Major Amputation Needed to Treat Purulent Tenosynovitis and Necrotizing Fasciitis in a Patient with a Human Bite and Severe COVID-19.

Background: Peripheral human bite wounds are rarely serious and are typically treated medically, with the most complex cases requiring only minor amputation or excision of the infected site. There are few to no reports documenting the development of purulent tenosynovitis, necrotizing fasciitis, and osteomyelitis from these lesions. Major amputations are required only rarely in these cases. Case Presentation: A 71-year-old woman presented with an uncontrolled infection following a self-inflicted bite wound to her left middle finger. A bacterial culture of the lesion revealed methicillin-resistant Staphylococcus aureus (MRSA). The infection could not be controlled with antibiotics or additional interventions, including debridement and minor amputation. She contracted severe COVID-19 while in the hospital which limited the available treatment options. In an attempt to control the infection, the patient ultimately underwent a major amputation of the distal left forearm. While recovering from the procedure, the patient succumbed to septic shock and cardiopulmonary arrest. Conclusion: The unusual progression of this case may be attributed to the interventions required to treat acute COVID-19 as well as a variety of confounding factors. For example, vasopressors and steroids used to treat severely-ill patients compromise the local and systemic physiologic responses to acute bacterial infection. It is important to reconsider clinical expectations during the pandemic and intervene as early as possible to prevent ongoing damage and clinical deterioration.

Purulent Flexor Tendon Rupture of the Hand due to Mycobacterium abscessus Infection: A Case Report and Review of the Literature.

Mycobacterium abscessus infection of the upper extremities is uncommon. However, M abscessus can cause severe chronic tenosynovitis, and delayed diagnosis may result in poor outcomes. We describe an unusual clinical case of purulent flexor tendon synovitis followed by subcutaneous tendon rupture due to M abscessus infection in a patient with diabetes mellitus. A 76-year-old man presented to our hospital with painful, erythematous swelling over his left fourth finger. On physical examination, the left fourth finger was swollen and reddish, with persistent exudate from the surgical scar. The left elbow was also swollen and reddish with persistent discharge, which was consistent with olecranon bursitis. The patient was unable to flex his left fourth finger, and the passive range of motion of the finger was also restricted. The physical examination findings and patient history suggested purulent flexor tendinitis. His infection healed after radical debridement of necrotic tissue and administration of antibiotics effective against M abscessus. Third-stage flexor reconstruction restored the function of the fourth finger. The combination of surgical debridement and chemotherapy was the most effective treatment for mycobacterial tenosynovitis. This case shows that M abscessus can cause chronic severe purulent tenosynovitis and flexor tendon rupture after tendon surgery. Although early diagnosis and combination treatment with debridement and chemotherapy might improve outcomes by limiting the severity and duration of damage to the flexor synovial system, late-presenting patients require combined radical debridement of necrotic tissue and aggressive chemotherapy followed by staged flexor tendon reconstruction.

Continuous Catheter Irrigation for the Treatment of Purulent Tenosynovitis during Two-Stage Flexor Tendon Reconstruction.

Two-stage flexor tendon reconstruction with a silicone rod is useful for restoring the tendon and tendon sheath but sometimes results in infection after the first-stage operation. We experienced a case in which we maintained the reconstructed tendon sheath by replacing an infected silicone rod with a polyvinyl chloride tube, followed by continuous catheter irrigation until the infection subsided. This procedure can effectively deal with infection of a silicone rod during two-stage flexor tendon reconstruction.