Significance of early diagnosis and surgical management in treating Mycobacterium immunogenum-related pyogenic extensor tenosynovitis: a case report.

BACKGROUND: Non-tuberculous mycobacteria (NTM) are environmental organisms that are increasingly contributing to human infections. Mycobacterium immunogenum, a variant of NTM discovered in 2001, is a rapidly growing mycobacterium that exhibits multidrug resistance. Reports of infections caused by this organism, particularly tenosynovitis in the musculoskeletal system, are limited. CASE PRESENTATION: A 71-year-old female with vesicular pemphigus, undergoing immunosuppressive therapy, presented with a progressively enlarging tumour on the dorsum of her right hand, along with erythematous papules that extended across her right forearm. The specimens of skin tissues and blood cultures revealed the presence of M. immunogenum. Magnetic resonance imaging evaluation led to the diagnosis of pyogenic extensor tenosynovitis. A multidrug regimen, comprising amikacin and clarithromycin, was initiated, followed by synovectomy. The patient underwent a course of 180 days of antimicrobial therapy and demonstrated no signs of disease recurrence one year after treatment completion. CONCLUSION: Early diagnosis and surgical intervention are crucial to prevent the adverse prognostic implications of pyogenic extensor tenosynovitis caused by M. immunogenum. Effective management requires precise microbial identification and susceptibility testing, necessitating collaborative engagement with microbiological laboratories.

High risk and low prevalence diseases: Flexor tenosynovitis.

INTRODUCTION: Flexor tenosynovitis (FTS) is a deep space infection of an upper extremity digit which carries a high rate of morbidity. OBJECTIVE: This review highlights the pearls and pitfalls of FTS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: FTS typically occurs after direct penetrating trauma to the volar aspect of an upper extremity digit. Development of a deep space infection that quickly propagates through the flexor tendon sheath of a digit can result in serious structural damage to the hand and place the patient at risk for significant morbidity such as finger amputation or even result in death. Signs of FTS include symmetrical swelling of the affected finger, the affected finger being held in a flexed position, pain on any attempt of passive finger extension, and tenderness along the course of flexor tendon sheath, known as the Kanavel signs. Systemic symptoms such as fevers and chills may occur. Recognition of these signs and symptoms is paramount in diagnosis of FTS, as laboratory and imaging assessment is not typically diagnostic. ED management involves intravenous antibiotics and emergent surgical specialist consultation. CONCLUSION: An understanding of the presentation and risk factors for development of FTS can assist emergency clinicians in diagnosing and managing this disease in an expedited fashion.

The value of ultrasound-defined tenosynovitis and synovitis in the prediction of persistent arthritis.

OBJECTIVES: The value of US-defined tenosynovitis in predicting the persistence of inflammatory arthritis is not well described. In particular, the predictive utility of US-defined tenosynovitis of larger tendons is yet to be reported. We assessed the value of US-defined tenosynovitis alongside US-defined synovitis and clinical and serological variables in predicting persistent arthritis in an inception cohort of DMARD-naïve patients with early arthritis. METHODS: One hundred and fifty DMARD-naïve patients with clinically apparent synovitis of one or more joints and a symptom duration of ≤3 months underwent baseline clinical, laboratory and US (of 19 bilateral joints and 16 bilateral tendon compartments) assessments. Outcomes were classified as persistent or resolving arthritis after 18 months' follow-up. The predictive value of US-defined tenosynovitis for persistent arthritis was compared with those of US-defined synovitis, and clinical and serological variables. RESULTS: At 18 months, 99 patients (66%) had developed persistent arthritis and 51 patients (34%) had resolving disease. Multivariate logistic regression analysis showed that US-detected digit flexor tenosynovitis [odds ratio (OR): 6.6, 95% CI: 2.0 , 22.1, P = 0.002] provided independent predictive data for persistence over and above the presence of US-detected joint synovitis and RF antibodies. In the RF/ACPA-negative subcohort, US-defined digit flexor tenosynovitis remained a significant predictive variable (OR: 4.7, 95% CI: 1.4, 15.8, P = 0.012), even after adjusting for US-defined joint synovitis. CONCLUSION: US-defined tenosynovitis provided independent predictive data for the development of persistent arthritis. The predictive role of US-defined digit flexor tenosynovitis should be further assessed; investigators should consider including this tendon site as a candidate variable when designing imaging-based predictive algorithms for persistent inflammatory arthritis development.

Synovitis due to Histoplasma capsulatum: a case series and literature review.

Musculoskeletal manifestations of Histoplasma capsulatum infection are uncommon but can mimic inflammatory arthritis. Early diagnosis of this complication is of critical importance in the era of potent immunosuppression for rheumatologic diseases. We conducted a retrospective chart review for patients with histoplasmosis and tenosynovitis, synovitis, or arthritis, diagnosed and treated at our institution between January 1, 2000, and December 31, 2019. We also reviewed the relevant literature. Four patients with biopsy-proven, culture-proven histoplasma tenosynovitis were identified at our institution. All four patients had wrist or hand involvement in an asymmetric pattern, and one patient had lower extremity involvement as well. Two patients were not immunocompromised at baseline. One patient underwent a lengthy evaluation and received immunosuppression for 4 years without improvement prior to the diagnosis of histoplasmosis. Histoplasma serologic tests varied among patients with localized infection. Pathologic findings revealed non-caseating granulomatous inflammation. Three patients recovered after 6-12 months of antifungal treatment. One patient still had recurrent infection despite 20 months of treatment. Histoplasma tenosynovitis and synovitis are rare causes of inflammatory arthritis. Infectious causes should be considered and carefully evaluated when patients present with asymmetric oligoarthritis. Early recognition is crucial for successful treatment, especially in patients with concomitant rheumatologic diseases receiving immunosuppressive treatment.

Common Hand Conditions: A Review.

Importance: Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and basilar (carpometacarpal) joint arthritis of the thumb can be associated with significant disability. Observations: Carpal tunnel syndrome is characterized by numbness and tingling in the thumb and the index, middle, and radial ring fingers and by weakness of thumb opposition when severe. It is more common in women and people who are obese, have diabetes, and work in occupations involving use of keyboards, computer mouse, heavy machinery, or vibrating manual tools. The Durkan physical examination maneuver, consisting of firm digital pressure across the carpal tunnel to reproduce symptoms, is 64% sensitive and 83% specific for carpal tunnel syndrome. People with suspected proximal compression or other compressive neuropathies should undergo electrodiagnostic testing, which is approximately more than 80% sensitive and 95% specific for carpal tunnel syndrome. Splinting or steroid injection may temporarily relieve symptoms. Patients who do not respond to conservative therapies may undergo open or endoscopic carpal tunnel release for definitive treatment. Trigger finger, which involves abnormal resistance to smooth flexion and extension ("triggering") of the affected finger, affects up to 20% of adults with diabetes and approximately 2% of the general population. Steroid injection is the first-line therapy but is less efficacious in people with insulin-dependent diabetes. People with diabetes and those with recurrent symptoms may benefit from early surgical release. de Quervain tenosynovitis, consisting of swelling of the extensor tendons at the wrist, is more common in women than in men. People with frequent mobile phone use are at increased risk. The median age of onset is 40 to 59 years. Steroid injections relieve symptoms in approximately 72% of patients, particularly when combined with immobilization. People with recurrent symptoms may be considered for surgical release of the first dorsal extensor compartment. Thumb carpometacarpal joint arthritis affects approximately 33% of postmenopausal women, according to radiographic evidence of carpometacarpal arthritis. Approximately 20% of patients require treatment for pain and disability. Nonsurgical interventions (immobilization, steroid injection, and pain medication) relieve pain but do not alter disease progression. Surgery may be appropriate for patients unresponsive to conservative treatments. Conclusions and Relevance: Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and thumb carpometacarpal joint arthritis can be associated with significant disability. First-line treatment for each condition consists of steroid injection, immobilization, or both. For patients who do not respond to noninvasive therapy or for progressive disease despite conservative therapy, surgical treatment is safe and effective.

[DE QUERVAIN'S TENOSYNOVITIS - CLINICAL PRESENTATION AND TREATMENT].

INTRODUCTION: De-Quervain tenosynovitis, named after the Swiss surgeon Fritz De Quervain, is a condition characterized by pain and tenderness over the first extensor compartment of the wrist. This compartment contains the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons in their individual retinacular sheath. Non-inflammatory thickening of the tendinous sheath leads to entrapment of the individual tendons and increased friction. The condition is more common in women, particularly aged 30-50 years old and those 4-6 weeks in their post-partum period. It can be associated with trauma or repetitive motion but is typically of unknown etiology. While most cases are self-limiting, treatment is often required and comprises of non-operative treatment: anti-inflammatory medication, wrist splints and local steroid injection; and operative treatment: surgical release of the 1st dorsal compartment.

Tenosynovitis caused by Mycobacterium marseillense, initially identified as Mycobacterium avium complex using AccuProbe and COBAS TaqMan.

BACKGROUND: Mycobacterium marseillense is a new species of the Mycobacterium avium complex. There has been only a few human infections caused by M. marseillense worldwide. CASE PRESENTATION: We report a case of tenosynovitis caused by M. marseillense in an immunocompetent adult in Japan. The isolate was initially identified as M. intracellulare using commercial real time polymerase chain reaction assays and later identified as M. marseillense with sequencing of the the rpoB and hsp65 regions, and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). CONCLUSIONS: This is the first case reporting on M. marseillense generating a positive result with commercial real time PCR assays targeting MAC. Human infections associated by M. marseillense might be underreported due to similarities with Mycobacterium intracellulare. To accurately identify M. marseillese, MALDI-TOF MS might provide a rapid and reliable method.

Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND: Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition. QUESTION/PURPOSE: What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics? METHODS: This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively. RESULTS: After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively. CONCLUSION: Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Olympic competition climbing: the beginning of a new era-a narrative review.

Climbing as a competition sport has become increasingly popular in recent years, particularly the sub-discipline of bouldering. The sport will debut in the Tokyo Summer Olympic Games. National and international competitions have three disciplines: lead (climbing with rope protection), bouldering (climbing at lower heights with mattress floor protection) and speed (maximum speed climbing on a standardised route in 1-on-1 mode). There is also a 'combined mode' of all three disciplines (combined) which forms the Olympic competition format; all competition formats are held on artificial walls. Existing literature describes a predominantly low injury frequency and severity in elite climbing. In comparison to climbing on real rock, artificial climbing walls have recently been associated with higher injury rates. Finger injuries such as tenosynovitis, pulley lesions and growth plate injuries are the most common injuries. As finger injuries are sport-specific, medical supervision of climbing athletes requires specific medical knowledge for diagnosis and treatment. There is so far little evidence on effective injury prevention measures in top athletes, and antidoping measures, in general, requiring further work in this field. An improved data situation regarding high-performance climbing athletes is crucial to ensure that the sport continues to be largely safe and injury-free and to prevent doping cases as extensively as possible.

A Rare Case of Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: a Case Report.

Tuberculosis (TB) is still a worldwide problem. We present a case of flexor tenosynovitis due to tuberculosis in the hand and wrist. A 42-year-old man presented to the outpatient clinic with a 2-year history of a slowly growing mass over the volar aspect of the left wrist. His MRI showed multiple rice bodies in the wrist and hand. An open biopsy was performed. Pathology specimens showed granulomatous lesions with central necrosis. The purified protein derivative (PPD) test was positive. In this case, granulomatous lesions with central necrosis, rice bodies, and positive PPD test confirmed the diagnosis of TB in the wrist and hand. There was no other concurrent evidence of TB elsewhere. Antituberculosis chemotherapy was commenced. Tuberculous tenosynovitis of the wrist and hand is very rare. The tuberculous tenosynovitis should be kept in mind as an infectious agent when patients are presenting with atypical clinical. Key words: tuberculosis, rice bodies, flexor tenosynovitis, wrist, hand.

CT scan assessment of the dimensions and morphological variations of the peroneal tubercle.

PURPOSE: The hypertrophied peroneal tubercle may result in lateral ankle pain with peroneal tendon tenosynovitis and rupture. The aim of this study was to evaluate different configurations and dimensions of the normal peroneal tubercle using two-dimensional CT scan. METHODS: Totally, 100 normal CT scans of cases older than 18 years of age were assessed to determine the shape of the peroneal tubercle. Moreover, height, length and width of different configurations of the normal peroneal tubercle were measured in axial and coronal sections of the ankle CT scans. RESULTS: Four different configurations based on the axial cut of the calcaneus were found; single-convex (59%), double-convex (24%), plateau (9%), and convex-concave (8%) without statistically significant difference between genders (p-value: 0.526). Totally, mean of height, length and width were 4.42 ± 1.38 mm, 28.88 ± 6.58 mm and 17.17 ± 3.85 mm, respectively. Although mean of the height in the single-convex and the double-convex types were 4.5 ± 1.4 mm and 5.0 ± 1.4 mm, respectively, the highest peroneal tubercle in the single-convex and the double-convex group were 10.2 mm and 8.5 mm, respectively. CONCLUSIONS: In cases with lateral ankle pain and suspicious to hypertrophied peroneal tubercle, two-dimensional CT scan can be an available practical modality to identify the pathological type of the peroneal tubercle based on the presented classification and normal values. As previously reported in the literature, considering cut-off point of 5 mm could result in overdiagnosis of the hypertrophied peroneal tubercle, especially in single-convex type; however, clinical correlation is always paramount. LEVEL OF EVIDENCE: Level IV.

Conventional versus ultrasound treat to target: no difference in magnetic resonance imaging inflammation or joint damage over 2 years in early rheumatoid arthritis.

OBJECTIVE: To investigate whether an ultrasound-guided treat-to-target strategy for early RA would lead to reduced MRI inflammation or less structural damage progression compared with a conventional treat-to-target strategy. METHODS: A total of 230 DMARD-naïve early RA patients were randomized to an ultrasound tight control strategy targeting DAS <1.6, no swollen joints and no power Doppler signal in any joint or a conventional strategy targeting DAS <1.6 and no swollen joints. Patients in both arms were treated according to the same DMARD escalation strategy. MRI of the dominant hand was performed at six time points over 2 years and scored according to the OMERACT RA MRI scoring system. A total of 218 patients had baseline and one or more follow-up MRIs and were included in the analysis. The mean MRI score change from baseline to each follow-up and the 2 year risk for erosive progression were compared between arms. RESULTS: MRI bone marrow oedema, synovitis and tenosynovitis improved over the first year and was sustained during the second year of follow-up, with no statistically significant differences between the ultrasound and the conventional arms at any time point. The 2 year risk for progression of MRI erosions was similar in both treatment arms: ultrasound arm 39%, conventional arm 33% [relative risk 1.16 (95% CI 0.81, 1.66), P = 0.40]. CONCLUSION: Incorporating ultrasound information in treatment decisions did not lead to reduced MRI inflammation or less structural damage compared with a conventional treatment strategy. The findings support that systematic use of ultrasound does not provide a benefit in the follow-up of patients with early RA. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, http://clinicaltrials.gov, NCT01205854.

Infectious Tenosynovitis of the Tibialis Anterior Due to Mycobacterium chelonae After Intravenous Heroin Injection.

Mycobacterium chelonae is a ubiquitous Gram-positive, acid-fast, non-spore-forming bacterium commonly encountered in nature associated with aquatic animals, soil, and water, including tap water. Nontuberculous mycobacterial tenosynovitis infections caused by M. chelonae in the lower extremity are uncommon, leading to a paucity of literature documenting the diagnosis and treatment of such cases. This report is of a 65-year-old male patient who was found to have an M. chelonae infection along the tibialis anterior tendon after injecting himself with heroin into the dorsal foot veins. This review covers the diagnosis and treatment as well as a case report on the outcome of infectious tenosynovitis of the tibialis anterior associated with M. chelonae. To date, this is the only reported case of tibialis anterior infectious tenosynovitis caused by M. chelonae after intravenous heroin injection.

Is there any effect of presence and size of os trigonum on flexor hallucis longus tendon lesions?

BACKGROUND: It was hypnotized that presence and larger size of os trigonum (OT) can affect flexor hallucis longus tendon (FHL), so tenosynovitis, degeneration and partial tear can be developed. METHODS: A total of 98 (Study group: 50, Control: 48) subjects included to study and compered status of FHL lesions. Sagittal length and axial width of OT were measured on MRI to determine effect of OT on FHL lesions and correlated with arthroscopic findings. RESULTS: FHL tenosynovitis (p: 0,025), degeneration (p: 0,01) and partial tear (p: 0.008) was identified statistically high in study group. Statistical analysis revealed that as length of OT increased, frequency of degeneration (p: 0.03) and partial tear (p: 0.00) of FHL increased. CONCLUSION: Analyzes were showed that the presence of os trigonum had an important role on the FHL pathologies. Additional finding of study was to demonstrate that possibility of FHL lesion increased as length of OT extended. LEVELS OF EVIDENCE: Level 3.

Automatic quantification of tenosynovitis on MRI of the wrist in patients with early arthritis: a feasibility study.

OBJECTIVES: Tenosynovitis (inflammation of the synovial lining of the sheath surrounding tendons) is frequently observed on MRI of early arthritis patients. Since visual assessment of tenosynovitis is a laborious task, we investigated the feasibility of automatic quantification of tenosynovitis on MRI of the wrist in a large cohort of early arthritis patients. METHODS: For 563 consecutive early arthritis patients (clinically confirmed arthritis ≥ 1 joint, symptoms < 2 years), MR scans of the wrist were processed in three automatic stages. First, super-resolution reconstruction was applied to fuse coronal and axial scans into a single high-resolution three-dimensional image. Next, 10 extensor/flexor tendon regions were segmented using atlas-based segmentation and marker-based watershed. A measurement region of interest (ROI) was defined around the tendons. Finally, tenosynovitis was quantified by identifying image intensity values associated with tenosynovial inflammation using fuzzy clustering and measuring the fraction of voxels with these characteristic intensities within the measurement ROI. A subset of 60 patients was used for training and the remaining 503 patients for validation. Correlation between quantitative measurements and visual scores was assessed through Pearson correlation coefficient. RESULTS: Pearson correlation between quantitative measurements and visual scores across 503 patients was r = 0.90, p < 0.001. False detections due to blood vessels and synovitis present within the measurement ROI contributed to a median offset from zero equivalent to 13.8% of the largest measurement value. CONCLUSION: Quantitative measurement of tenosynovitis on MRI of the wrist is feasible and largely consistent with visual scores. Further improvements in segmentation and exclusion of false detections are warranted. KEY POINTS: • Automatic measurement of tenosynovitis on MRI of the wrist is feasible and largely consistent with visual scores. • Blood vessels and synovitis in the vicinity of evaluated tendons can contribute to false detections in automatic measurements. • Further improvements in segmentation and exclusion of false detections are important directions of future work on the path to a robust quantification framework.

Clinical manifestations and outcomes of musculoskeletal nontuberculous mycobacterial infections.

To investigate the clinical manifestations and outcomes of musculoskeletal (MSK) nontuberculous mycobacterium (NTM) infections. This study was a retrospective cohort study using the Siriraj Hospital database from 2005 to 2017. Enrolled were all patients aged 15 or older who had an MSK infection with NTM identified in synovial fluid, pus, or tissue by an acid-fast bacilli stain, culture, or polymerase chain reaction. Of 1529 cases who were diagnosed with NTM infections, 39 (2.6%) had an MSK infection. However, only 28 patients met our inclusion criteria. Their mean age (SD) was 54.1 (16.1) years, and half were male. Of this cohort, 25% had previous musculoskeletal trauma, 18% prior bone and joint surgery, 14% prosthetic joint replacement, and 11% HIV infection. The median symptom duration (IQR) was 16 (37.4) weeks. The most common MSK manifestation was arthritis (61%), followed by osteomyelitis (50%), tenosynovitis (25%), and spondylodiscitis (14%). The most common organism was M. abscessus (18%), and M. kansasii (18%), followed by M. intracellulare (14%), M. marinum (14%), M. fortuitum (7%), and M. haemophilum (7%). In addition to medical treatment, most patients underwent surgery (82%), comprising debridement, osteotomy, prosthesis removal, and amputation, while 18% received only medical treatment. The treatment outcomes were complete recovery in 46%, improvement with some residual disability and deformities in 29%, and death in 3.6%. Musculoskeletal NTM infections were uncommon. Most patients had underlying joint disease or were immunocompromised hosts. Surgical management, as an adjunct to medical therapy, was necessary.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies.

Pyogenic flexor tenosynovitis (PFT)is a potentially devastating closed-space infection of the flexor tendon sheath of the hand that can result in considerable morbidity. Management of PFT, regardless of the pathogen, includes prompt administration of empirical intravenous antibiotics and often surgical treatment. However, currently, there is no standardized treatment algorithm for PFT in regards to the need for, timing, or type of surgical treatment. Many utilize a combination of surgical decompression and sheath irrigation. However, despite prompt treatment, and regardless of the protocol used, complication rates can be high, leading to impaired function and even amputation of the affected digit. Further research is needed to elucidate the role of local antibiotics and corticosteroids in treating this condition and potentially preventing the morbid outcomes that are currently seen. This paper reviews the background, microbiology, and treatment options and controversies surrounding PFT.

Hand Infections.

Infections are common in hand surgery and proper management is important to achieve optimal outcomes. Although most cases are not urgent, less common, severe infections such as flexor tenosynovitis and necrotizing fasciitis require urgent identification with both medical and surgical management. It is common for diagnoses to be missed or delayed because clinical and laboratory indicators are often variably present. Delayed identification and management can result in poor outcomes with permanent deficits. This article will provide a review of hand infections with a focus on identifying serious hand infections requiring urgent or emergent treatment, and distinguishing these from less urgent scenarios.

Tenosynovitis caused by Mycobacterium malmoense in two kidney transplant recipients and review of the literature.

We report two unrelated cases of tenosynovitis caused by Mycobacterium malmoense in kidney transplant recipients. Both patients received immunosuppression and were referred to our tertiary hospital because of persisting complaints lasting >6 months not responding to corticosteroids or surgery. The mycobacterial cultures were positive for the slow-growing M. malmoense after several weeks of incubation. The patient in Case 1 was treated with a combination of surgical debridement and antibiotics, whereas the patient in Case 2 was only treated surgically. Both cases illustrate the doctor's delay in diagnosing mycobacterial infections, and remind us that nontuberculous mycobacterial infections should be part of the differential diagnosis of tenosynovitis, especially in immunocompromised patients.