Acute Tenosynovitis Research Articles

Acute Tenosynovitis Due to Group A Streptococcus

Acute Tenosynovitis Due to Group A Streptococcus

Septic acute Tenosynovitis of the Flexor Hallucis Longus Tendon Complicating a Lower Limb Erysipelas

Erysipelas is the most common bacterial dermal-hypodermal acute not necrotizing infection [1,2]. Its evolution is usually mild but can be complicated mainly by local abscess or necrosis [3-7]. In this context osteo-articular complications and septic acute tenosynovitis are rarely described in the literature with a rate of 1.2% [3]. We report in the light of a literature review a case of recurrent erysipelas of the leg in a young patient of 29 years complicated by septic acute tenosynovitis of the flexor hallucis longus (FHL), to remind this complication mainly observed in severe forms of erysipelas which is not the case of our patient.

Clinical Characteristics, Histopathology, and Tissue Immunolocalization of Chikungunya Virus Antigen in Fatal Cases.

Death in patients with chikungunya is rare and has been associated with encephalitis, hemorrhage, and septic shock. We describe clinical, histologic, and immunohistochemical findings in individuals who died following chikungunya virus (CHIKV) infection. We identified individuals who died in Puerto Rico during 2014 following an acute illness and had CHIKV RNA detected by reverse transcriptase-polymerase chain reaction in a pre- or postmortem blood or tissue specimen. We performed histopathology and immunohistochemistry (IHC) for CHIKV antigen on tissue specimens and collected medical data via record review and family interviews. Thirty CHIKV-infected fatal cases were identified (0.8/100 000 population). The median age was 61 years (range: 6 days-86 years), and 19 (63%) were male. Death occurred a median of 4 days (range: 1-29) after illness onset. Nearly all (93%) had at least 1 comorbidity, most frequently hypertension, diabetes, or obesity. Nine had severe comorbidities (eg, chronic heart or kidney disease, sickle cell anemia) or coinfection (eg, leptospirosis). Among 24 fatal cases with tissue specimens, 11 (46%) were positive by IHC. CHIKV antigen was most frequently detected in mesenchymal tissues and mononuclear cells including tissue macrophages, blood mononuclear cells, splenic follicular dendritic cells, and Kupffer cells. Common histopathologic findings were intra-alveolar hemorrhage and edema in the lung, chronic or acute tenosynovitis, and increased immunoblasts in the spleen. CHIKV infection likely caused fatal septic shock in 2 patients. Evaluation of tissue specimens provided insights into the pathogenesis of CHIKV, which may rarely result in septic shock and other severe manifestations.

Image Diagnosis in Extensor Tendons Injuries in the Radiocarpal Region in Horses

Background: Soft tissue injuries are common in sport horses, especially those involving tendons, with few current reports in the literature on the diagnosis of extensor injuries, especially with regard to ultrasound characteristics, being essential for the diagnosis of these injuries. The objective of the study is to characterize the clinical signs and the alterations of images, especially ultrasound, in the diagnosis of these lesions of the dorsal radiocarpal region, through case reports of horses seen at the Medical Clinic of Large Animals of the Federal University of Campina Grande (MCLA/UFCG), Patos-PB, Brazil.Cases: The study includes five “vaquejada” competitions horses, of which two were active and the others were away from the sport before the onset of the problem, with injuries to the extensor tendons in the radiocarpal region. Two of the animals had involvement of the common digital extensor muscle tendon (CDEMT), with acute and chronic tenosynovitis, and three with involvement of the extensor carpi radialis muscle tendon (ECRMT), presenting acute tendonitis, septic tenosynovitis and rupture, all of traumatic etiology, except for one whose cause has not been determined. On physical examination, the affected tendon was noticeable in three cases, and two had other injuries associated with the tendons. Bone alteration in the radiographic examination was observed in two cases, however, one of them related to another disease in the radiocarpal palmar region. Ultrasound images, performed in all cases, showed different characteristics and degrees of the involvement of the tendon and its sheath.Discussion: The scarcity of current reports of extensor tendon injuries in horses can be attributed to the fact that they do not suffer as much overload or effect from biomechanics compared to flexor tendons, in addition to being an area of little soft tissue covering these tendons. Although the involvement of the extensor tendons is more frequent in the pelvic limbs, due to lacerations, the occurrence of lesions in the dorsal radiocarpal region may be related to excess flexion, being easily susceptible to trauma to solid objects. The specific clinical examination, associated with a well-explored anamnesis, can allow us to locate the lesion and achieve a presumptive diagnosis. In three cases, tendon injuries were noticeable on inspection and palpation, important points to guide the diagnosis. However, in two cases with associated injuries this perception became difficult. Regardless of the clinical diagnosis, imaging diagnosis in lesions of the locomotor system was essential, as it allowed us to assess bone involvement, accurately determine the location of the lesion, its extent and prognosis, which would not be possible only in the clinic. Through ultrasonography it was possible to classify the lesions into acute (hypoechoic areas) and chronic (hyperechoic areas or with heterogeneous pattern of variable echogenicity), in addition to the thickness and characteristic of the liquid in the tendon sheath, which are also important aspects for lesion classification. Thus, we conclude that the dorsal region at the carpal level is susceptible to trauma and can easily compromise the extensor tendons. And for the diagnosis and adequate conduct, it is necessary to determine ultrasound image regarding the different types of lesions, which is provided in the present study.

Pembrolizumab- and/or pazopanib-induced remitting seronegative symmetrical synovitis with pitting edema in a patient with renal cell carcinoma

Immune checkpoint inhibitors and angiogenesis inhibitors are novel treatment options for renal cell carcinoma and widely used in clinical practice. They are related with adverse events that occur as a consequence of immune system activation and inhibition of angiogenesis. Herein, we report a rare case of inflammatory arthritis seen in a patient treated with an anti Programmed cell death-1 pembrolizumab and an anti-vascular endothelial growth factor pazopanib. A 60-year-old Caucasian male presented to our clinic with inflammatory arthritis with pitting edema. He had been started on pembrolizumab therapy for metastatic renal cell carcinoma after enrolling in the KEYNOTE-679 study. After six cycles of treatment with pembrolizumab, metastasis had been determined in the lung. Then, the patient's therapy was changed to pazopanib. While the patient was on pazopanib treatment, he noticed a gradual swelling of both hands. Rheumatoid factor, anti-nuclear antibody and anti-cyclic citrullinated peptide were negative. Joint ultrasonography revealed acute tenosynovitis and soft tissue swelling with pitting edema, and a diagnosis of remitting seronegative symmetrical synovitis with pitting edema was made. Management and outcome: He was started on 10 mg prednisolone daily. His symptoms dramatically responded to corticosteroid. He continued to take pazopanib. Then, the patient was discharged with 10 mg prednisolone daily. Pembrolizumab- and/or pazopanib-induced remitting seronegative symmetrical synovitis with pitting edema can be among the rare rheumatic immune-related adverse events that clinicians may encounter as the immune check point inhibitors and anti-VEGF use increases. Corticosteroid therapy can relieve symptoms and cessation of therapy may not be necessary.

Tenoscopy for Acute Septic Digital Flexor Tenosynovitis Treatment in 13 Thoroughbred Horses

Septic tenosynovitis of the digital flexor tendon sheath (DFTS) is a potentially career-ending and lifethreatening problem in horses. This study aimed to describe the outcomes of tenoscopy for the treatment of acute septic digital flexor tenosynovitis in horses. Tenoscopy was performed on 13 Thoroughbred horses with acute septic tenosynovitis of the DFTS. Surgical time was 56-148 min (mean 85.6 min, median 84.0 min). In the synovial fluid analysis, mean white blood cell count, mean neutrophil proportion, and mean total protein were 42.9 × 10 3 cells/μl (range, 7.2-109.5 cells/μl), 89.5% (range, 68-97%), and 4.0 g/dl (range, 2.5-5.2 g/dl), respectively. Microbial growth in the synovial fluid culture was detected in 2 of 11 horses. All horses survived and returned to their intended use without complications. The present study demonstrated that the tenoscopy is useful for treating acute septic tenosynovitis of the DFTS in horses.

A55: Clostridium difficile Infection‐Associated Reactive Arthritis in a Pediatric Cohort

Background/Purpose:Clostridium difficile infection (CDI) has increased among children and is associated with significant morbidity and mortality. CDI‐associated reactive arthritis (CDIAReA) has been described in adults and a few pediatric case reports, but little is known about CDIAReA in pediatric patients.Methods:Children ages 2–20 with CDIAReA in 2004–2013 were identified within a multistate pediatric care network's electronic medical record. Administrative data were used to identify cases defined by: 1) a diagnosis code for arthritis and 2) the CDI diagnosis code and/or positive C. difficile test in any setting (ambulatory or inpatient). Records were reviewed to confirm presence of symptomatic CDI and acute arthritis and/or tenosynovitis that met the following inclusion criteria: 1) occurrence between 4 weeks before and 12 weeks after CDI diagnosis, 2) documentation by a physicianlevel provider or imaging, 3) no other cause identified, and 4) negative synovial fluid cultures (if obtained).Results:111 patients were identified for record review, and 13 met the inclusion criteria. Median age of confirmed cases was 13.2 years [range 3.4, 19.3], with similar sex distribution (6 females, 7 males). Approximately half (46%) of cases had chronic medical conditions, including 3 (23%) with autoimmune diseases, whose underlying condition did not explain their acute arthritis. Among subjects with CDIAReA, all CDIs were community‐associated and mild, except for 1 subject with preexisting lupus nephritis. Arthritis was most often migratory (85%) and polyarticular (54%) involving large and small joints, with a median of 6 affected joints [range 2, 15]. The most commonly involved joints were knees (69%) and ankles (69%) followed by wrists (62%) and elbows (54%). Eight patients (62%) experienced concurrent fever, and 9 (69%) had rash. Over half (62%) were hospitalized due to joint pain. Of these, 5 (38%) were suspected to have septic arthritis and 2 (15%) underwent surgical drainage procedures for presumed septic hip arthritis with purulent effusions (both culture‐negative). Median time from onset of gastrointestinal symptoms to resolution of joint symptoms was 30 days [range 8,76]. Symptoms generally resolved with treatment of underlying CDI and, in 69%, NSAID use. Three subjects (23%) without prior arthritis had subsequent recurrent episodes of migratory joint pain not associated with documented CDI. Aside from the primary physician, 85% were evaluated by emergency physicians, 69% by rheumatologists, 54% by inpatient pediatricians, and 46% by orthopedists. Of confirmed cases, 5 (38% [95% CI 14, 68%]) were never diagnosed with CDIAReA by their treating providers.Conclusion:CDIAReA is an under‐recognized pediatric condition characterized by a painful, migratory, often polyarticular arthritis of large and small joints in the setting of CDI. Though a self‐limited condition in this cohort, its acuity led to considerable morbidity and resource utilization, in some cases due to confusion with septic arthritis. Further research is needed to determine the incidence and risk factors for pediatric CDIAReA.

Progressive disseminated histoplasmosis in systemic lupus erythematosus—an unusual presentation of acute tenosynovitis and a literature review

Progressive disseminated histoplasmosis is a disease where Histoplasma capsulatum affects multiple organs due to the inability of host cellular immunity to control the infection. Progressive disseminated histoplasmosis mainly involves the bone marrow, liver, and lungs. We report an unusual initial presentation of progressive disseminated histoplasmosis presenting as acute tenosynovitis in a systemic lupus erythematosus (SLE) patient. This report highlights the point that H. capsulatum may present as focal lesions and a high level of suspicion is needed to make the diagnosis, especially in SLE patients. We specifically reviewed reported cases of progressive disseminated histoplasmosis in SLE patients, and a review of the literature is presented.

Rapid Development of Sarcoid Tenosynovitis

We report a case of acute tenosynovitis from sarcoidosis and review previously reported cases of this entity. A woman with known pulmonary sarcoidosis rapidly developed painless nodules in the tendon sheaths of the dorsum of both hands and wrists. Sarcoid tenosynovitis is almost exclusively found in the upper extremity. The flexor and extensor tendons are equally affected. The condition may respond to medical therapy including corticosteroids and other immunomodulating medications. Surgical debulking and tendon sheathectomy have also been curative. The disease has also been reported to spontaneously resolve. Our patient dramatically improved while on methotrexate.

Use of Continuous Marcaine Irrigation in the Management of Suppurative Flexor Tenosynovitis

We describe a surgeon, nursing, and patient-friendly method of treating acute pyogenic tenosynovitis using a 2-incision, closed sheath irrigation method and postoperative usage of a continuous marcaine ON-Q pain pump. The advantages of this technique include the ease of catheter placement intraoperatively and the use of a smaller diameter tubing within the flexor sheath. In addition, this technique eliminates the need for nursing staff to perform irrigation, and most importantly, the technique results in improved postoperative pain control allowing an early aggressive postoperative therapy protocol. We retrospectively reviewed 9 patients with an average age of 42.8 years (range: 20 to 66 y) who presented with acute pyogenic flexor tenosynovitis. All patients underwent surgery on the day of presentation to us with the described technique with the catheter left in place for 2 days. Outcome measurements included length of hospital stay, final range of motion, recurrence of infection, and complications. Average hospital stay was 2.8 days (range: 2 to 6 d). There were no recurrent infections. Seven patients regained full total active motion of the involved digit. The 2 patients with incomplete recovery of digital motion regained 125 and 105 degrees of total active motion, respectively. In addition, there were 3 minor complications including cold intolerance (2 patients) and local skin necrosis that responded to local wound care (1 patient). This novel method of managing acute flexor tenosynovitis seems to be safe, effective, and very friendly for surgeons, nurses as well as patients. Intraoperative pearls for catheter placement using a 22-guage wire inside a musical sharp5 pediatric French feeding tube are also described.

Rice-Body Formation and Tenosynovitis of the Wrist: A Case Report

A 61-year-old woman presented with mild pain and swelling on the volar aspect of the wrist, hand, and little finger. Radiography showed a soft-tissue mass shadow, and magnetic resonance imaging showed acute tenosynovitis of the flexor tendons and an inflammatory mass inside the carpal tunnel. Laboratory test results were normal, except for an elevated erythrocyte sedimentation rate (40 mm/h). The patient had an ambiguous Mantoux test result but no history of mycobacterial exposure. Exhaustive investigations for rheumatic disease were negative. Surgical exploration of the lesion revealed rice bodies in the common flexor tendon synovial sheath, extending distally to the tip of the fifth finger. Removal of the rice bodies and thorough excision of the sheath was performed. The patient regained a full and painless range of motion in about 3 months. One-year follow-up revealed no underlying disorder.

MRI of sports-related injuries of the foot and ankle: part 2

La osteonecrosis del escafoides tarsiano (OET) puede acontecer tanto en la infancia (entidad denominada enfermedad de Köhler) como en la edad adulta. En los niños la enfermedad es infrecuente, se incluye dentro de las osteocondrosis de crecimiento y tiene un buen pronóstico, y en la mayoría de los casos evoluciona hacia la curación espontánea sin secuelas. En el adulto, la OET es también una lesión rara. Existen formas idiopáticas conocidas como enfermedad de Müller-Weiss y formas secundarias que se deben a fracturas del escafoides o aparecen en presencia de factores de riesgo que favorecen la aparición de la enfermedad. La OET idiopática suele presentarse en mujeres de edad media y ser bilateral, mientras que las formas secundarias suelen darse en pacientes jóvenes, sin ningún predominio de sexo y en estos casos la afección es unilateral. A diferencia de la infancia, en la OET del adulto nunca hay curación espontánea. Sin tratamiento la enfermedad presenta invariablemente una evolución crónica y progresa hacia el colapso de la zona necrótica, con deformidad, fisuración y migración del escafoides, y en último término se desarrolla un pie plano y una artrosis astragaloescafocuneana que es causa de dolor, a veces tan intenso que llega a impedir la deambulación del paciente. En estos casos, el diagnóstico y el tratamiento tempranos son cruciales para evitar el desarrollo de secuelas, por lo que la OET debe tenerse siempre en cuenta en pacientes con dolor en el mediopié.Osteonecrosis (ON) of the tarsal navicular bone has been described in children (Köhler's disease) and in adults. Köhler's disease belongs to the group of osteochondroses, is relatively rare, and usually has a self-limited and reversible clinical course. In adulthood, this is also an uncommon entity. There are two distinct forms of this condition: the idiopathic or spontaneous ON also known as Müller-Weiss disease, which appears in patients without risk factors for osteonecrosis, and secondary ON caused by well-recognized predisposing factors or by traumatic injuries. Spontaneous ON or Müller-Weiss disease is seen most frequently in middle- aged women and it's usually bilateral; in secondary ON, the age and sex distribution is dependent upon the primary disease, although it generally affects younger patients without gender differences, and the involvement is unilateral. ON of the adult navicular is usually more severe than Köhler's disease. In absence of treatment, it is characterized by a chronic clinical course, with collapse, deformity and osseous fragmentation, severe and sometimes devastating pain and disability, and progressive flatfoot deformity with secondary talonaviculocuneiform osteoarthritis. A high level of awareness of this condition is needed to prompt diagnosis and treatment before advanced collapse occurs. Although uncommon, it should be included in the differential diagnosis of adult patients with midfoot pain.

Calcium pyrophosphate deposits--a chameleon

Calcium Pyrophosphate Dihydrate (CPPD) crystals deposit in articular fibro- or hyaline cartilage (chondrocalcinosis), joint capsules, synovium, periarticular ligaments and tendons resulting in an age dependent prevalence. These calcifications may be asymptomatic or may manifest as acute pseudogout arthritis, pseudorheumatoid arthritis, bursitis, tenosynovitis, tendinitis, polymyalgic syndrome or chronic pyrophosphate arthropathy. The diagnosis is based on the presence of intracellular CPPD crystals in synovial fluid detected by polarizing microscopy, the characteristic radiological changes and the typical clinical presentations. The therapy is symptom oriented or disease specific in case of an underlying metabolic disease such as hemochromatosis, hyperparathyroidism, hypophosphatasia, hypomagnesemia or hypothyroidism.

Sesamoiditis of the index finger presenting as acute suppurative flexor tenosynovitis

Sesamoiditis involving the hand is uncommon, usually reported in the thumb, and has not been reported in the index finger. As rare as this clinical entity remains, its presentation simulating an acute suppurative flexor tenosynovitis is even more rare. We report a patient who presented with Kanavel's 4 cardinal signs of acute suppurative tenosynovitis who was subsequently found to have an acute sesamoiditis of the index finger. This finding was supplemented by a cadaveric and radiographic study to better delineate the anatomy of the index sesamoid and further explain the clinical presentation.

Incidence and causes of tenosynovitis of the wrist extensors in long distance paddle canoeists.

OBJECTIVES: To investigate the incidence and causes of acute tenosynovitis of the forearm of long distance canoeists. METHOD: A systematic sample of canoeists competing in four canoe marathons were interviewed....

Aseptic Tenosynovitis of the Digital Flexor Tendon Sheath, Fetlock and Pastern Annular Ligament Constriction

The anatomy of the digital flexor tendon sheath and related tendons and ligaments is described. Diagnosis and management of acute tenosynovitis and long-term tenosynovitis and associated tendon injuries are discussed, as well as the syndrome of stenosis of the fetlock canal (or fetlock annular ligament constriction) and palmar annular ligament constriction. Desmitis of the palmar annular ligament is also described.

Acute Calcium Pyrophosphate Dihydrate Crystal-Induced Tenosynovitis

Calcium pyrophosphate dihydrate crystal deposition in tendon sheaths is a rare cause of acute and chronic tenosynovitis. An elderly patient with acute wrist pyrophosphate tenosynovitis and transient periarticular calcification is described.

Tendons: high-field-strength, surface coil MR imaging.

High-resolution magnetic resonance (MR) images of the tendons of the hands, wrists, feet, and ankles of six healthy volunteers and six cadavers were obtained using receive-only surface coils and reduced-field-of-view imaging. Normal anatomy was identified and compared with gross anatomic sections of the six cadavers. Experimentally produced tears of the calcaneal (Achilles) tendon in domestic swine were identified on MR images. The hands and feet of 11 patients were examined, and a variety of pathologic lesions were identified, including acute posttraumatic rupture, acute tenosynovitis, chronic tendonitis, and postsurgical complications. MR imaging provides inherently greater soft-tissue contrast than any other currently available imaging modality. With the use of surface coils and reduced-field-of-view imaging to enhance spatial resolution, MR imaging has become a valuable tool for imaging tendons. Advantages over other available modalities include excellent depiction of anatomic detail, superior contrast resolution, and the potential for multiplanar imaging.

Acute suppurative tenosynovitis of the hand: diagnosis with US.

The sonographic findings in seven patients with surgically proved acute tenosynovitis of the hand (bacterial in six cases, of presumed viral origin in one) were reviewed. In the six patients with bacterial tenosynovitis the affected flexor tendon was larger than that of the contralateral normal digit. In five patients hypoechoic areas were identified surrounding the flexor tendon that proved to be pus at surgery. Sonography failed to depict a small amount of pus in the tendon sheath in one patient. The affected tendon of the single patient with tenosynovitis thought to be of viral origin was normal in size, but a focal tendon sheath fluid collection was detected that proved to be sterile at surgery. Sonography appears to be a useful imaging technique in the early diagnosis of acute suppurative tenosynovitis of the hand.

Scanning Electron Microscopic Studies of Extensor Tendon Degeneration in Rheumatoid Arthritis

Examination of the surfaces of four normal and six rheumatoid tendons in the hand by scanning electron microscopy clearly showed the processes of degeneration affecting the tendons in rheumatoid arthritis. These findings seemed to correspond to the clinical state. The surfaces of the healthy tendons displayed fine networks of closely enmeshed collagen fibrils and parallel arrangements of collagen bundles. In acute rheumatoid tenosynovitis numerous inflammatory cells were found on the surfaces of the tendons, later crater and groove formations followed, as was observed in degenerated tendons and ruptured stumps in cases in which the active stage already had calmed down. The hypothesis is discussed that disorganization of tendons in rheumatoid disease may be caused by lysosomal enzymes present in greater concentration in the synovial fluid components of rheumatoid patients than in healthy subjects.