The sequelae of late diagnosis in tuberculous flexor tenosynovitis of the hand--a report of 2 cases.

Abstract

Case 1 A 57-year-old immigrant worker from former Yugoslavia presented with a 10-month history of painful and recurrent swelling of the flexor tendon sheaths of the left wrist with severely limited active digital flexion. He had received non-steroidal antiinflammatory drugs and physical therapy with no beneficial effects. Laboratory findings included an elevated ESR, and a positive tuberculin skin test reaction. The patient had no history of tuberculosis, but the chest radiograph revealed scar tissue in the left upper lobe, which was suggestive of old, healed tuberculosis. Plain radiographs of the left hand were normal, except for a slight soft tissue swelling on the palmar aspect of the wrist. At surgery, we found a compressed median nerve in the carpal tunnel, synovial fluid, and a caseous mass within the wall of the flexor tendon sheaths. The superficial and deep flexor tendons were partially ruptured and adhered to each other (Figure 1). Tenosynovectomy with complete excision of the affected tissues was performed and the median nerve was released. Tuberculous tenosynovitis was confirmed by histological examination of the synovial exudate, the caseous mass showing necrosis, acute inflam mation, and numerous caseating granulomas, as well as by cultures positive for Mycobacterium tuberculosis. Gentle mobilization was started 4 days after surgery. Postoperative management, including administration of pyrazinamide, rifampin, and isoniazid for 3 months, was started after consultation with the internist. Drug susceptibility tests, confirming sensitivities to all anti tuberculous drugs, were completed after chemotherapy was initiated. The use of rifampin and isoniazid was continued for an additional 9 months to ensure adequate treatment of this advanced stage of the disease.