Tuberculosis of the wrist causing carpal tunnel syndrome in a patient with rheumatoid arthritis: A case report.

Among extrapulmonary tuberculosis, osteoarticular tuberculosis is a rare manifestation, and cases related to osteoarticular tuberculosis of large joints have been reported previously. However, tuberculous tenosynovitis causing carpal tunnel syndrome is a rare manifestation, especially in the background of rheumatoid arthritis. A 67-year-old Sri Lankan male with a background of rheumatoid arthritis presented with progressively enlarging left wrist swelling associated with pain and numbness for 2 months. He was on Methotrexate and Hydroxychloroquine as disease-modifying agents, and his symptoms related to arthritis were well controlled. On examination, lobulated subcutaneous swelling was noted in distal forearm extending to the palmar region with evidence of carpal tunnel syndrome which was confirmed by nerve conduction studies. There was no pre-operative evidence to suggest tuberculosis both clinically and biochemically. Synovial thickening due to rheumatoid arthritis was considered as the probable diagnosis and surgical decompression of the carpal tunnel was performed. Intraoperatively, synovial thickening was noted around the flexor tendons with evidence of median nerve compression in the carpal tunnel. Thickened synovial mass was completely excised. Histology and culture were positive for tuberculosis. Following excision and 9 months of anti-tuberculosis treatment, he was asymptomatic with good range of motion of fingers. In conclusion, a combination of surgical excision and anti-tuberculosis treatment was successful to achieve good functional outcomes. In a country like Sri Lanka, where tuberculosis is still prevalent, uncommon musculoskeletal manifestations may not be infrequent. Therefore, clinicians should have a high degree of suspicion when treating such patients.

Idiopathic calcinosis cutis causing cubital tunnel syndrome: A case report and review of literature.

Calcinosis cutis is a type of heterotopic calcification where abnormal calcium deposition occurs in skin or subcutaneous tissue. Among the subtypes of calcinosis cutis, the idiopathic variety occurs without underlying biochemical calcium abnormality. We report a rare case of idiopathic calcinosis cutis causing cubital tunnel syndrome. A 63-year-old female presented with pain and numbness in the ulnar aspect of her left hand. The X-ray of the left elbow showed deposition of radiopaque material on the posteromedial aspect. Her nerve conduction study showed evidence of ulnar nerve compression at the elbow supporting the diagnosis of ulnar nerve compression by the mass of calcium deposition. Surgical exploration was performed, and significant ulnar nerve compression was noted due to the mass effect of the calcium deposition. Excision of the mass and ulnar nerve decompression with anterior transposition was performed with satisfactory outcomes. Although calcinosis cutis causing cubital tunnel syndrome has been previously reported, all patients had some form of calcium dysregulation. We report the first case of ulnar nerve compression at the cubital tunnel due to idiopathic calcinosis cutis. Excision of the mass and ulnar nerve decompression with anterior transposition was successful in our patient despite the incomplete excision of the calcium deposition.

Two squamous cell carcinomas of the skin in a patient with Lynch syndrome.

INTRODUCTION AND IMPORTANCE: Although synchronous and metachronous tumours of the bowel are well known associations of Lynch syndrome, the association of skin malignancies in such patients are extremely rare. CASE PRESENTATION: A 40-year-old Sri Lankan man with a strong family history of colorectal cancer had an extended right hemicolectomy for a moderately differentiated adenocarcinoma. Two months after surgery, he developed two discrete ulcerative skin lesions in the chin and occipital region which excision biopsy confirmed to be squamous cell carcinoma. After more than two years of follow-up, patient remains disease free. CLINICAL DISCUSSION: The Muir Torre variant of Lynch syndrome is characteristically associated with sebaceous adenomas and carcinomas, though occurence of squamous cell carcinomas are rare. In reported cases, defective mismatch repair genes associated with Lynch syndrome may suggest an increased predisposition for squamous cell carcinomas. CONCLUSION: Patients with Lynch syndrome should be educated on the importance of seeking an early medical consult for new skin lesions and raising awareness of this rare phenomenon for physicians involved in follow up is important.

Extra and Intramuscular Distribution of the Thoracodorsal Nerve with Regard to Nerve Reconstruction Surgeries.

Background The lateral branch of the thoracodorsal nerve (LBTN) is used for nerve transfer in facial, musculocutaneous, axillary nerve injuries and for irreparable C5, C6 spinal nerve lesions and accessory nerve defects. For a successful surgical outcome, the nerve to be used in nerve transfer should be of adequate length and thickness for nerve coaptation. Aim Our objective was to evaluate the length of the LBTN that could be obtained as a donor nerve, externally and within the muscle. Method Eight (8) cadavers with intact upper limbs and thorax which could be positioned in the anatomical position were selected for the study. Cadavers with dissected axillae, brachial plexus or upper limbs were excluded. The thoracodorsal neurovascular bundle was dissected and the number of branches of the thoracodorsal nerve was identified along with its lateral branch. The lateral branch was dissected up to the latissimus dorsi muscle and further intramuscularly. All lengths were measured using a vernier caliper. Results The mean length of the LBTN, up to its first intramuscular branch, is 8.14 cm (range 5.99-12.29 cm). Beyond this, the intramuscular nerve branched further and was of very minute diameter. The mean unbranched intramuscular length of the nerve is 3.36 cm (range 1.3-7.71 cm) which is 41.28% of the total length of the LBTN. Conclusion A significant proportion of the LBTN is found within the latissimus dorsi muscle. This length could potentially be used for direct nerve coaptation by intrafascicular dissection.