TUBERCULOUS TENOSYNOVITIS: A CASE REPORT

Tuberculosis (TB) is a chronic disease caused by Mycobacterium tuberculosis . The World Health Organization estimates that one-quarter of the global population is infected, and despite progress in treatment and control, TB remains a major public health burden. Osteoarticular TB accounts for about 1.5% of all extrapulmonary TB cases. Tuberculous tenosynovitis is an uncommon form of osteoarticular TB that primarily affects hands and wrists. A.F., a 69-year-old man from Salvador, Bahia, retired, with hypertension, diabetes, and hypothyroidism, developed sudden edema of the left hand in 2023, followed later by edema in the right hand, along with paresis, paresthesia, 12 kg weight loss, and inflammatory signs in the right hand. Sporotrichosis was suspected, and he was treated with itraconazole without improvement. He was hospitalized in 2024 for investigation of right-hand tenosynovitis. Biopsy showed ulcerated cutaneous inflammation, granulation tissue, squamous epithelium with reactive changes, intense inflammatory infiltrate in the dermis, focal histiocytic reaction with multinucleated giant cells, fibrinopurulent exudate, and necrotic areas, but no defined etiology. He was treated with antibiotics without response. Electroneuromyography showed mild-to-moderate carpal tunnel syndrome with demyelination bilaterally. Rheumatology requested lesion microscopy, which suggested ruptured/suppurated epidermal inclusion cyst without evidence of neoplasia or viral, fungal, or parasitic agents. On 24/07/24, he underwent excision of secretion from the palmar region and carpal tunnel on the right; an encapsulated lesion around the flexor tendons was observed, suggestive of chronic tenosynovitis with “rice bodies,” reminiscent of mycobacterial infection, and rupture of flexor tendons of the fingers was noted. Secretions did not confirm mycobacterial infection, but culture for aerobes grew Pseudomonas fluorescens , which was treated with clinical improvement. MRI showed decreased inflammatory/tenosynovitis process at the level of the flexor tendon sheath in the right hand. After prolonged ciprofloxacin use without full improvement, surgical re-approach and new cultures/biopsy were performed due to abscess formation in the right wrist. On 30/10/24, rapid molecular test for TB was positive in the tenosynovitis sample. Standard 12-month TB therapy was initiated, with favorable evolution. Thus, osteoarticular TB must be included in the differential diagnosis of chronic monoarthritis, as delayed diagnosis may worsen prognosis.