A systematic review of inflammatory cells and markers in human tendinopathy.

BACKGROUND: This article systematically reviews the current evidence regarding inflammation in Tendinopathy with the aim to increase understanding of a potential common pathophysiology. METHODS: Following the PRISMA statements, the terms: (tendinopathy OR (tendons AND rupture)) AND (inflammation OR (inflammation AND cells) OR immune system OR inflammation mediators OR bacteria) were used. One thousand four hundred thirty-one articles were identified which was screened down to 53. RESULTS: 39/53 studies mentioned inflammatory cells but had contradicting conclusions. Macrophages were the most common cell type and inflammatory markers were detectable in all the articles which measure them. CONCLUSIONS: The included studies show different conclusions, but this heterogeneity is not unexpected since the clinical criteria of 'tendinopathy' encompass a huge clinical spectrum. Different 'tendinopathy' conditions may have different pathophysiology, and even the same clinical condition may be at different disease stages during sampling, which can alter the histological and biochemical picture. Control specimen sampling was suboptimal since the healthy areas of the pathological-tendon may actually be sub-clinically diseased, as could the contralateral tendon in the same subject. Detection of inflammatory cells is most sensitive using immunohistochemistry targeting the cluster of differentiation markers, especially when compared to the conventional haematoxylin and eosin staining methods. The identified inflammatory cell types favour a chronic inflammatory process; which suggests a persistent stimulus. This means NSAID and glucocorticoids may be useful since they suppress inflammation, but it is noted that they may hinder tendon healing and cause long term problems. This systematic review demonstrates a diversity of data and conclusions in regard to inflammation as part of the pathogenesis of Tendinopathy, ranging from ongoing or chronic inflammation to non-inflammatory degeneration and chronic infection. Whilst various inflammatory markers are present in two thirds of the reviewed articles, the heterogenicity of data and lack of comparable studies means we cannot conclude a common pathophysiology from this systematic review.

Mycobacterium szulgai infection in the flexor sheath of the right index finger in an immunocompetent patient.

A 53-year-old woman was identified with Mycobacterium szulgai infection in the flexor sheath of the right index finger. Tissue was debrided at operation, and the patient was successfully treated with appropriate antimicrobials. M. szulgai is a rare cause of non-tubercular mycobacterium infection worldwide, and there are currently no clear guidelines on diagnosis and management. This is the first case reporting M. szulgai infection in the flexor sheath of the right index finger of a non-immunocompromised patient in the UK.

Achilles tendon infection due to Mycobacterium chelonae.

Atypical tuberculous tenosynovitis of the foot and ankle is extremely rare. The determination of the Mycobacterium species is essential because resistance of atypical mycobacterial strains to antituberculous drugs is often encountered. We report a case of Mycobacterium chelonae paratendinous and intratendinous infection involving the Achilles tendon. Repeat aggressive irrigation and debridement procedures, coupled with removal of foreign materials and the appropriate use of prolonged antibiotic therapy, can result in a successful long-term outcome.

Septic flexor tendonitis and suspensory desmitis in an alpaca.

CASE DESCRIPTION: A 2-year-old male Suri alpaca was referred for evaluation of severe right forelimb lameness of 2 weeks' duration following a traumatic episode. CLINICAL FINDINGS: Examination of the distal aspect of the metacarpus revealed 4 wounds exuding purulent material. On weight bearing, the metacarpophalangeal joint was severely hyperextended with the palmar surface touching the ground. Ultrasonography of the palmar surface of the metacarpus revealed desmitis of the proximal suspensory ligament, a large core lesion of the deep digital flexor tendon at mid-metacarpus, and complete loss of fiber pattern within the deep digital flexor tendon and lateral aspect of the superficial digital flexor tendon distally. TREATMENT AND OUTCOME: The alpaca was treated systemically with antimicrobials and anti-inflammatory drugs and underwent repeated antimicrobial intraosseous regional limb perfusion. A bandage and splint were applied to stabilize the affected forelimb in an anatomically correct position, and the alpaca underwent prolonged stall confinement. At the time of hospital discharge 5 days after initial evaluation, clinical evidence of infection at the wound sites was absent. Three months following treatment, the alpaca was moving freely in a small paddock and had moderate hyperextension of the metacarpophalangeal joint. CLINICAL RELEVANCE: Treatment of septic flexor tendonitis and suspensory desmitis with antimicrobial intraosseous regional limb perfusion in combination with systemic treatment with antimicrobials and orthopedic support resulted in an excellent outcome in this alpaca. Antimicrobial intraosseous regional limb perfusion is simple to perform and has the potential to be beneficial in the treatment of infections in the distal portion of a limb in camelids.

Achilles tendinitis in Vibrio vulnificus sepsis: a rare presentation.

Vibrio vulnificus infection commonly presents as sepsis or wound infection. A case of alcoholic liver cirrhosis developed acute left heel pain and swelling 2 days after ingesting raw fish. Two sets of blood cultures indicated V. vulnificus. HLA-B27 was negative. Ultrasonography revealed left Achilles tendinitis. Fluid aspirated from the left retrocalcaneal bursa was sterile. The patient recovered completely 3 weeks after treatment. To our knowledge, V. vulnificus septicaemia with Achilles tendinitis, which may be the only indication of reactive arthritis (ReA), has not been reported previously. Prompt recognition of this life-threatening infection and adequate treatment with antibiotics is vital.

Resection of the common digital extensor tendon in a gelding.

A four-year-old gelding was lame owing to a chronic septic common digital extensor tendon and sheath. The horse had been treated by open surgical lavage but the sepsis had recurred after three months. Physical, ultrasonographic, cytological and histological examinations confirmed chronic septic tenosynovitis and tendonitis. The entire intrathecal component of the common digital extensor tendon was resected under general anaesthesia and the synovial lining of the sheath was ablated. Postoperatively the horse regained good limb function and became sound.

Similarly increased serum IgA1 and IgA2 subclass antibody levels against Klebsiella pneumoniae bacteria in ankylosing spondylitis patients with/without extra-articular features.

IgA1 and IgA2 subclass serum antibodies against whole Klebsiella pneumoniae bacteria were studied earlier in the sera of 98 patients with ankylosing spondylitis (AS) and in 100 healthy blood donors by enzyme immunoassay. In this study, the patients were divided into groups according to the clinical picture, i.e., the presence or absence of iritis and enthesitis. The previous findings of increased IgA1 and IgA2 subclass antibody levels against K. pneumoniae in AS patients when compared to the healthy controls were not specifically associated with any single AS patient group in the present study, but instead were similarly seen in all patient groups with/without extra-articular features. This is in line with the previous studies suggesting a role for K. pneumoniae in the pathogenesis of AS.

Deep scopulariopsosis: a case report and sensitivity studies.

A 36-year-old female was admitted to hospital for debridement of chronically inflamed tendon sheaths and adjacent tissues near the left ankle. Despite antibiotic therapy and initial surgical interventions, the inflammation had progressed slowly over 16 months. Histopathological examination of excised tissues in September 1973 revealed a chronic granulomatous inflammation of tendon sheaths and muscle. Many branched hyphal segments, intercalary swollen cells, and a few conidia-like bodies were seen in sections, and also in KOH- and PAS-stained slides prepared from homogenized tissues. Culture of homogenized tissues yielded pure colonies of Scopulariopsis brevicaulis. Sensitivity tests were initially begun with amphotericin B, potassium iodide, and potassium tartrate (0.05-15 mug/ml of the phytone-yeast extract agar), and no inhibitory effect was observed. Subsequently, amphotericin B, antimony, 5-fluorocytosine (5-FC), griseofulvin, hamycin, and mycostatin were tested (25-300 mug/ml of the phytone-yeast extract agar). Of these chemicals, griseofulvin and hamycin proved to be most effective. Antimony and 5-FC were ineffective, and mycostatin produced a negligible effect on growth. The four strains of Lysobacter antibioticus, the producer of myxin antibiotic, strongly inhibited the growth of the fungus.