¹Debasish Mishra

¹Lifecare Hospital Musaffah

Background(s): Tenosynovitis, inflammation of fluid-filled synovium within tendon sheath, could be secondary to arthritis ( rheumatoid arthritis, gout, spondyloarthritis etc), overuse, infective (post injury, bite or spread from other sites) and idiopathic. Reactive tenosynovitis secondary to distant infection is a rare phenomenon. Untreated chronic tenosynovitis can result in finger stiffness, deformities, adhesions and contractures [1]. To rule out any treatable pathology is of astute importance in such cases. Here we describe case of a common infection with uncommon presentation as bilateral reactive extensor tenosynovitis of forearm.

Method(s): 54 year male, visited Rheumatology OPD with persistent swelling of bilateral forearms for 3 years. He denied history of any joints pain / joint swelling, skin rash, low back pain, fever, cough, weight loss, diarrhea or bleeding per rectum, any other significant rheumatic or other systemic illnesses. On examination, he had lobular, fluctuating, non-tender, non-pulsatile swelling over bilateral forearm extensor aspect ( fig-1A). On review of records, he had persistently high inflammatory markers with normal hemogram , liver and renal function. His rheumatoid factor, anti CCP, ANA and HLA B 27 were negative. His previous US scan of bilateral forearm showed fluid collection with diffuse thickening of sheath of extensor digitorum and extensor carpi radialis longus and brevis tendons in forearm extending upto wrist (fig 1B,C). Bilateral wrist and other small joints were normal. He had previously been treated with multiple courses of NSAIDs and oral steroids, with minimal to no response.

Result(s): US guided aspiration of  collection around extensor digitorum tendon was done and analysis revealed inflammatory fluid with total leucocyte count 17,450 (with 70% polymorphs). Gram’s stain, AFB stain, Tb-PCR, crystal analysis and culture of same were negative. On further work up, his Mantoux was 18 mm and Tb-quantiferon was positive. He, however, had no current symptoms / past history or contact with active tuberculosis patient. His chest x ray was unremarkable, however HRCT chest showed multiple tiny well defined centrilobular nodules in bilateral lungs with few enlarged pre-vascular lymph nodes. His sputum AFB, Tb-PCR, gene-expert and culture were negative. He denied any invasive intervention. Hence, under high clinical suspicion of tuberculosis with reactive bilateral extensor tenosynovitis, he was started on anti-tubercular regime. He received intra-tendinous steroid injection over all peritendinous collection. On follow up, his CRP showed significant reduction with improvement in symptoms. He has completed his 6 months course of anti-tubercular therapy and has no recurrence of symptoms.

Conclusion(s): Musculoskeletal tuberculosis, although uncommon, can manifest with varied features[2]. Reactive arthritis (Poncet’s ) secondary to tuberculosis or tuberculous tenosynovitis[3] is well described in literature, however, reactive tenosynovitis is very rare phenomenon to occur. High clinical index of suspicion is needed to rule out tuberculosis in such cases.