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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 99-101

Pseudotumoral form of soft-tissue tuberculosis of the wrist


1 Orthopedic Surgery and Trauma Department, Maamouri Hospital, Nabeul, Tunisia
2 Emergency Department, Mongi Slim Hospital, Tunis, Tunisia

Date of Web Publication8-Feb-2017

Correspondence Address:
Mohamed Ali Sbai
Orthopedic Surgery and Trauma Department, Maamouri Hospital, 8000, Nabeul
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.1016/j.ijmyco.2015.08.001

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  Abstract 


Tuberculosis is a major public health problem in developing countries. Hand and wrist is a rare localization for extra-pulmonary tuberculosis, a pseudotumoral form of soft tissue tuberculosis of the wrist is exceptional.
We report the case of a 45-year-old male presenting with a painful swelling of the dorsal aspect of the right wrist evolving for six months. Clinical study was evoking a ganglion cyst of the wrist. Intraoperatively a pseudotumoral mass with rice bodies was found, suggesting tuberculous tenosynovitis. The histopathological study revealed caseating giant cell granulomas with epithelioid cells. Cultures on Löwenstein–Jensen medium detected Mycobacterium tuberculosis.
Synovectomy with removal of all the rice bodies followed by anti-tuberculous chemotherapy provided uneventful recovery.

Keywords: Tuberculosis, Mycobacterium tuberculosis, Pseudotumoral form, Tenosynovitis, Rice bodies, Wrist


How to cite this article:
Sbai MA, Benzarti S, Msek H, Boussen M, Khorbi A. Pseudotumoral form of soft-tissue tuberculosis of the wrist. Int J Mycobacteriol 2016;5:99-101

How to cite this URL:
Sbai MA, Benzarti S, Msek H, Boussen M, Khorbi A. Pseudotumoral form of soft-tissue tuberculosis of the wrist. Int J Mycobacteriol [serial online] 2016 [cited 2021 Dec 3];5:99-101. Available from: https://www.ijmyco.org/text.asp?2016/5/1/99/199751




  Case report Top


We report the case of a 45-year-old male without any significant pathological history presenting with a painful swelling of the dorsal aspect of the right wrist evolving for 6 months with no local inflammatory signs. The patient did not complain about other joints. There was no history of fever, weight loss, loss of appetite, trauma, or septic inoculation, and the patient was not immunodeficient. Clinical study revealed a dorsal swelling of soft consistency of the right wrist, which was movable, painless, and without local inflammatory signs. The mass was approximately 4 cm 5 cm and the wrist range of motion was slightly affected, evoking a ganglion cyst of the wrist([Figure 1]).
Figure 1: Clinical appearance evoking a ganglion cyst of the wrist.

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The rest of the pleuropulmonary and musculoskeletal examination was without abnormalities. Plain radiographs of the wrist showed a thickening of the soft tissues of the dorsal aspect of the wrist. Analytical study showed elevated erythrocyte sedimentation rate (ESR=50) and a normal white blood cell count.

Under the impression of a ganglion cyst, an excision was planned. We intra-operatively discovered a well-circumscribed, encapsulated mass attached to the deep layers([Figure 2]) with the presence of extensor tenosynovitis and multiple rice bodies([Figure 3]). The patient underwent marginal excision of the mass, synovectomy, and removal of all the rice bodies, some of which were attached to the wall of the mass.
Figure 2: Intraoperative view showing the pseudotumoral mass attached to the deep layers.

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Figure 3: Intraoperative view showing the rice bodies, suggesting tuberculous tenosynovitis.

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Histopathological study revealed caseating giant-cell granulomas with epithelioid cells, confirming the diagnosis of tuberculosis. Cultures on Löwenstein–Jensen medium detected Mycobacterium tuberculosis. Antituberculous chemotherapy included isoniazid (INH), rifampicin (RIF), pyrazinamide (PZA), and ethambutol (EMB) for 2 months, followed by INH and RIF for the next 6 months.

The patient uneventfully recovered postoperatively and regained full and painless range of motion with disappearance of the swelling in about 2 months([Figure 4]). At the 2-year follow up, no recurrence was detected.
Figure 4: (A) Uneventful recovery with full and painless range of motion and (B) disappearance of the swelling 2 months postoperatively.

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  Discussion Top


Although lymph node masses are common in tuberculosis (TB), parenchymal masses are rare and usually located in digestive organs [1]. This type of TB raises clinical and radiological diagnostic issues, leading to frequent misdiagnosis and improper treatment. TB of the hand and wrist is usually classified according to the type of tissue involved: cutaneous TB, tuberculous tenosynovitis, bursitis, osteomyelitis, arthritis, and tuberculous hypersensitivity reactions [2]. Tenosynovial involvement is the most common presentation of TB of the hand and wrist. Painful swelling and limitation of movement are the classic symptoms. Tenosynovitis has a gradual onset and is slowly progressive. Tuberculous tenosynovitis has several classic presentations: the compound palmar ganglion, the “sausage digit”, and carpal tunnel syndrome. Other uncommon manifestations of tuberculous tenosynovitis are extremely rare [2]. Despite the tissular reaction that the synovial girdle creates, representing a real barrier, articular infringement following tenosynovitis remains possible after several years of development [3].

The pseudotumoral presentation of TB of the hand and wrist is rare, with only one case on the volar aspect of the wrist reported in the literature [4]. This form of TB occurring in the hand and wrist is difficult to diagnose due to the absence of specific symptoms and presentation that is highly suggestive of a ganglion cyst. Ultrasonography and magnetic resonance imaging (MRI) are of great help in diagnosing this particular form of TB.

Extrapulmonary tuberculosis usually results from reactivation of primary foci and secondary hematogenous spread. In the musculoskeletal system, organisms are ingested by mononuclear cells that merge into epithelioid cells. A tubercle is formed when lymphocytes form a ring around a group of epithelioid cells, followed by caseation within the center of the tubercle [5].

Rice bodies are common in many rheumatic diseases, such as rheumatoid arthritis or systemic lupus erythematosus, but they can also be observed in cases of TB and tuberculous tenosynovitis. Rice bodies of tubercular origin were first described in 1895 [6]. Macroscopically, they appear similar to the rice bodies that arise in rheumatoid arthritis. On microscopic analysis, they are composed of fibrous tissue. According to Woon et al. [7], finding rice bodies or melon seeds is highly suggestive of tuberculous tenosynovitis. They should be removed, as their presence stimulates synovial proliferation and promotes recurrences.

The treatment of TB of the hand and wrist is primarily medical and based on antituberculous chemotherapy. Various short- and long-term chemotherapy protocols have been proposed with different combinations of INH, RIF, EMB, and PZA [8].

TB of the wrist can take several aspects usually dominated by carpal TB and tenosynovitis. The pseudotumoral form of the soft tissues of the wrist mimicking a ganglion cyst is exceptional, but should be suggestive of TB. Laboratory tests, ultrasound, and MRI are useful tools to guide diagnosis, with confirmation provided by histological study and treatment based on antituberculous chemotherapy.

Conflicts of interest

The authors declare no conflicts of interest.



 
  References Top

1.
R. Agarwal, R. Srinivas, A.N. Aggarwal, Parenchymal pseudotumoral tuberculosis: case series and systematic review of literature, Respir. Med. 102 (2008) 382–389.  Back to cited text no. 1
    
2.
M.M. Al-Qattan, A. Al-Namla, A. Al-Thunayan, et al, Tuberculosis of the hand, J. Hand Surg. Am. 36 (2011) 1413– 1422.   Back to cited text no. 2
    
3.
M.A. Sbai, S. Benzarti, K. Bouzaidi, et al, A rare localization of tuberculosis of the wrist: the scapholunate joint, Int. J. Mycobacteriol. 4 (2015) 161–164.  Back to cited text no. 3
    
4.
K.C. Wu, H.M. Tang, K.T. Yeh, et al, Extrapulmonary tuberculosis in the wrist presenting as a ganglion cyst-like mass: a case report, Tzu Chi Med. J. 24 (2012) 77–79.  Back to cited text no. 4
    
5.
D.A. Spiegel, G.K. Singh, A.K. Banskota, Tuberculosis of the musculoskeletal system, Tech. Orthop. 20 (2005) 167–178.  Back to cited text no. 5
    
6.
H. Reise, Die reiskorpschen in tuberculs erkranken synovalsacken, Dtsch. Z. Chir. 42 (1895) 1.  Back to cited text no. 6
    
7.
C.Y. Woon, E.S. Phoon, J.Y. Lee, et al, Rice bodies, millet seeds, and melon seeds in tuberculous tenosynovitis of the hand and wrist, Ann. Plast. Surg. 66 (2011) 610–617.  Back to cited text no. 7
    
8.
J. Debeyre, Il reste peu d'indications chirurgicales dans le traitement des tuberculoses osseuses, Rev. Meéd. 29 (1972) 3459–3466.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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