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CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 197-200

Isolated tuberculous peroneal tenosynovitis—A rare case report


Department of Orthopaedics, Andhra Medical College, Vishakhapatnam, Andhra Pradesh, India

Date of Submission28-Nov-2019
Date of Decision31-Jul-2020
Date of Acceptance28-Jun-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Ashok K Patnala
Department of Orthopaedics, Andhra Medical College, B-98, Dayal Nagar, Visalakshi Nagar, Vishakhapatnam, Andhra Pradesh - 5300432
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_108_19

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  Abstract 


Tuberculous peroneal tenosynovitis is a rare disease. The disease develops insidiously, and there will be a progressive inflammation of tendon sheath with limitation of excursion of inflamed tendons. We report a case of a 55-year-old man who was initially diagnosed as tendon sheath giant cell tumor clinically and radiologically, and after biopsy, it turned out to be tuberculous peroneal tenosynovitis.

Keywords: Peroneal tendon, tenosynovitis, tuberculosis


How to cite this article:
Murugan AK, Sampatirao MK, Muddapu P, Patnala AK. Isolated tuberculous peroneal tenosynovitis—A rare case report. J NTR Univ Health Sci 2020;9:197-200

How to cite this URL:
Murugan AK, Sampatirao MK, Muddapu P, Patnala AK. Isolated tuberculous peroneal tenosynovitis—A rare case report. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Oct 25];9:197-200. Available from: https://www.jdrntruhs.org/text.asp?2020/9/3/197/296824




  Introduction Top


Musculoskeletal tuberculosis accounts for 1%–5% of all cases of tuberculosis.[1],[2],[3] Though it constitutes only 1%–5% of tuberculosis, it contributes to significant morbidity, deformity, and functional disability. Within that, tuberculosis tenosynovitis accounts for 1%–2% of all musculoskeletal tuberculosis.[4] Tuberculosis tenosynovitis is an uncommon form of musculoskeletal tuberculosis occurring primarily in flexor tendons of hand (compound palmar ganglion), but other tendon sheaths of finger and ankle region, radial and ulnar bursae are rarely involved.[4]


  Case Report Top


A 55-year-old man presented as an outpatient with complaints of pain and swelling of the right ankle for 2 months. The swelling was insidious at onset and gradually progressive. The pain was also insidious, dull aching type with no radiation, aggravated by walking, usually on uneven grounds usually on, relieved by analgesics. History of prolonged cough was present. History of loss of weight was present. No history of trauma, fever, early morning stiffness, and other joint involvement. The patient was found to be a known case of pulmonary tuberculosis and on category-II antituberculosis drug for the past 4 months. There was no family history of similar swelling.

On examination, a tender firm swelling of size 7 cm × 4 cm × 2 cm [Figure 1], which is oval in shape present over posterolateral to lateral malleolus with margins palpable and extending along with the peroneal tendons without any changes in and around overlying skin. The swelling was movable in one plane, and the pain was aggravated on the eversion of the foot. And there was no translucency, fluctuation, reducibility, compressibility, and visible pulsation. General examination and physical examination was within normal limits. The complete blood count was normal with elevated ESR (80 mm/1st hour). CRP was positive. Mantoux test was positive. A chest radiograph showed right upper lobe cavitary lesion, and ankle radiographs [Figure 2] showed no bony abnormality. Ultrasound of a swelling showed a well-defined heterogeneously hypoechoic mass lesion of size 55 mm × 25 mm seen in the lateral aspect of the right ankle encasing ankle portion of peroneal brevis and longus tendons. Intact tendon fiber showed normal echo, no evidence of calcific foci, and bone involvement suggestive of tendon sheath giant cell tumor. Fine-needle aspiration cytology report showed moderate cellular smear oval to spindle-shaped cells arranged in sheets with focal papillary formation, few lymphocytes, and macrophage in the background of mucomyxoid material with features consistent with tendinitis. The malignancy was ruled out.
Figure 1: On table, clinical photograph of patient show swelling at posterolateral aspect of the right ankle

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Figure 2: X-ray ankle showing soft tissue swelling noted in posterior and lateral aspect of right ankle joint

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Then the patient was admitted and operated on for diagnostic and therapeutic biopsy by tenosynovectomy done under spinal anesthesia. Fibrosed, thickened, and inflamed peroneal tendon sheath was identified [Figure 3], [Figure 4], [Figure 5] and sent for a histopathology examination. HPE report was sent to two different labs, showed granulation tissue with fibrosis, and dense inflammatory cell infiltrates comprising lymphocytes, plasma cells, and multifocal epithelioid cell granuloma with Langhans type of giant cells, foci of necrosis was seen, no atypical cellular features were seen suggestive of tuberculous synovitis. Cultures showed no growth. The patient was continued on antitubercular treatment and under follow-up.
Figure 3: Intraoperative picture of mass arising from the peroneal tendon sheath

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Figure 4: Shows the gross specimen of excised tendon sheath (70 mm × 40 mm × 15 mm)

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Figure 5: Showing normal peroneus longus and brevis tendons after excision of involved sheath

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  Discussion Top


As per the global tuberculosis (TB) report 2017, the estimated incidence of TB in India was approximately 28,00,000, accounting for about a quarter of the world's TB cases.[5] Pathologically both parietal and visceral tenosynovium is replaced by granulation.[4] As the infection progresses, the disease spread along the sheath from the muscle to the tendon and its insertion. There are weaknesses and muscle wasting; rarely, a tendon may fray and rupture spontaneously.[4] Clinically, the swelling is doughy with semifluctuation, creaking, or crepitations are palpable on movements.[4] There are two theories for the development of tuberculous tenosynovitis: direct inoculation [trauma, syringe], and hematogenous dissemination from the primary focus.

The disease is classified into three stages: the earliest hygromatous form; a serofibrinous form; and a fungoid form. The hygromatous form usually appears as serious exudates within a normal-appearing tendon sheath; however, the tendon sheath may be thinned or replaced by granulation tissue. As the infection evolves, the serofibrinous form is manifested by obliteration of the tendon sheath with fibrous tissue and caseous inflammatory debris. Rice bodies appear in the synovial fluid. Intertendinous adhesion may form, or complete rupture may occur. The fungoid stage involves extensive caseation and granulation tissue formation, causing the obliteration of the tendon and sheath with the formation of the sinus tracts and cold abscess.[6],[7] Our case presented at the serofibrinous stage, as demonstrated by the presence of fibrotic inflamed synovium.

Characteristic magnetic resonance imaging features include synovial thickening with relatively little synovial sheath fluid, by contrast to acute suppurative synovitis where synovial sheath fluid is the predominant feature. The synovial sheath thickening was due to the replacement of the synovial sheath with granulation tissue.[1] Rice bodies are fibrinous mass present in 50% of tuberculosis cases.[1]

Laboratory studies have minor diagnostic value. Patients may present with anemia, leukopenia, thrombocytopenia, monocytosis, basophilia, and eosinophilia. The sedimentation rate can sometimes be elevated in an average of 30 mm/h, and positive for the tuberculin skin test strongly indicates a tuberculous process.[8],[9] But in previously immunized or allergic patients, test results were not definitive. MRI and plain radiographs also have no diagnostic specificity in regards to tuberculosis.

The diagnosis of tuberculous tenosynovitis is usually based on histological and bacteriological examination of material obtained during the operation. However, culture and histologic diagnosis are not 100% reliable in detecting mycobacterium infection.[9] Brashear et al. stated that typical caseous granulomatous lesions in the tendon sheath are usually tuberculous, and a culture or guinea pig inoculation for tuberculosis may give false-negative results. On histopathologic examination of our patient, necrotizing granulomatous inflammation was observed.


  Conclusion Top


Though tuberculous etiology is the uncommon cause of tenosynovitis in India, like a country where TB is not unusual, it should be included in the differential diagnosis in a patient with chronic ankle pain and swelling.[1],[10] Complete excision of the lesion followed by antitubercular therapy is the treatment of choice tuberculous tenosynovitis of foot and the ankle.[1]

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Diwanji SR, Shah ND. Tuberculous tenosynovitis of flexor digitorum longus tendon. Orthopaedics 2008;31:499.  Back to cited text no. 1
    
2.
Varshney MK, Trikha V, Gupta V. Isolated tuberculosis of Achilles tendon. Joint Bone Spine 2007;74:103-6.  Back to cited text no. 2
    
3.
Goldberg I, Avidor I. Isolated tuberculous tenosynovitis of the Achilles tendon. A case report. Clin Orthop Rel Res 1985;194:185-8.  Back to cited text no. 3
    
4.
Tuli SM. Tuberculosis of the Skeletal System. 4th ed.. New Delhi: Jaypee Brothers Medical Publishers; 2010. p. 187-90.  Back to cited text no. 4
    
5.
India TB report 2018 annual report status. Chapter 2, page9.  Back to cited text no. 5
    
6.
Abdelwahab IF, Kenan S, Hermann G, Klein MJ, Lewis MM. Tuberculous peroneal tenosynovitis. A case report. J Bone Joint Surg Am 1993;75:1687-90.  Back to cited text no. 6
    
7.
Sanders CJ, Schucany WG. Tuberculous tenosynovitis. Proc (Bayl Univ Med Cent) 2008;21:71-2.  Back to cited text no. 7
    
8.
Bickel WH, Kimbrough RF, Dahlin DC. Tuberculous tenosynovitis. J Am Med Assoc 1953;151:31-5.  Back to cited text no. 8
    
9.
Brashear HR, Winfield HG. Tuberculosis of the wrist: A report of ten cases. South Med J 1975;68:1345-9.  Back to cited text no. 9
    
10.
Ogut T, Gokce A, Kesmezacar H, Durak H, Botanlioǧlu H, Erginer R. Isolated tuberculous tenosynovitis of the Achilles tendon: A report of two cases. Acta Orthop Traumatol Turc 2007;41:314-20 [In Turkish].  Back to cited text no. 10
    


    Figures

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



 

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