O'Shaughnessy Maureen A, Tande Aaron J, Vasoo Shawn, Enzler Mark J, Berbari Elie F, Shin Alexander Y
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
J Hand Surg Am. 2017 Feb;42(2):e77-e89. doi: 10.1016/j.jhsa.2016.11.014. Epub 2016 Dec 20.
Fungal infections involving the tenosynovium of the upper extremity are uncommon and are often misdiagnosed. This study evaluates the epidemiology, diagnosis, treatment, and outcomes of patients with fungal tenosynovitis of the upper extremity over a 20-year period.
A retrospective review of all culture-confirmed cases of fungal tenosynovitis of the upper extremity treated between 1990 and 2013 at a single institution was performed. Clinical data included patient and epidemiologic risk factors, causative fungal organism, surgical management, antimicrobial regimen, recurrence rates, and outcomes.
There were 10 patients (9 female, 1 male) who met the inclusion criteria. The mean patient age was 60 years (range, 47-76 y). Identified pathogens included Histoplasmacapsulatum (7), Coccidioides posadasii/immitis (2), and Cryptococcus neoformans (1). Eight patients were on immunosuppressant medications at the time of diagnosis. The most common clinical presentation was subacute localized pain, swelling, and erythema consistent with tenosynovitis. The diagnosis was delayed by a median of 6 months (range, 0-48 mo). The most helpful diagnostic imaging studies included magnetic resonance imaging and ultrasound. All patients were treated with extensive surgical synovectomy and debridement. Seven patients were treated by a single surgery, whereas 3 required multiple consecutive debridements (2, 7, and 10 surgeries). The mean course of initial antimicrobial therapy was 8.2 months (range, 3-12 mo). Clinical recurrence was noted in 3 patients (30%) during a median follow-up period of 46 months (range, 7-250 mo). Both patients with Coccidioides infection incurred recurrence.
Although uncommon, surgeons and clinicians should consider a diagnosis of fungal tenosynovitis among immunocompromised patients with signs of mild tenosynovitis and should consider operative debridement and biopsy. Although the majority of patients were successfully treated with surgical debridement and antimicrobial therapy, a recurrence rate of 30% highlights the need for close post-treatment follow-up.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.
累及上肢腱鞘的真菌感染并不常见，且常被误诊。本研究评估了20年间上肢真菌性腱鞘炎患者的流行病学、诊断、治疗及预后情况。
对1990年至2013年在单一机构接受治疗的所有经培养确诊的上肢真菌性腱鞘炎病例进行回顾性研究。临床资料包括患者及流行病学危险因素、致病真菌种类、手术治疗、抗菌治疗方案、复发率及预后情况。
有10例患者（9例女性，1例男性）符合纳入标准。患者平均年龄为60岁（范围47 - 76岁）。鉴定出的病原体包括荚膜组织胞浆菌（7例）、波萨达斯球孢子菌/粗球孢子菌（2例）和新型隐球菌（1例）。8例患者在诊断时正在使用免疫抑制药物。最常见的临床表现为与腱鞘炎相符的亚急性局部疼痛、肿胀和红斑。诊断延迟的中位时间为6个月（范围0 - 48个月）。最有用的诊断性影像学检查包括磁共振成像和超声。所有患者均接受了广泛的手术滑膜切除术和清创术。7例患者接受了单次手术，而3例患者需要连续多次清创（2次、7次和10次手术）。初始抗菌治疗的平均疗程为8.2个月（范围3 - 12个月）。在中位随访期46个月（范围7 - 250个月）内，3例患者（30%）出现临床复发。两例球孢子菌感染患者均复发。
尽管罕见，但外科医生和临床医生应在有轻度腱鞘炎体征的免疫功能低下患者中考虑真菌性腱鞘炎的诊断，并应考虑手术清创和活检。尽管大多数患者通过手术清创和抗菌治疗获得成功治疗，但30%的复发率凸显了治疗后密切随访的必要性。
研究类型/证据水平：治疗性研究V级
