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 Table of Contents 
CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 865-866  

Wrist swelling – Is it tuberculosis?


Department of Pediatrics, Paediatric TB Clinic, B. J. Wadia Hospital for Children, Mumbai, Maharashtra, India

Date of Web Publication15-Feb-2018

Correspondence Address:
Dr. Miti Aatish Shah
BLDG 102, Flat B/202, Suryakiran CHS, Tilak Nagar, Chembur, Mumbai - 400 089, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_200_17

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  Abstract 


The hand and wrist are rare sites for tuberculosis (TB) and account for < 1% of all skeletal TB. Though rare, TB of the wrist is a cause of major morbidity. A common feature in the available reports on wrist TB is a delay in diagnosis causing residual stiffness and pain after treatment. Although TB of the wrist has a varied presentation, the majority of lesions respond to conservative treatment. We report a 12-year–old girl who presented with wrist swelling, having intercarpal, carpometacarpal, and radiocarpal joint involvement which turned out to be tuberculous and it healed with residual deformity.

Keywords: Children, musculoskeletal, tuberculosis, wrist


How to cite this article:
Shah MA, Shah I. Wrist swelling – Is it tuberculosis?. J Family Med Prim Care 2017;6:865-6

How to cite this URL:
Shah MA, Shah I. Wrist swelling – Is it tuberculosis?. J Family Med Prim Care [serial online] 2017 [cited 2019 May 22];6:865-6. Available from: http://www.jfmpc.com/text.asp?2017/6/4/865/225526




  Background Top


The hand and wrist are rare sites for tuberculosis (TB) and account for <1% of all skeletal TB. Though rare, TB of the wrist is a cause of major morbidity.[1] A common feature in the available reports on wrist TB is a delay in diagnosis as the disease has an insidious and indolent course [2] causing residual stiffness and pain after treatment. Although TB of the wrist has a varied presentation, the majority of lesions respond to conservative treatment. We report a 12-year-girl who presented with wrist swelling, having intercarpal, carpometacarpal, and radiocarpal joint involvement which turned out to be tuberculous and it healed with residual deformity.


  Case Report Top


A 12-year-old girl presented with gradually increasing swelling of the left wrist joint for 6 months associated with pain and restriction of movement. There was no cross fluctuation or lymphadenitis. There was no contact with TB and other joints were normal. Other systems were normal. She was immunized with Bacillus Calmette–Guérin at birth. Our clinical diagnosis was left wrist arthritis and our differentials were tuberculous arthritis, juvenile idiopathic arthritis, and septic arthritis of the wrist joint. Chest X-ray was normal and HIV ELISA was negative. Magnetic resonance imaging (MRI) of the left wrist showed infective arthritis involving the intercarpal, carpometacarpal, and radiocarpal joint suggestive of TB. She underwent synovial biopsy by dorsal approach, which on histopathology showed multiple caseating epithelioid granulomas suggestive of TB. Smear on Ziehl–Neelsen (ZN) stain showed the presence of two acid-fast bacilli (AFB). TB culture at the end of 6 weeks did not grow any organism. She was started on isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months followed by isoniazid and rifampicin for rest of the treatment duration.[3] At 6 months of anti-TB treatment (ATT), her ultrasound of the wrist showed carpal bone erosion and collection in radiocarpal and intercarpal bones. She was given ATT for 1 year. She was left behind with residual left wrist contracture.


  Discussion Top


TB of the wrist is slowly progressive, which causes difficulties in early diagnosis. Late diagnosis leads to poor functional outcome even in the presence of regular ATT.[4] Pain and swelling are the most common presenting features, followed by discharging sinuses.[5] A similar case was recently reported where a 10-year-old boy presented with painful swelling in the dorsum of the left wrist joint of 5-month duration.[6] Our patient also presented with pain, swelling, and restriction of movement for 6 months. Skeletal involvement in TB wrist usually includes capitate and distal radius.[7]

Like another prospective study of five patients,[7] where all patients underwent an open biopsy, curettage and diagnosis confirmed by histopathological/microbiological examination, our case also had histopathology showing multiple caseating epithelioid granulomas and smear on ZN stain showed the presence of two AFB.

A prolonged course of ATT is the basis of treatment. The treatment of TB of the wrist is primarily and essentially medical, with surgery reserved for certain situations or complications.[8],[9] Watts and Lifeso [10] recommended that treatment should be continued for a minimum of 12 months for osteoarticular involvement. In our case too, 6 months of treatment had shown only partial involvement, and hence, treatment was continued for 12 months.

Although the symptoms may not be dramatic, chronic infection tends to be progressive and eventually results in radiographically evident destruction of cartilage and bone. There was a recent case report in the Indian setting, of an 8-year-old boy having wrist TB presenting as hamate osteitis. At 6-month follow-up, the patient had no pain or deformity at the wrist. He had some restriction of motion, with 40 degrees of palmar and dorsal flexion and 20 degrees of ulnar and radial deviations being possible. The lesions also healed radiologically without any sequelae.[11] Our patient had a deformity at the end of treatment. Wrist stiffness is seen frequently and has a significant functional impact.

Limitations

Follow-up MRI of the patient could not be done.


  Conclusion Top


Tuberculous arthritis of the wrist is a rare condition. Diagnosis is often difficult due to slow progression and nonspecific symptoms. Definitive diagnosis depends on histopathological examination and microbiological confirmation. Antituberculous treatment is effective, but the functional outcome depends on early diagnosis before the development of radiological evidence of joint destruction. Recurrence after treatment is common, and hence, follow-up in every case is mandatory.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prakash J, Mehtani A. Isolated tuberculosis of scaphoid in the skeletally immature: A rare cause of chronic wrist pain. BMJ Case Rep 2015;2015: pii: bcr2015209569.  Back to cited text no. 1
    
2.
Tsai MS, Liu JW, Chen WS, de Villa VH. Tuberculous wrist in the era of effective chemotherapy: An eleven-year experience. Int J Tuberc Lung Dis 2003;7:690-4.  Back to cited text no. 2
    
3.
Technical and Operational Guidelines for TB Control in India 2016. Central Tuberculosis Division. Available from: http://www.tbcindia.nic.in/index1.php?lang=1&level=2&sublinkid=4573 and lid=3177. [Last accessed on 2016 Dec 14; Last updated on 2016 May 11].  Back to cited text no. 3
    
4.
Benchakroun M, El Bardouni A, Zaddoug O, Kharmaz M, El Yaacoubi M, Ouadghiri M, et al. Tuberculosis of the wrist. Symptoms and outcome in eleven cases. Rev Chir Orthop Reparatrice Appar Mot 2004;90:337-45.  Back to cited text no. 4
    
5.
Tuli SM. Tuberculosis of the skeletal system: bone, joints, spine, and bursal sheaths. 1st ed. New Delhi: Jaypee Brothers Medical Publishers, 1993:116-17.  Back to cited text no. 5
    
6.
Aghoutane EM, Salama T, El Fezazi R. Tuberculosis of the wrist in children: A rare manifestation. Int J Mycobacteriol 2017;6:106-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Agarwal A, Kant KS, Kumar A, Shaharyar A, Verma I, Suri T. Lytic lesions of distal radius in children: A rare tubercular presentation. Hand Surg 2014;19:369-74.  Back to cited text no. 7
    
8.
Sbai MA, Benzarti S, Msek H, Boussen M, Khorbi A. Pseudotumoral form of soft-tissue tuberculosis of the wrist. Int J Mycobacteriol 2016;5:99-101.  Back to cited text no. 8
  [Full text]  
9.
Kotwal PP, Khan SA. Tuberculosis of the hand: Clinical presentation and functional outcome in 32 patients. J Bone Joint Surg Br 2009;91:1054-7.  Back to cited text no. 9
    
10.
St Clair Strange FG. Current concepts review. Tuberculosis of bones and joints (78-A:288-298, Feb 1996) by Watts and Lifeso. J Bone Joint Surg Am 1998;80:604.  Back to cited text no. 10
    
11.
Goel A, Sabat D, Sambharia AK. Tuberculosis of wrist joint in an 8-year-old child presenting as hamate osteitis: A rare case report. J Clin Orthop Trauma 2015;6:293-5.  Back to cited text no. 11
    




 

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