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 Table of Contents  
Year : 2023  |  Volume : 38  |  Issue : 1  |  Page : 111-114

Tubercular flexor tenosynovitis with carpal tunnel syndrome mimicking as compound palmar ganglion: A rare case report

Department of Orthopedics, Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS), Lucknow, Uttar Pradesh, India

Date of Submission28-Jan-2023
Date of Acceptance12-Feb-2023
Date of Web Publication20-Apr-2023

Correspondence Address:
Jaydeep Patel
Department of Orthopedics, Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS), Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_8_23

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Introduction: Tubercular flexor tenosynovitis is an infrequent condition, which has a mixed clinical picture, but with careful examination and investigation, it should be diagnosed earlier before the involvement of underlying bones and nerves. Case Report: We present a case of a 69-year-old man who came with complaints of progressive swelling over the palm and forearm. He was presented as compound palmar ganglion but finally diagnosed as a case of chronic flexor tenosynovitis with association of carpal tunnel syndrome of tubercular origin without involvement of the underlying bones and was treated by complete excision and antitubercular therapy. Conclusion: Tuberculous flexor tenosynovitis is a condition that can be managed by excision and antitubercular therapy. However, it presents as a challenge to the surgeons when the presentation is very late. Hence, early identification and treatment are the main goals of this article.

Keywords: ATT, compound palmar ganglion, flexor tenosynovitis

How to cite this article:
Mahapatra S, Mishra M, Patel J, Mishra P, Singh D. Tubercular flexor tenosynovitis with carpal tunnel syndrome mimicking as compound palmar ganglion: A rare case report. J Bone Joint Dis 2023;38:111-4

How to cite this URL:
Mahapatra S, Mishra M, Patel J, Mishra P, Singh D. Tubercular flexor tenosynovitis with carpal tunnel syndrome mimicking as compound palmar ganglion: A rare case report. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:111-4. Available from: http://www.jbjd.in/text.asp?2023/38/1/111/374438

  Introduction Top

Atypical presentation of tuberculosis is not uncommon in developing countries. Among extrapulmonary sites, tendons are very rarely involved. Flexor tenosynovitis associated with tuberculosis is an uncommon condition in which a swelling is present across the wrist joint on either side of the flexor retinaculum. Initially, patients present with compound palmar ganglion. A therapeutic challenge consists of treating disease and its associated presentation. Compound palmar ganglion, also known as chronic flexor tenosynovitis, is a condition involving the flexor tendons around the wrist, above, and below the flexor retinaculum. Most common etiologies are tuberculosis and rheumatoid arthritis.

It is very common in developing countries. In tuberculous tenosynovitis, the route of infection can be either direct inoculation or by hematogenous focus of lungs/lymph nodes, and so on. Identification of the condition followed by early initiation of treatment is essential considering the various differential diagnoses that resemble this condition. Treatment of choice for such conditions includes complete excision of the mass followed by antitubercular medications. With early diagnosis and treatment, good recovery can be achieved.

  Case Report Top

A 69-year-old man came with complaints of a painful and progressively increasing swelling over the left palm and forearm for a duration of 1 year [Figure 1]. There were tingling and numbness over the fingers. He did not have the classical loss of appetite and weight loss scenario of tuberculosis. There was no contact history of tuberculosis. Examination revealed a bilobed swelling, proximal and distal to the flexor retinaculum with a positive cross fluctuation test. Symptom of carpal tunnel syndrome also present in our case. Radiographs of the hand were normal. The magnetic resonance imaging of the hand and forearm was reported as compound palmar ganglion with median nerve compression [Figure 2].
Figure 1: Swelling over palm and forearm

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Figure 2: Magnetic resonance imaging showing swelling over wrist

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Excision of the lesion was carried out under regional anesthesia. Flexor retinaculum was divided to reveal a bilobed mass [Figure 3], which was incised to let out all the rice bodies [Figure 4], and the cyst wall was excised. Thorough wound wash was given and wound was primarily closed.
Figure 3: Bilobed mass

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Figure 4: Rice bodies

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Polymerase chain reaction was reported as positive for Mycobacterium tuberculosis. Histopathological examination revealed multiple granulomas and caseous necrosis [Figure 5] Antitubercular therapy (ATT) was started on the third day post-surgery. Finger mobilization was started on the third day post-surgery. Wrist mobilization was started at the end of first week post-surgery. After 3 months of post-surgery, the patient recovered well and had an almost normally functioning hand [Figure 6].
Figure 5: Histopathology image

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Figure 6: Three-month postoperative picture

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  Discussion Top

Tuberculosis is a very common disease in India. Though lymph nodes are the most frequent extrapulmonary site for tuberculosis[1] infection of the tenosynovium is one entity that should not be delayed in treatment because of the destructive nature of the lesion and the permanent disability it causes. Rice bodies are characteristic of compound palmar ganglion of tuberculous etiology. Immediate initiation of treatment in the form of complete debulking and ATT is essential because of the notorious nature of the disease, as it destroys the underlying bones. After debulking, early physiotherapy is essential to attain the maximum function ability of the hand. Tuberculous tenosynovitis of the wrist is a well-documented condition and it mainly affects the volar tendons of the wrist.[2] Involvement of synovial sheath of hand is quite rare.

Tubercular tenosynovitis of the hand constitutes <1% of skeletal tuberculosis. The other conditions that can have a similar kind of presentation are systemic lupus erythematosus, rheumatoid arthritis, gouty arthritis, pigmented villonodular synovitis, and sometimes even the fungal infection of the tendon sheaths. There is an ample amount of literature present on compound palmar ganglion presenting with tenosynovitis and tendon ruptures; however, a compound palmar ganglion presenting with a compression neuropathy of median nerve is very rare. The diagnosis is often delayed due to slow progression and nature of the disease.[3] Tubercular infection of the wrist and hand is very rare. Diagnosis and treatment of this clinical entity are usually delayed due to asymptomatic swelling. Early diagnosis and treatment are most important as the lesion is destructive. Histopathological examination and culture are mandatory as the same condition mimics other inflammatory conditions such as systemic lupus erythematosus, rheumatoid arthritis, gouty arthritis, and fungal infections.[4],[5],[6]This condition should be treated surgically by wide excision of the lesion, thorough debridement, and release of the carpal tunnel to prevent the further recurrences.

  Conclusion Top

Tubercular tenosynovitis of wrist with carpal tunnel syndrome may mimic as a compound palmar ganglion of wrist. This is a curable condition, and strenuous efforts should be taken to treat this condition as early and completely as possible. Early diagnosis and treatment matter the most in this condition. Slow progression and asymptomatic presentation other than swelling in early stages are main factors for the late diagnosis. Both surgery and ATT are the mainstay of the treatment of tubercular tenosynovitis. Early diagnosis and proper management are very important to avoid complications.

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Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

  References Top

Ozvaran MK, Baran R, Tor M, Dilek I, Demiryontar D, Arinç S, et al. Extrapulmonary tuberculosis in non-human immunodeficiency virus-infected adults in an endemic region. Ann Thorac Med 2007;2:118-21.  Back to cited text no. 1
[PUBMED]  [Full text]  
Hoffman KL, Bergman AG, Hoffman DK, Harris DP Tuberculous tenosynovitis of the flexor tendons of the wrist: MR imaging with pathologic correlation. Skeletal Radiol 1996;25:186-8.  Back to cited text no. 2
Shen PH, Chu CM, Huang GS, Wu SS, Lee CH Tuberculous tenosynovitis of the flexor tendons of the wrist and hand. J Med Sci 2002;22:227-9.  Back to cited text no. 3
Cuomo A, Pirpiris M, Otsuka NY Case report: Biceps tenosynovial rice bodies. J Pediatr Orthop B 2006;15:423-e425.  Back to cited text no. 4
Lall H, Nag SK, Jain VK, Khare R, Mittal D Tuberculous extensor tenosynovitis of the wrist with extensor pollicis longus rupture: A report. J Med Case Rep 2009;3:142.  Back to cited text no. 5
Tyllianakis M, Kasimatis G, Athanaselis S, Melachrinou M Rice-body formation and tenosynovitis of the wrist: A report. J Orthop Surg 2006;14:208-11.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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