Weakness of left hand in a diagnosed case of pulmonary tuberculosis: A rare case of disseminated tuberculosis with wrist tenosynovitis

Dear Editor,

Tuberculous tenosynovitis is seen in only about 5% of cases of bone and joint tuberculosis.¹ This disease is more common in males and preferentially affects the dominant hand.^{1, 2, 3} Various studies have shown that tuberculous tenosynovitis of the wrist has a predilection for the flexor tendons of the hand.^4,5 We are presenting here a case of disseminated tuberculosis who had initially presented to us with a clinical picture of pulmonary tuberculosis but later developed tenosynovitis of the left wrist with the involvement of extensor tendons which is a rare presentation of tuberculous tenosynovitis.

A 33-year-old male patient presented with complaints of hemoptysis of two days duration. He also gave a history of intermittent fever, cough, and weight loss of 4 kgs in the preceding four weeks before hemoptysis. On evaluation, he had normocytic normochromic anemia (Table 1), and a chest roentgenogram showed a non-homogenous opacity in the right upper and lower zone (Fig. 1). Sputum was positive for acid-fast bacilli and cartridge-based nucleic acid amplification (CBNAAT) confirmed drug-sensitive mycobacterial tuberculosis (MTB) infection. After about three weeks of initiating antitubercular therapy, the patient presented with complaints of progressive swelling of the left wrist. He also complained of numbness in all fingers except the thumb of the left hand and reduced strength in the left wrist. The swelling had a boggy consistency, and it was extending proximal and distal to the wrist. The swelling was non-tender, fluctuant, and had a well-defined margin. Movements were painful in extremes of motion, and extension was limited at the wrist joint and fingers.

Table 1.

Baseline laboratory investigations at presentation.

Serial number	Parameters (unit)	Index	Reference limits
1	Hemoglobin (gm/dl)	12.3	12–15.5
2	White blood cells (× 103/μL)	7.2	4–11
3	Neutrophil:lymphocyte ratio	2.83	0.8–3.5
4	Platelets (× 103/μL)	167	150–450
5	Protein (gm/dl)	7.6	5.2–8.5
6	Albumin (gm/dl)	3.9	3.5–5.5
7	Albumin:globulin ratio	1.05	0.8–2.2
8	Bilirubin (mg/dl)	0.2	0.2–1.0
9	Creatinine (mg/dl)	0.8	0.6–1.2
10	AST (U/L)	34	15–37
11	ALT (U/L)	31	12–78
12	Random blood glucose (mg/dl)	108	<200
13	Erythrocyte sedimentation rate (mm/hr)	16	0–20
14	LDH (U/L)	198	225–450
15	C-reactive protein (mg/dl)	2.46	1.0–10
16	Procalcitonin (ng/ml)	0.1	<0.5
17	Uric acid (mg/dl)	3.5	2–7
18	Rheumatoid factor (IU/ml)	2.1	<14.0
19	Anti-CCP (U/ml)	0.1	<5
20	ANA (IFA)	Not detected

Fig. 1.

Chest roentgenogram showing non-homogenous opacity in right upper and lower zone.

There was no evidence of any bony injury on the roentgenogram of the left wrist. Rheumatoid factor, serum uric acid, and anti-nuclear antibody levels were normal. The patient was initially suspected to have Poncet's arthropathy and was given a trial of anti-inflammatory drugs; however, he continued to be symptomatic. On magnetic resonance imaging (MRI), there was evidence of synovitis of the left wrist joint with altered marrow density signal involving the distal end of the radius, ulna, and proximal carpal bones. There was thickening of the tendon sheath of the extensor digitorum longus and related synovium (Fig. 2). On clinical suspicion of tuberculous tenosynovitis, we did ultrasonography (USG)-guided needle aspiration of synovial fluid. CBNAAT of synovial fluid was positive for MTB. The patient was diagnosed with tuberculous tenosynovitis and managed conservatively with splinting and gradual mobilization over six weeks. He was administered first-line antitubercular therapy as per drug sensitivity for a total duration of 12 months. He is on our follow-up for the last year and is presently asymptomatic. Patient consent was obtained.

Fig. 2.

Post-gadolinium enhancement MRI coronal T1FS, T1 SPIR SAG, and T1FS axial sequence shows marrow enhancement in carpal bones, distal radius, and thickened enhancing synovium (red arrows). Note peritendinous enhancement around flexor and extensor tendon in axial sequence (red arrows).

Hematogenous spread from a primary site like lungs, kidneys, or direct inoculation from an adjacent joint or bony structure may lead to the development of tuberculous tenosynovitis.^{1, 2, 3, 4} Patients usually present with an insidious onset slow-growing painless swelling along the inflamed tendon.¹ This form of tuberculosis is commonly known to involve the flexor side of the hand and ulnar border compared to the extensor aspect and radial border, respectively.^4,5 Few cases involving extensor tendon tenosynovitis have been described.^1,4 Differential diagnoses include varied etiologies like pyogenic infection, rheumatoid arthritis, gouty arthritis, systemic lupus erythematous, De Quervain's synovitis, and fungal infections.^1,3,6

MRI permits an assessment of the extent of the lesion and accurately identifies involved tendons and is the gold standard investigation of choice.^3,6 Traditionally, an open biopsy and tissue sampling were required to confirm the diagnosis of tuberculosis.^1,2,4,7,8 Patients are usually treated with intensive phase (rifampicin, isoniazid, ethambutol, and pyrazinamide) for two months followed by a continuation phase. The total duration of therapy may vary depending on clinical response. Joint immobilization followed by gradual mobilization is an important aspect of treatment. The recurrence rate can be as high as 50%, and patients are required to be followed up regularly.

In this report, we are describing a case of pulmonary tuberculosis who developed tenosynovitis of the hand while on antitubercular therapy. He had developed tenosynovitis in his non-dominant hand which is uncommon as per prevailing literature evidence. Tuberculous tenosynovitis is commonly known to affect flexor tendons; however, in this case, the extensor tendon was also affected. We could successfully diagnose tuberculous tenosynovitis by USG-guided needle aspiration and demonstration of MTB in the synovial fluid thus avoiding an open surgery. This case emphasizes early suspicion of this rare form of tuberculosis and proves that with advancements in molecular diagnostics in tuberculosis, we need not always resort to surgical procedures to establish the diagnosis.

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Patients informed consent was obtained.

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Not Applicable.

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Nil.

Disclosure of competing interest

The authors have none to declare.