Bhandari Sambhawana, Perdomo Wendy, Rudinskaya Alla, Chawdhary Karan, Odujoko Oluwole
Internal Medicine, Danbury Hospital, Nuvance Health, Danbury, USA.
Rheumatology, Danbury Hospital, Nuvance Health, Danbury, USA.
Cureus. 2021 Dec 31;13(12):e20845. doi: 10.7759/cureus.20845. eCollection 2021 Dec.
Nontuberculous mycobacterial tenosynovitis is a rare entity that is often misdiagnosed as bacterial or inflammatory tenosynovitis. We present a case of a 64-year-old man who presented with pain and swelling of his right wrist for several weeks. Magnetic resonance imaging (MRI) of his right upper extremity showed findings consistent with prominent tenosynovitis in the right extensor digitorum tendon sheath. Surgical debridement showed reactive histopathology with negative Gram stain, culture, and acid-fast bacilli stain; after which, steroids were started along with methotrexate and hydroxychloroquine, which was later changed to anti-tumor necrosis factor (anti-TNF) therapy. Due to minimal improvement, repeat operative debridement was done showing macroscopic rice bodies with pathology revealing chronic granulomatous inflammation with necrosis. However, repeated infectious work-up remained negative. After his symptoms progressed to involve his right index finger, his tenosynovium was sampled again, which was positive for acid-fast bacilli (AFB) staining for rare mycobacterial organisms, with cultures growing faint transparent colonies that were sent to the state laboratory for speciation. He was started on empiric therapy with clarithromycin, ethambutol, and rifampin following which his wound fully healed. This case illustrates the insidious course of nontuberculous mycobacteria (NTM) tenosynovitis leading to delayed diagnosis along with unwarranted treatments that could be harmful. Open tissue biopsy is important in the context of a lack of clinical response to common treatment modalities, in the absence of an alternative diagnosis with a similar clinical picture.
非结核分枝杆菌腱鞘炎是一种罕见疾病，常被误诊为细菌性或炎性腱鞘炎。我们报告一例64岁男性，其右腕疼痛肿胀数周。右上肢磁共振成像（MRI）显示结果与右手示指伸肌腱腱鞘内明显腱鞘炎相符。手术清创显示反应性组织病理学表现，革兰氏染色、培养及抗酸杆菌染色均为阴性；此后，开始使用类固醇药物，同时联用甲氨蝶呤和羟氯喹，后改为抗肿瘤坏死因子（抗TNF）治疗。因改善甚微，再次进行手术清创，可见大体上的米粒体，病理显示为伴有坏死的慢性肉芽肿性炎症。然而，反复进行的感染相关检查结果均为阴性。在其症状进展至累及右手示指后，再次对其腱鞘进行取样，抗酸杆菌（AFB）染色显示罕见分枝杆菌属微生物阳性，培养长出微弱透明菌落，送至州立实验室进行菌种鉴定。随后开始使用克拉霉素、乙胺丁醇和利福平进行经验性治疗，之后其伤口完全愈合。该病例说明了非结核分枝杆菌（NTM）腱鞘炎隐匿的病程，导致诊断延迟以及可能有害的不必要治疗。在对常见治疗方式缺乏临床反应且无类似临床表现的替代诊断时，开放组织活检很重要。
