Age / Sex : 26 / M

Chief complaint : Palpable mass of right wrist (D; 4 years)

1) What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(Quiz는 quiz일 뿐이오니 답안은 한개만 보내주시기 바라오며, 복수의 답안을 보내주시는 분은 정답이 포함되어 있더라도 부득이 semi-correct answer로 처리토록 하겠습니다.)

Courtesy: 박진균(Park, Jin-Gyoon), 전남대병원(Chonnam National University Hospital)

Tuberculous tenosynovitis

Discussion

Findings:

1) Lateral radiograph of wrist reveals soft tissue thickening in dorsal aspect.

2) MR images of wrist reveal marked distension of tendon sheath of extensor compartment 4. T1-weighted images reveal intermediate signal intensity of distended tendon sheath. T2-weighted images reveal numerous rice bodies in distended tendon sheath. Contrast enhanced images reveal thin wall enhancement of distended tendon sheath.

Differential Diagnosis:

 Tenosynovitis due to rheumatoid arthritis

 Atypical mycobacterial tenosynovitis

Synovial chondromatosis

Diagnosis:  Tuberculous tenosynovitis

Discussion:

Primary tuberculous tenosynovitis is a rare condition. The clinical onset of tuberculous tenosynovitis is gradual and insidious, with slowly progressive swelling in the involved part, followed by pain and limitation of motion. The symptoms are so mild that the disease often is well advanced, even of several years duration, before the patient seeks treatment. Tuberculous tenosynovitis may appear in various form (hygromatous form, serofibrinous form, and fungoid form) as a result of the long duration of the disease, the varying resistance of individual, and the varying virulence of the organism. Rice bodies appear in serofibrinous form. Tuberculous tenosynovitis most commonly involves the tendon sheaths of the hand and wrist. And flexor tendon sheaths more commonly affect than extensor tendon sheaths.

MR images of tuberculous tenosynovitis have revealed prominent synovial thickening around tendon with fluid collection in the tendon sheath. The thickened tendon sheath usually present as low signal intensity on T1-weighted image. The small low-signal foci or dots scattered in the synovial fluid on T2-weighted image may refer to regions of tissue debris, caseous material or rice bodies. On contrast enhanced T1-weighted image, there is enhancement of thickened tendon sheath. But, the low signal foci in the synovial fluid on T2-weighted image are not enhanced.

References:

1.     Suso S, Peidro L, Ramon R. Tuberculous synovitis with rice bodies presenting as carpal tunnel syndrome. J Hand Surg  Am 1988;13:574-576

2.     Jaovisidha S, Chen C, Ryu KN, Sitiwongpairat P, Pekanan P, Sartoris DJ, et al. Tuberculous tenosynovitis and bursitis: imaging findings in 21 cases. Radiology 1996;201:507-513.

3.     Hsu CY, Lu HC, Shih TTF. Tuberculous infection of the Wrist: MRI features. AJR 2004;183:623-628

4.     Tyllianakis M, Kasimatis G, Athanaselis S, Melachrinou M. Rice-body formation and tenosynovitis of the wrist: a case report. Journal of Orthopaedic Surgery 2006;14:208-211