withheld.

REFERENCES

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Footnotes

  • Series editor: Gary D Wright

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