Extrapulmonary tuberculous involvement of musculoskeletal system accounts for only 1% to 5% of cases.1 Tuberculosis of tendon sheath of the hand, although less common, is an established condition. Tuberculous involvement of the feet tendon is even rarer. This article presents a rare case of tuberculous tenosynovitis of flexor digitorum longus tendon in a 68-year-old man.
| || || |
| Figure 1: Clinical photograph showing location of swelling in relation to the medial malleolus and flexor digitorum longus tendon (A). Intraoperative photograph showing tuberculous granulation tissue covering the tendon. Posterior tibial neurovascular bundle is isolated (B). Intraoperative photograph after debridement showing healthy flexor digitorum longus tendon (C). |
A 68-year-old male farmer in India presented with a painless swelling of 3 months duration over the medial aspect of the left ankle. It was slowly increasing in size. There were no constitutional symptoms or past history of major illness. He was treated with nonsteroidal anti-inflammatory drugs by his primary care physician.
Examination of the left ankle and foot revealed nontender, fluctuant swelling, anteroinferior to medial malleolus (Figure 1A). Overlying skin appeared normal. The ankle joint had a full range of motion. Posterior tibial neurovascular bundle was unaffected. Plain radiographs of the ankle and chest were normal. Laboratory findings, including erythrocyte sedimentation rate (ESR), were within normal limits. Mantoux test was not performed.
During excision, purulent material was noted on incising the subcutaneous tissue. Gram staining, acid fast bacilli staining, and pyogenic culture detected no organism. Histopathological examination showed nonspecific inflammation.
Two months postoperative the patient presented with recurrence of swelling at the same site. Magnetic resonance imaging showed small hypointense collection in the tendon sheath of left flexor digitorum longus behind the left ankle joint and adjacent to the lower end of tibia on T2-weighted, STIR, and gradient (T2 with fat saturation) images, which appeared hypo intense on T1-weighted images (Figure 2), suggesting tenosynovitis.
Tenosynovectomy was performed. Pus was observed on incising subcutaneous tissue. Flexor digitorum longus tendon was covered with granulation tissue (Figure 1B). The tendon sheath was thickened and inflamed. Complete tenosynovectomy with extensive debridement of surrounding granulation tissue was performed.
| || || |
| Figure 2: MRI of the ankle joint; T1-weighted axial image showing two, small, well defined, subcutaneous, mildly hypointense areas(white arrows), suggestive of inflammatory collection (A). STIR sagittal (B) and (C) gradient (T2 with fat saturation) images show small hyperintense collection in the tendon sheath of the flexor digitorum longus tendon behind the ankle joint and adjacent lower end of tibia(white and black arrows respectively). |
The flexor digitorum longus tendon was found to be healthy (Figure 1C). The wound was primarily closed and the ankle was immobilized in a below-knee cast. Mycobacterium tuberculosis was isolated on culture. Histopathological examination, this time revealed epithelioid granuloma (Figure 3).
| |Figure 3:
Photomicrograph of histopathology examination of synovium showing casseous necrosis with granuloma formation (black arrow), typical of tuberculous infection. (Hematoxylin-eosin, 10).
Three weeks postoperative the cast was removed and weight bearing was allowed as tolerated. The patient received anti-tuberculous chemotherapy for 9 months, which included streptomycin (750 mg) for the first month, pyrazinamide (1500 mg) and ethambutol (1200 mg) for first 3 months, and rifampicin (450 mg) and isoniazide (300 mg) for all 9 months. The patient was called for follow-up examination every 2 months. Two years postoperative, he is symptom free, with full range of motion in the left ankle joint.
Tuberculous tenosynovitis was first described by Acrel in 1777.2 Kanavel,3 in 1923 reported a complete description of its clinical and pathological features. Wrist and hand tendons are principal sites of involvement, where 0.7% to 5 % of all the osteoarticular tuberculous lesions are found.4
Tuberculous infection of the feet is rare with few cases reported in literature. Adams et al5 reported involvement of foot tendons in their series. Bickel et al6 reported a series of 21 cases of tuberculous tenosynovitis, in which involvement of Achilles, extensor, and peroneal tendons were described. Isolated reports of involvement of peroneal, anterior tibial, posterior tibial, and extensor hallucis longus tendon are available.4,7-9 No other reports exist on flexor digitorum longus tendon.
Most patients with tuberculous tenosynovitis are >60 years. The disease starts as a slow growing insidious swelling along the involved tendon. There may be a history of tuberculosis or exposure. Pain, erythema, and restriction of joint movements may occur. Laboratory findings are usually within normal limits, except for raised ESR and C-reactive protein (CRP) levels.
Characteristic imaging features include synovial thickening with relatively little synovial sheath fluid, in contrast to acute suppurative tenosynovitis, where synovial sheath fluid is the predominant feature. The synovial thickening is due to replacement of the synovial sheath with granulation tissue. Rice bodies or Melon seeds are fibrinous masses (tubercles) present in 50% of tuberculosis cases. They favor a diagnosis of tuberculosis if detected on ultrasound or seen during surgery. Fifty percent of patients have normal chest radiographs, and tuberculin skin test is positive in most of the patients.1
Diagnosis of tuberculosis can be made on any one of the following criteria10: 1) Mycobacterium tuberculosis revealed on culture material; 2) biopsy material showing caseating granulomas typical of Mycobacterium tuberculosis infection, occasionally accompanied by demonstration of acid-fast organism in the histopathologic sections; or 3) autopsy material revealing caseating granulomas typical of Mycobacterium tuberculosis infection.
An inordinate delay in confirming this diagnosis is not uncommon because of lack of suspicion, its ability to resemble other forms of rheumatologic disease, and absence of tuberculous disease elsewhere or in the past. Culture and guinea pig inoculation may be false negative, if the sample is inadequate. In one series of new cases of skeletal tuberculosis, a mean delay was reported of 19 months before correct diagnosis.11
According to the literature, extensive surgical debridement along with full course of anti-tuberculous chemotherapy, including streptomycin for the first month is recommended. This protocol should be strictly followed as this condition has a high recurrence rate.12 Bickel et al6 reported 7 recurrences , only 2 of them received streptomycin following surgery. Mangini et al13 reported 3 cases of recurrence in 27 patients treated surgically and followed by chemotherapy. He noted that these 3 cases may have been inadequately treated by chemotherapy.
More than 50% of cases recur within 1 year of treatment.9,14 But, recurrence as late as 36 years after initial treatment has been reported.15 Isolated medical or surgical treatment alone significantly increase the risk of recurrence.16 Garrido et al14 reported that disease relapse resulted mainly from irregular therapy rather than from drug resistance or other factors.
Our patient presented with painless recurrent swelling over ankle with no constitutional symptoms or past history of tuberculosis .There was a delay of five months in diagnosis, which was suspected on magnetic resonance imaging and established with culture and histopathology. Extensive tenosynovectomy with five drug anti-tuberculous treatment gave excellent results.
Although tuberculosis is an uncommon cause of tenosynovitis, particularly in the foot, it should be in the differential diagnosis of chronic tenosynovitis, especially in countries where tuberculosis is prevalent. With large number of patients with acquired immunodeficiency syndrome being diagnosed with tuberculosis, there is a worldwide increase in pulmonary and extrapulmonary tuberculosis. Patients should be treated aggressively with surgery and chemotherapy and followed closely to detect and treat recurrence early.
- Aboudola S, Sienko A, Carey R, Johnson S. Tuberculous tenosynovitis. Hum Pathol. 2004; 35(8):1044-1046.
- al Soub H. Tuberculous tenosynovitis: a rare manifestation of a common disease. Int J Clin Pract. 1998; 52(1):56-58.
- Kanavel AB. Tuberculous tenosynovitis of the hand: A report of fourteen cases of tuberculous tenosynovitis. Surg Gynecol Obstet. 1923; 37:635-647.
- Goldberg I, Avidor I. Isolated tuberculous tenosynovitis of the Achilles tendon. A case Report. Clin Orthop Relat Res. 1985; (194):185-188.
- Adams R, Jones G, Marble HC. Tuberculous tenosynovitis. New England J Med. 1940; 233:706-708.
- Bickel WH, Kimbrough RF, Dahlin DC. Tuberculous tenosynovitis. JAMA. 1953; 151(1):31-35.
- Abdelwahab IF, Kenan S, Hermann G, Klein MJ, Lewis MM. Tuberculous peroneal tenosynovitis. A case report. J Bone Joint Surg Am. 1993; 75(11):1687-1690.
- Memisoglu K, Anik Y, Willke A, Sarlak AY. Tuberculous tenosynovitis of the anterior tibial and extensor hallucis longus tendon: case report. Foot Ankle Int. 2005; 26(4):332-335.
- Hooker M S, Schaefer RA, Fishbain JT, Belnap CM. Tuberculous tenosynovitis of the tibialis anterior tendon: a case report. Foot Ankle Int. 2002; 23(12):1131-1134.
- Sen P, Kapila R, Salaki I, Louria DB. The diagnostic enigma of extra-pulmonary tuberculosis. J Chronic Dis.1977; 30(6):331-350.
- 11. Albornoz MA, Mezqarzedeh M, Neumann CH, Myers AR. Granulomatous tenosynovitis: a rare musculoskeletal manifestation of tuberculosis. Clin Rheumatol. 1998; 17(2):166-169.
- Pimm LH, Waugh W. Tuberculous tenosynovitis. J Bone Joint Surg Br. 1957; 39(1):91-101.
- Mangini U. Le tendovaginiti tubercolari della mano. Arch Putti Chir Organi Mov. 1956; 7:299.
- Garrido G, Gomez-Reino J, Fernández-Dapica P, Palenque E, Prieto S. Review of peripheral tuberculous arthritis. Semin Arthritis Rheum. 1988; 18(2):142-149.
- Jackson RH, King JW. Tenosynovitis of the hand: a forgotten manifestation of tuberculosis. Rev Infect Dis. 1989; 11(4):616-618.
- Regnard PJ, Barry P, Isselin J. Mycobacterium tenosynovitis in the flexor tendons of the hands: A report of five cases. J Hand Surg [Br]. 1996; 21(3):351-354.
Dr Diwanji is from Muni Seva Ashram and Kailash Cancer Hospital, and Dr Shah is from the Department of Radiology, S.S.G. Hospital and Medical College, Gujarat, India.
Drs Diwanji and Shah have no relevant financial relationships to disclose.
This investigation was performed at Muni Seva Ashram and Kailash Cancer Hospital and S.S.G. Hospital and Medical College, Gujarat, India.
Correspondence should be addressed to: Sanket R. Diwanji, MS(Ortho), B-201, Jal-Tarang Apartment, Halar Cross Rd, Valsad 396001, Gujarat, India.