Wrist Tenosynovitis due to Mycobacterium bovis Infection: Case Series and Review of the Literature

From the * Department of Orthopaedics and Traumatology, Medicana International Hospital, Ankara, Turkey; † Department of Orthopaedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey; ‡ Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey; § Department of Hand Surgery, Ankara University Faculty of Medicine, Ankara, Turkey; and ¶ Department of Hand Surgery, Medicana International Hospital, Ankara, Turkey.

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Corresponding author.

Haldun O. Kamburoğlu, MD, FEBOPRAS, Plastik Rekonstrüktif ve Estetik Cerrahi A.D., Hacettepe Üniversitesi Hastaneleri, 06100 Sihhiye/Ankara, Turkey, E-mail: moc.oohay@aknolah

Received 2014 Apr 20; Accepted 2014 Oct 22.

Copyright © 2014 The Authors. Published by Lippincott Williams & Wilkins on behalf of The American Society of Plastic Surgeons. PRS Global Open is a publication of the American Society of Plastic Surgeons.

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Abstract

Summary:

Tuberculosis infections are still one of the most important public health problems among developing countries. Musculoskeletal involvement represents 10–15% of all extrapulmonary cases. Tuberculosis tenosynovitis is usually misdiagnosed as nonspecific tenosynovitis. To avoid misdiagnosis and mistreatment, it is important to be alert for mycobacterial infections. This article presents 3 patients with wrist tenosynovitis, which was caused by Mycobacterium bovis infection. The article also includes review of the literature.

Tuberculosis infections are still one of the most important public health problems among developing countries. Musculoskeletal involvement represents 10–15% of all extrapulmonary cases. Upper extremity involvement is extremely rare. 1 Tuberculosis tenosynovitis of the wrist is uncommon, and this may cause misdiagnosis, which will be discussed further.

Mycobacterium canettii, Mycobacterium tuberculosis, Mycobacterium africanum, Mycobacterium microti, Mycobacterium pinnipedii, Mycobacterium caprae, and Mycobacterium bovis are the members of the Mycobacterium tuberculosis complex (MTC). Mycobacterium marinum is another microorganism, which causes hand infections among fishermen and cooks. M. bovis displays the broadest spectrum of host infection, including humans and domestic or wild bovines and goats. 2,3 Main contamination source for humans is the usage of unpasteurized milk; however, direct contact with infected animals and inhalation of contagious aerosols are causes of infection in humans.

Transmission from human to human is extremely rare; on the other hand, this would be seen in immunosuppressed patients. 4 After developing of the advanced pasteurization techniques, contamination by gastrointestinal system became less important. However, milkers, livestock farmers, and slaughterhouse workers are still at risk for contamination with inhalation and direct contact. In Western Europe, only a few bacteriologically proven human tuberculosis cases have been reported due to M. bovis. 5–7

Mycobacterial culture is still one of the most sensitive ways to diagnose mycobacterial infections. There are several methods for molecular typing of MTC isolates. Restriction fragment length polymorphism based on IS6110 polymorphism is current “gold standard” in molecular epidemiological studies of mycobacterial infections. 8 Polymerase chain reaction is another genetic test to differentiate MTC members.

M. bovis is thought to be responsible for 5–10% of all tuberculous infections. This report presents 3 patients with wrist tenosynovitis caused by M. bovis infection. The article also includes review of the literature. Principles outlined in the Declaration of Helsinki were followed in this study.

CASE REPORTS

Surgical procedures were performed under tourniquet and standard general anesthesia. Samples were sent for pathological and microbiological examinations. Tuberculous granulomas and Langhans giant cells were seen at histological sections. After diagnosing the tuberculosis infection histologically, isoniazid, rifampicin, pyrazinamide, and ethambutol were administered. Aerobic and anaerobic cultures were negative for all 3 patients’ samples. We have isolated the acid-resistant bacillus with BACTEC Mycobacteria Growth Indicator Tube 960 system (Becton, Dickinson Company, NJ). Molecular analysis of M. bovis was made with restriction fragment length polymorphism technique. At the end of the second month of antituberculosis therapy, pyrazinamide and ethambutol were stopped, and chemotherapy was continued for a 9-month period with isoniazid and rifampicin combination.

Case 1

A 56-year-old butcher was presented with loss of extension of the index and the third finger of his left hand. Approximately 6 months ago, the patient realized a swelling at left wrist. He has taken some painkillers and antibiotics. As swelling did not provide relief, local corticosteroid injection was administered. The patient’s disability (loss of extension due to tendon rupture) suddenly started 1 week after steroid injection. History of tuberculosis and trauma were negative.

In physical examination, he was unable to extend the index and third finger. Passive movements of these joints were normal. There was a mild swelling on the dorsal aspect of the wrist. Plain radiographies were normal. Sedimentation rate was 32 mm at 1 hour (0–24 mm). C-reactive protein (CRP) level was 0.6 mg/dL (0–0.5 mg/dL). Chest radiography was normal. Purified protein derivative (PPD) test and HIV tests were also negative.

An incision was made on the dorsal side of the wrist. Extensor retinaculum was incised. Thickened synovial tissues were removed and ruptured extensor tendons were found and repaired properly (Fig. (Fig.1). 1 ). There were rice-like bodies around synovial tissues. Four years after the surgery, there were no signs of recurrence.