BCGitis of the wrist after intravesical BCG therapy: A case report.

Septic arthritis of the wrist can result in joint destruction, making timely diagnosis crucial for initiating empiric antibiotics and surgical intervention. Mycobacterium is a rare cause of this disorder. A 47-year-old man with bladder cancer was treated surgically and received BCG intravesical therapy. Eleven months later, this patient developed severe carpal BCGitis requiring total carpal resection. The first step was addition of a cement spacer and radiometacarpal stabilisation (Masquelet technique). Secondary infections occurred aggravating the prognosis. This case emphasises the importance of taking into account the patient's medical history. Tuberculosis of the wrist is a rare etiology for septic arthritis; delayed treatment leads to severe complications and functional sequelae.

Septic Joints: Finger and Wrist.

Infections in the joints of the hand and wrist carry the risk of significant morbidity. Common presenting symptoms include joint redness, swelling, and pseudoparalysis that occurs several days following a penetrating trauma. Diagnostic workup should be expedited, including a laboratory evaluation and arthrocentesis. Imaging, including radiographs, ultrasound, computed tomography, and/or MRI, are helpful tools in diagnosis. Once infection is identified, prompt surgical debridement and antibiotics are required. Once the infection has been managed, hand therapy is initiated to decrease the risk of stiffness. Stiffness is the most common complication following infection; additional reported complications include arthritis, ankylosis, and amputation."

Hand and wrist tuberculosis in paediatric patients - our experience in 44 patients.

Skeletal tuberculosis (TB) of the hand and wrist is rare, accounting for less than 1% of all osteoarticular TB. Although rare, TB of the hand and wrist is a cause of major morbidity. A common feature among all available reports on TB of the hand and wrist was a delay in diagnosis, causing residual stiffness and pain after treatment. Minimal initial symptoms, rarity of the lesion and ability of wrist TB to mimic more common pathologies account for the delay. Skeletal TB may behave differently in this age compared with the adult population. Further, the disease may affect the growing bone, causing residual deformities. The paucity of studies from different countries, coupled with a difficulty in diagnosis resulting in major morbidity, led us to carry out a study on this topic. A total of 44 patients with skeletal lesions in the hand and wrist were studied. The diagnosis was confirmed by biopsy. Patients were started on multidrug antitubercular treatment (ATT). Those not responding were scheduled for debridement. All patients were assessed using the Green O'Brian scoring system. All these patients were studied separately for clinical presentation, nutritional status (Rainey-Mcdonald nutritional index), time from onset of symptoms to presentation, treatment required, prognosis and complications. The proximal phalanx of the fourth digit and the metacarpal of the fifth digit were the most commonly involved bones in our series, with five cases of each. The capitate was the most common carpal bone, followed by the lunate. The duration of symptoms ranged from 5 weeks to 24 weeks (mean: 7.6 weeks). Most of these patients presented with complaints of pain, followed by swelling. 13 patients did not respond favourably to ATT over an 8-week period and were scheduled for surgery. Three of these patients had multidrug resistance. There was one case of a pathological fracture in our series and seven cases of arthritis/residual significant pain at the end of follow-up. For all the other patients, the results were excellent. A very high index of suspicion, MRI and early biopsy are required for a timely diagnosis of skeletal TB of the hand and wrist. Early commencement of ATT was the most important factor for good results. The possibility of multidrug resistance should be kept in mind for patients not responding to treatment.

Cutaneous mucormycosis of the upper extremity in an immunocompetent host: case report.

Cutaneous mucormycosis, a relatively common infection in immunocompromised patients, remains rare in the immunocompetent patient outside the setting of major trauma. We report a case of an immunocompetent patient who developed left upper extremity Rhizopus infection following arterial puncture. Treatment included surgical debridement, liposomal amphotericin B, and hyperbaric oxygen wound therapy; the patient recovered fully. A review of the literature of cases of upper extremity Mucor infection is included for context. We feel that a high degree of suspicion for Mucor infection is warranted in patients with the described risk factors who do not respond to first-line antibiotics.

Arthroscopic management of septic arthritis of the wrist.

Bacterial septic arthritis of the wrist is a joint-threatening emergency that is often treated by open irrigation and debridement (I and D). There is evidence that patients with isolated septic arthritis of the wrist require fewer operations and have a shorter hospital stay when treated arthroscopically. This article describes the surgical technique for arthroscopic I and D of the wrist and discusses the indications and benefits of arthroscopic versus open I and D for septic arthritis of the wrist.

Comparison of arthroscopic and open treatment of septic arthritis of the wrist. Surgical technique.

BACKGROUND: Open irrigation and débridement is the standard of treatment for septic arthritis of the wrist. Although isolated cases of arthroscopic irrigation and débridement have been reported, a comparison of arthroscopic and open techniques has not been performed, to our knowledge. The purpose of this study was to compare the two methods of management. METHODS: A retrospective comparison of patients with septic arthritis of the wrist initially treated, over an eleven-year period, with open or arthroscopic irrigation and débridement was undertaken at a single institution. The clinical presentation, laboratory and microbiological findings, hospital course, complications, and outcomes were compared between the two groups. RESULTS: Between 1997 and 2007, thirty-six patients with septic arthritis involving a total of forty wrists were identified. Nineteen wrists (seventeen patients) were initially treated with open irrigation and débridement, and twenty-one wrists (nineteen patients) were initially treated arthroscopically. Eleven wrists in the open-treatment cohort required repeat irrigation and débridement, and eight wrists in the arthroscopy cohort required a repeat procedure. If a repeat irrigation and débridement was required, it was performed in an open fashion in all but two cases. When the comparison included all of the patients in the series, no difference between the two cohorts was found with regard to the number of irrigation and débridement procedures required or the length of the hospital stay. However, when the comparison was limited to the patients with isolated septic arthritis of the wrist, it was found that only one of seven wrists in the open-treatment cohort but all eight wrists in the arthroscopy cohort had been successfully managed with a single irrigation and débridement procedure (p = 0.001). No patient in whom isolated septic arthritis of the wrist had been treated with arthroscopic irrigation and débridement required a second operation. The patients in whom isolated septic arthritis of the wrist was treated with the open method stayed in the hospital for an average of sixteen days compared with a six-day stay for those in whom isolated septic arthritis of the wrist was treated with the arthroscopic method (p = 0.04). The ninety-day perioperative mortality rate in the series was substantial (18% [three patients] in the open-treatment cohort and 21% [four patients] in the arthroscopy cohort). CONCLUSIONS: Arthroscopic irrigation and débridement is an effective treatment for patients with isolated septic arthritis of the wrist; these patients had fewer operations and a shorter hospital stay than did patients who had received open treatment. However, these benefits were not seen in patients with multiple sites of infection.

Indolent infectious tenosynovitis afflicting rheumatoid patients treated with tumor necrosis factor inhibitors: case report.

Tumor necrosis factor (TNF) is a cytokine associated with the pathogenesis of rheumatoid arthritis. Tumor necrosis factor inhibitors have become important biological treatments that favorably alter the natural history of rheumatoid disease. Side effects include an increased risk of malignancy and infection, particularly tuberculosis. We present 2 patients with rheumatoid arthritis on TNF inhibitors in whom flares of wrist tenosynovitis, initially diagnosed as rheumatoid disease exacerbations, were caused by infections with uncommon opportunistic pathogens. Diagnostic and treatment recommendations for this subset of rheumatoid patients are discussed.

"You never asked doc., I do fish".

Joint pains and swellings are routine complaints in rheumatology clinics. Infectious diseases may mimic common rheumatic conditions and thus need to be ruled out before initiating any immunosuppressive treatment. Mycobacterium marinum is an organism that can present with a typical arthritis picture. A 60-year-old gentleman with a complicated medical history presented with a right wrist swelling which was initially managed as a case of remitting seronegative arthritis. He eventually required tenolysis and the biopsy showed M. marinum. On inquiry, he was found to be an avid fisherman. This report discusses typical diagnostic pitfalls, literature review on the reported cases and treatment strategies. The most important point is to ask for occupational and hobby history in such cases.

Comparison of arthroscopic and open treatment of septic arthritis of the wrist.

BACKGROUND: Open irrigation and débridement is the standard of treatment for septic arthritis of the wrist. Although isolated cases of arthroscopic irrigation and débridement have been reported, a comparison of arthroscopic and open techniques has not been performed, to our knowledge. The purpose of this study was to compare the two methods of management. METHODS: A retrospective comparison of patients with septic arthritis of the wrist initially treated, over an eleven-year period, with open or arthroscopic irrigation and débridement was undertaken at a single institution. The clinical presentation, laboratory and microbiological findings, hospital course, complications, and outcomes were compared between the two groups. RESULTS: Between 1997 and 2007, thirty-six patients with septic arthritis involving a total of forty wrists were identified. Nineteen wrists (seventeen patients) were initially treated with open irrigation and débridement, and twenty-one wrists (nineteen patients) were initially treated arthroscopically. Eleven wrists in the open-treatment cohort required repeat irrigation and débridement, and eight wrists in the arthroscopy cohort required a repeat procedure. If a repeat irrigation and débridement was required, it was performed in an open fashion in all but two cases. When the comparison included all of the patients in the series, no difference between the two cohorts was found with regard to the number of irrigation and débridement procedures required or the length of the hospital stay. However, when the comparison was limited to the patients with isolated septic arthritis of the wrist, it was found that only one of seven wrists in the open-treatment cohort but all eight wrists in the arthroscopy cohort had been successfully managed with a single irrigation and débridement procedure (p = 0.001). No patient in whom isolated septic arthritis of the wrist had been treated with arthroscopic irrigation and débridement required a second operation. The patients in whom isolated septic arthritis of the wrist was treated with the open method stayed in the hospital for an average of sixteen days compared with a six-day stay for those in whom isolated septic arthritis of the wrist was treated with the arthroscopic method (p = 0.04). The ninety-day perioperative mortality rate in the series was substantial (18% [three patients] in the open-treatment cohort and 21% [four patients] in the arthroscopy cohort). CONCLUSIONS: Arthroscopic irrigation and débridement is an effective treatment for patients with isolated septic arthritis of the wrist; these patients had fewer operations and a shorter hospital stay than did patients who had received open treatment. However, these benefits were not seen in patients with multiple sites of infection. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Flexor tendon synovitis of the hand as first manifestation of atypical tuberculosis.

We present the case of a 73-year old patient suffering from chronic flexor tendon synovitis of the wrist with carpal tunnel syndrome. He underwent synovectomy and median nerve release. Primary bacteriology was negative. Histology of the excised synovia revelead non-caseating granuloma as typical for sarcoidosis. Further screening for sarcoidosis was negative. Culture of a sample harvested from the poorly healing wound was finally positive for Mycobacterium tuberculosis. Tuberculostatic treatment was started and the wound gradually healed. To the best of our knowledge, this is the first reported case of atypical non-caseating and sarcoidosis-like granulomas of the flexor tendon synovia of the hand as first manifestation of tuberculosis.

Mycobacterium tuberculosis-induced carpal tunnel syndrome: management and follow-up evaluation.

PURPOSE: To determine the clinical characteristics of 12 patients with Mycobacterium tuberculosis-induced carpal tunnel syndrome. This article also presents our intraoperative findings and surgical treatment results. METHODS: Twelve patients with tuberculosis-induced carpal tunnel syndrome who had surgery during a 10-year period that began in March 1991 were reviewed. The entrance criterion was a positive histologic report of tuberculosis for surgical specimens. The preoperative evaluation leading to diagnosis was reviewed for all patients. Transection of the transverse carpal ligament and complete synovectomy were performed for all patients. After surgery the patients were given an antituberculosis regimen for 1 year and were followed up for an average of 6 years. RESULTS: Twelve cases from a total of 1,180 patients with carpal tunnel syndrome were traced to M tuberculosis involvement of synovial tissue of the flexor tendons. Ten patients had large rice bodies in thick synovial membranes, and in the other 2 patients thick synovial tissue with yellow exudates were observed during surgery. In contrast to tendon involvement with rupture, no direct median nerve involvement was noted. Histopathologic study results of surgical specimens were positive for tuberculosis in all patients. Eight of 10 initial smears showed acid-fast bacillus and all 10 cultures of the specimens were positive for tubercle bacilli. Surgery and antituberculosis therapy were associated with a desirable outcome and sensory disturbance in the median nerve distribution resolved in all patients. Anterior wrist swelling disappeared and there has been no clinical or laboratory evidence of recurrence in all treated patients. CONCLUSIONS: Early diagnosis and surgical treatment combined with antituberculosis medical treatment are important in treating this condition. All patients treated were relieved of symptoms of synovial proliferation at the wrist, with no recurrence of the condition during the follow-up period. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Histoplasmosis infection presenting as an isolated subcutaneous periarticular upper limb swelling in the immunosuppressed patient.

Atypical mycobacterial and fungal infections may occur in immunosuppressed patients. The impaired host response can make the clinical presentation atypical. Blood and tissue cultures may be negative in the acute phase of the illness, which can lead to a delay in diagnosis. In those patients with AIDS or other underlying immunosuppressive conditions, histoplasmosis cannot always be eradicated, but treatment that achieves chronic suppression may be adequate to maintain functional capacity. This report describes two immunosuppressed patients who presented with isolated subcutaneous histoplasmosis infection around the wrist.

MR imaging: arthropathies and infectious conditions of the elbow, wrist, and hand.

The superior soft tissue contrast and multiplanar capability of MR imaging has contributed to earlier diagnosis and implementation of effective treatment for a variety of arthropathies and infectious conditions of the elbow, wrist, and hand. Because of overlapping clinical signs and symptoms, MR imaging plays an important role in delineating the features and staging of each of these conditions. This article discusses the seropositive and seronegative inflammatory arthropathies, with emphasis on early detection and surveillance, as well as gout, synovial osteochondromatosis, pigmented villonodular synovitis, tenosynovitis, and de Quervain's tenosynovitis. Certain noninflammatory arthritides and infectious conditions are also reviewed.

Co-existent gout and septic arthritis at the wrist: a case report.

This article presents an exceptional clinical manifestation of gout in the wrist. The patient suffered from an association of septic and urate-crystal-induced arthritis. At the time, the serum uric acid concentration was still normal. The association of septic and urate-crystal-induced arthritis has been reported in other locations. The pathophysiology of the precipitation of urate crystals in the presence of an infectious process is discussed.

A case of Mycobacterium scrofulaceum osteomyelitis of the right wrist.

INTRODUCTION: The objective of the case report is to highlight the possibility of osteomyelitis caused by atypical mycobacteria. Such an infection may simulate tuberculous bone infection and yet fail to respond to standard anti-tuberculous drug therapy. CLINICAL PICTURE: A 66-year-old man who suffered from diabetes mellitus presented with osteomyelitis of the right wrist, with extensive synovial swellings of the flexor tendon sheaths. The clinical features, radiological appearances and histology suggested a tuberculous infection, but subsequent culture grew an atypical mycobacterium, Mycobacterium scrofulaceum. TREATMENT AND OUTCOME: There was good clinical improvement and control of the infection with a regime of kanamycin, ethambutol and ethionamide to which the organism was sensitive. CONCLUSION: This case illustrates the need to be aware of the possibility of infection with atypical mycobacteria in cases of suspected tuberculosis of the skeletal system which fail to respond to standard treatment.

[A case of arthritis of the wrist caused by Mycobacterium marinum. Review of the literature]. / A propos d'un cas d'arthrite du poignet à Mycobacterium marinum. Revue de la littérature.

The authors report the case of a woman aquarium keeper who developed septic arthritis of her right wrist due to Mycobacterium marinum. Clinical status and history, histopathologic and microbiologic characteristics are reviewed and discussed. The authors emphasize the importance of urgent and aggressive surgery combined with antimicrobial chemotherapy.

Three-phase bone and Ga-67 scintigraphy in disseminated sporotrichosis.

A 27-year-old man, who had been shoveling gravel in southern Texas for 3 years, had a history of papules and nodules in the left lateral wall of the abdomen. The lesions increased in number and severity with spread to other regions of the body. A punch biopsy of the right arm lesion revealed intracellular, round and cigar shaped budding yeast. The cultures grew Sporotrichum schenkii. Three-phase bone imaging and a Ga-67 scan defined the extent of the disease including involvement of the right tibia, left second metacarpal, and the left wrist joints, the latter two of which were not apparent on clinical examination.