WRIST TENOSYNOVITIS AND SPINA VENTOSA (TUBERCULAR DACTYLITIS) DUE TO TUBERCULOUS AND NON-TUBERCULOUS MYCOBACTERIAL INFECTIONS IN RENAL TRANSPLANT RECIPIENTS

Introduction:

Wrist tenosynovitis and spina ventosa (tubercular dactylitis) are uncommon manifestations of mycobacterial infections in renal transplant recipients. In this report we describe two cases of tenosynovitis caused by tuberculous and nontuberculous mycobacteria.

Methods:

In this report we describe two cases of wrist tenosynovitis in renal allograft recipients, one caused by Mycobaterium tuberculosis and the other by Mycobacterium intracellulare (Mycobacterium Avium Complex).

Results:

The first patient was a renal allograft recipient in 2006, native kidney disease being IgA nephropathy. He had chronic HBV infection and was on antivirals since prior to transplant, he had undergone a left native nephrectomy for a multilocular cystic renal neoplasm in 2018. He was on dual immunosuppression with prednisolone and mycophenolate, cyclosporine having been withdrawn in 2008.

He presented with a four year history of swelling of the dorsum of the left hand extending to the forearm. Clinical examination showed nontender left wrist flexor and extensor aspect gross synovitis with firm globular 4x4cm swelling over the dorsum of the hand. There were no signs of inflammation. Xray of the hand and wrist were unremarkable. USG showed nodular synovial thickening around the fourth extensor compartment of hand and flexor tendons at carpal tunnel extending to palms and up to its distal attachment to phalanx. MRI of the wrist showed diffuse synovial thickening and multiple loose bodies around the fourth extensor compartment and flexor tendons in the carpal tunnel and palm.

He underwent a left flexor and IF volar synovectomy. Multiple rice bodies were noted on excision of the tenosynovium. Histopathology showed multiple ill-defined and discrete granulomas composed of histiocytes, lymphocytes and Langhans type of multinucleate giant cells. Special stains for AFB and fungal organisms were negative. Mycobacterial MGIT cultures grew Mycobacterium tuberculosis with monoresistance to Isoniazid. He was treated successfully with a one year course of first line ATT with which he had complete resolution of the swelling of his wrist.

The second patient was a renal allograft recipient in 1990. He had stable graft function and was on dual immunosuppression with prednisolone and azathioprine. He presented with multiple swellings of the dorsum of the right hand, index finger and forearm. 

USG showed tenosynovitis with collections involving the extensor tendons of the right wrist extending up to the level of the midshaft of the metacarpals and also the flexor tendons of the right index finger extending proximal to the second MTP joint up to the PIP joint and soft tissue swelling and periosteal reaction involving the proximal phalanx of the right index finger suggestive of dactylitis. A synovial biopsy showed large areas of necrosis with inflammatory infiltrates and epithelioid granulomas. The Xpert TB PCR on the tissue was however indeterminate. Mycobacterial MGIT cultures grew Mycobacterium intracellulare – a species in the Mycobacterium Avium Complex. He was treated with a one year course of Rifampicin Clarithromycin and Ethambutol with which he had resolution of the swellings.

Conclusions:

In this report we present two rare cases of mycobacterial infections in renal transplant recipients presenting as chronic wrist tenosynovitis. The differentials of both tuberculous and non-tuberculous mycobacterium infections must be considered in patients presenting with chronic tenosynovitis. Radiological imaging, histopathology and most importantly mycobacterial cultures help in identifying the etiological agent and tailoring the treatment.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.