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Master’s dissertation (Dissertations and theses)
Atypical mycobacterial tenosynovitis in an immunocompetent individual
El Moussaoui, Majdouline
2018
 

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Keywords :
tenosynovitis; Atypical mycobacterial; M. heraklionese
Abstract :
[en] The term ‘tenosynovitis’ refers to simultaneous inflammation of both a tendon and its surrounding synovial sheath. Its etiologies are multiple and include infectious, inflammatory, metabolic, neoplastic, connective tissue and mechanical stress-related diseases. My master’s thesis is a case report of a chronic tenosynovitis of the flexor digitorum superficialis caused by non-tuberculous mycobacteria in an immunocompetent patient followed by a review of the literature concerning this very rare entity. We reported the case of a 52-year-old caucasian woman, who presented with pain and swelling of the right thumb and second finger after a trip in Jamaica. Quickly afterwards, she developed paraesthesias and hypoesthesia in the territory of the median nerve. Suspecting carpal tunnel syndrome, she underwent surgery without any clinical improvement. De Quervain's tenosynovitis was suspected on an ultrasonographic basis and she was treated with nonsteroidal anti-inflammatory drugs and a splint. This only resulted in temporary symptomatic improvement. Suspecting a rheumatoid arthritis, salazopyrine was tried but was ineffective. Complex regional pain syndrome type II as a result of her carpal tunnel surgery was considered but articular ultrasound showed synovitis poorly vascularized with low fluid, inconsistent with this diagnosis. The inflammatory signs progressed with extension of the swelling to the forearm. An infectious etiology was suspected. Cultures on synovial fluid were performed as well as multiple serological analyses but were all negative. Several weeks later, the patient developed a skin fistula with externalization of purulent liquid. A surgical biopsy was performed and histologic examination of the extracted tissue showed intense chronic inflammation with numerous necrotizing and no necrotizing granulomas. Polymerase chain reactions (PCR) on biopsy specimen found Mycobacterium heraklionense DNA and aerobic culture showed secondary infection with methicillin-sensitive Staphylococcus aureus (MSSA). Mycobacterial infection was treated with clarithromycine 500 milligrams (mg) twice a day, rifampicin 300 mg twice a day and ethambutol 400 mg three times a day for six months and a radical synovectomy was performed. MSSA secondary infection was treated with Cefazolin (6 grams by continuous intravenous infusion) then minocycline 100 mg twice a day for one month. The patient improved gradually with complete disappearance of the swelling and significant reduction of the pain. Non-tuberculous mycobacteria are increasingly recognized as a cause of infection in both immuno-compromised and competent hosts. Mycobacterium heraklionense sp. (M. heraklionense) is a recently described member of the Mycobacterium terrae complex (MTC). To date, there are few reported cases of Mycobacterium heraklionense-associated hand tenosynovitis. Most of the patients reported had no obvious predisposing conditions, although a specific genetic variation leading to an increased susceptibility, such as mutations in the interleukin (IL)-12/IL-23 axis, is difficult to rule out. The diagnosis of M. heraklionense infection is very challenging since standard methods for the culture of mycobacteria show low efficiency in this setting. Hence, more elaborate molecular detection methods are particularly useful and should be considered in case of diagnostic wavering. Treating M. heraklionense is also particularly difficult since it is resistant to quinolones, rifampicin, sulfamethoxazole, and doxycycline. Moreover, the optimal duration of treatment is still unknown. The current treatment consists of a triple antibiotherapy (clarithromycine, ethambutol, rifampicine) for at least 6 months as well as surgical debridement of the infection site. However, despite optimal medical care, devastating surgery, and even amputation, is sometimes necessary. In conclusion, atypical mycobacterial infection should be suspected for any chronic hand tenosynovitis of unknown origin. Prompt diagnosis is crucial since it avoids both side-effects of corticotherapy and long-term sequelae and recurrences.
Disciplines :
Immunology & infectious disease
Author, co-author :
El Moussaoui, Majdouline  ;  Centre Hospitalier Universitaire de Liège - CHU > Département de médecine interne > Service d'hématologie clinique
Language :
English
Title :
Atypical mycobacterial tenosynovitis in an immunocompetent individual
Defense date :
2018
Institution :
ULiège - Université de Liège
Degree :
diplôme médecine
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since 11 July 2021

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