CASE SERIES |
https://doi.org/10.5005/jojs-10079-1167 |
Clinical Insights into Tubercular Tenosynovitis: A Series of Eight Compound Palmar Ganglion Cases
1–4Department of Orthopedics, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India
Corresponding Author: Prem K Kothimbakkam, Department of Orthopedics, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India, Phone: +91 9840544411, e-mail: drpremkumar.kvk@gmail.com
Received: 17 April 2024; Accepted: 26 May 2024; Published on: 14 Jane 2024
ABSTRACT
Chronic flexor tenosynovitis of the wrist is often associated with tuberculosis in developing countries as opposed to rheumatoid arthritis in developed countries. A case series of compound palmar ganglion (eight cases) mimicking flexor tenosynovitis, for which magnetic resonance imaging (MRI) revealed conclusive evidence of cystic swelling and melon seed bodies. Early identification, meticulous surgical excision, and the initiation of appropriate antitubercular therapy are of utmost importance.
How to cite this article: Gokulakrishnan E, Kothimbakkam PK, Vadivelkumar B, et al. Clinical Insights into Tubercular Tenosynovitis: A Series of Eight Compound Palmar Ganglion Cases. J Orth Joint Surg 2024;6(2):177–180.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Compound palmar, Median nerve, Melon seeds, Tuberculous tenosynovitis
INTRODUCTION
Chronic flexor tenosynovitis of the wrist, colloquially known as compound palmar ganglion, represents a unique facet within the spectrum of extrapulmonary tuberculosis.1 This tenosynovitis can mimic carpal tunnel syndrome presented as a simple swelling.2 This distinctive condition presents diagnostic challenges, especially given its geographical variability. In developing countries such as India, it is often associated with tubercular tenosynovitis of the ulnar bursa, while in other countries, rheumatoid arthritis takes precedence.3 This geographical diversity underscores the need for a nuanced exploration of the epidemiology and tailored management strategies surrounding compound palmar ganglion (Fig. 1).
Fig. 1: Clinical pictures showing swelling arising from the ulnar bursa with significant compression over the median nerve
Amid its diagnostic intricacies, the condition’s atypical presentation, occasionally mirroring rheumatoid arthritis or systemic lupus erythematosus, contributes to delayed diagnoses.4 This highlights the importance of clinical awareness and precision in differential diagnosis when addressing this complex clinical entity. The pivotal components for ensuring positive prognosis involve early identification, meticulous surgical excision, and the initiation of appropriate antitubercular therapy (ATT) (Fig. 2).
Fig. 2: Magnetic resonance imaging shows cystic swelling with characteristic melon seed bodies along with involvement of flexor tendons
Despite being less prevalent in developed countries, tuberculous tenosynovitis remains a significant concern in the developing world, posing substantial public health challenges.2 Timely medical and surgical interventions are imperative to address potential musculoskeletal complications. In presenting a series of cases, we aim to illustrate diverse clinical scenarios, highlight diagnostic intricacies, and share successful management strategies encountered in our clinical practice. Every case presented adds to the comprehensive knowledge of tuberculous tenosynovitis manifested as compound palmar ganglion (Fig. 3).
Fig. 3: Intraoperative picture showing compression of median nerve with encasing flexor tendons along with multiple melon seed bodies
EPIDEMIOLOGY
Tuberculous tenosynovitis, an infrequent yet well-documented condition, primarily affects the wrist and volar aspect of the hand, constituting about 5% of osteoarticular tuberculosis cases. Hematogenous spread from primary sites or direct inoculation, often associated with factors such as trauma, occupational joint overuse, old age, low socioeconomic status, malnutrition, and immunosuppression, can contribute to its occurrence.5
CASE DESCRIPTIONS
Our study consists of eight cases documented during the period from June 2020 to May 2023, which are presented below.
Case 1
A 40-year-old female, a construction worker by profession, visited the outpatient department with a 6-month history of swelling over the volar aspect of the right wrist, accompanied by dull aching pain and nocturnal exacerbation, tingling, numbness in the index finger, and other constitutional symptoms. Clinical examination revealed an hourglass swelling exhibiting crepitus and fluctuation proximal and distal to the flexor retinaculum. Radiography showed diffuse soft tissue swelling, and magnetic resonance imaging (MRI) showed multiple melon seed bodies. The patient was treated with 9 months of antitubercular chemotherapy and exhibited improvement (Fig. 4).
Fig. 4: Histopathology showing Langerhans giant cells with multiple granulomatous lesions
Case 2
A 26-year-old female student presented with an 8-month history of volar pain, swelling, discomfort, and tingling sensation of the right wrist. Previous treatments, including aspiration and fine-needle aspiration cytology (FNAC), provided no relief. Examination revealed a 6 cm × 2 cm nontender swelling extending longitudinally proximal and distal to the flexor retinaculum. A positive Mantoux test and normal radiographs led to tenosynovectomy. Postsurgical excision, histopathology revealed granulomatous inflammation with caseous necrosis and positive GeneXpert.
Case 3
A 32-year-old housewife came with a chronic history of swelling over her wrist joint (left). Examination showed volar swelling with limited mobility exhibiting crepitus proximal and distal to the flexor retinaculum. MRI showed multiple melon seed bodies, hence the same procedure was continued. The histopathological examination reported tubercular compound palmar ganglion.
Case 4
A 22-year-old housewife came with a chronic history of swelling over the left distal forearm extended toward the wrist, associated with pain on pressure. Examination revealed an hourglass-shaped swelling with tingling along the median nerve course. MRI showed multiple melon seeds with chronic tenosynovitis of flexor tendons. Surgery revealed thickening of the flexor tendon sheath and caseous necrosis. The patient received ATT for 9 months, achieving a full recovery.
Case 5
A 65-year-old housewife presented with a 9-month history of volar pain, swelling, discomfort, and tingling sensation of the right wrist along with wasting of the thenar group of muscles. Examination revealed a 6 cm × 2 cm nontender swelling extending longitudinally proximal and distal to the flexor retinaculum. Postsurgical excision, histopathology revealed granulomatous inflammation with caseous necrosis and positive GeneXpert.
X-ray showed localized osteopenia. Surgery revealed a mass with melon seed bodies. Histopathology confirmed granulomatous inflammation, and polymerase chain reaction (PCR) was positive for Mycobacterium tuberculosis. The patient completed ATT with no recurrence.
Case 6
A 55-year-old male, a butcher by profession, presented with an increasing swelling along the volar part of the left wrist, for the past 8 months. Examination revealed two swellings with positive cross-fluctuation, numbness in the median nerve territory, and limited wrist and finger movements. Radiographs were normal, and surgery revealed a fluctuant mass with melon seed bodies. Histopathology confirmed granulomatous inflammation with caseous necrosis. The patient received antitubercular chemotherapy and regained full strength in the hands.
Case 7
A 70-year-old male farmer came with swelling and dull aching pain in the right wrist. He gave a history of swelling over the volar aspect of the right wrist, accompanied by dull aching pain and nocturnal exacerbation, tingling, numbness in the index finger, and other constitutional symptoms. Examination revealed an hourglass swelling with cross-fluctuation. Radiography showed diffuse soft tissue swelling. Surgery revealed a bilobed mass with melon seed bodies, diagnosed as compound palmar ganglion. Histopathology confirmed granulomatous inflammation with caseous necrosis. The patient received ATT and regained full function.
Case 8
A 56-year-old farmer presented with a 7.5-month history of volar pain, swelling, discomfort, and tingling sensation of the right wrist along with wasting of the thenar group of muscles. Examination revealed median nerve compression. Radiography showed osteopenia and soft tissue swelling. Surgery revealed melon seed bodies compressing structures in the forearm and wrist. Histopathology confirmed multiple granulomas and caseous necrosis. The patient completed ATT, recovered well, and returned to normal activity without recurrence.
DISCUSSION
Compound palmar ganglion, an old term for tuberculous tenosynovitis, is not well-documented in the literature.6 While many studies typically observe a higher incidence in males aged 20–50 years, affecting the right hand more than the left in right-handed individuals, the present study shows a different trend.7-9 In the current research, the age range is wide (20–79 years), and females are more prevalent (five out of eight cases). This contradicts findings in studies such as Baidoo et al., where males were mostly affected.5 These differences highlight the diversity in how wrist conditions manifest, emphasizing the need for comprehensive understanding across various demographics.
The literature suggests a higher prevalence of this condition in individuals working with cattle and laborers, often linked to occupational exposure. However, our diverse case series challenges the conventional association, showcasing varied professions such as construction worker, student, housewife, butcher, farmer, and teacher.7,10 The multifaceted nature of predisposing factors, including trauma, aligns with our findings, emphasizing the intricate relationship among occupation, trauma, and the onset of the condition. Since literature indicates synovial tuberculosis is typically blood-borne, direct inoculation through cuts and bruises does not seem to play a major role in synovial tuberculosis.11
Histology of the tissue samples shows a granulomatous character. In initial stages, granulation tissue replaces the tendon, progressing to the obliteration of the sheath by fibrous tissue. Within the sheath, there is the presence of yellow serous fluid, and caseation may lead to the formation of melon seed or rice bodies. Failure of healing by fibrosis can result in extensive caseation and granulation.12 Melon seed bodies, characteristic of tubercular compound palmar ganglion, were evident in multiple cases, further confirming the tubercular etiology.13
Stiffness in the fingers, occasionally accompanied by paresthesias along the median nerve distribution. The hallmark is an hourglass-shaped swelling proximal and distal to the palmar retinaculum. Notably, a soft crepitus results due to movement of melon seed bodies within the bursa, eliciting a transmitted fluid impulse between compartments.14 Constitutional symptoms, often associated with tuberculosis in other body parts, were observed in some cases in this study.
Laboratory studies are not of great importance because the diagnosis is usually made both pathologically and microbiologically from material obtained at the time of surgery.15
Differential diagnoses such as chronic tenosynovitis and rheumatoid arthritis were considered in the initial assessments.2 However, the combination of clinical, radiological, and histopathological findings led to a conclusive diagnosis of tubercular compound palmar ganglion. The delay in diagnosis, a common challenge in tuberculous tenosynovitis, is highlighted, emphasizing the need for high index of clinical suspicion and timely investigations.
The cases reinforce the significance of initiating antitubercular treatment promptly while awaiting diagnostic results. Surgical excision, with an emphasis on thorough curettage and synovectomy, emerged as an effective strategy, particularly in cases with evidence of carpal tunnel syndrome. Surgical interventions effectively addressed complications such as nerve compression, identified through clinical signs and imaging. In some instances, there is a need for vigilant follow-up to monitor the potential for local recurrence.
Learning points from these cases reiterate the importance of considering tuberculosis in the differential diagnosis of palmar swellings, especially in regions with a high endemicity of tuberculosis. Additionally, the role of imaging, including MRI and ultrasound, in accurate diagnosis and surgical planning is highlighted.
CONCLUSION
In conclusion, our comprehensive case series sheds light on the diverse clinical manifestations and diagnostic intricacies associated with tubercular compound palmar ganglion. The study challenges traditional demographic patterns, emphasizing the condition’s occurrence across a broad age-group and a higher prevalence among females. The multifaceted nature of predisposing factors, including varied professions and trauma, highlights the complexity in understanding the onset of the condition. Surgical excision with conclusive tissue diagnosis coupled with ATT is key to an effective treatment. This research contributes valuable insights into the management and diagnostic considerations surrounding this uncommon manifestation of extrapulmonary tuberculosis, which is very common among the South Asian population due to late presentation owing to social stigma.
ORCID
Esa Gokulakrishnan https://orcid.org/0009-0002-0067-5174
Prem K Kothimbakkam https://orcid.org/0000-0002-4087-2052
Bharath Vadivelkumar https://orcid.org/0000-0002-8358-2311
Vijayashankar Murugesan https://orcid.org/0000-0002-8744-4610
REFERENCES
1. Talukder S, Bandyopadhay A, Biswas S, et al. Imaging of compound palmar ganglion with pathologic correlation. S Afr J Radiol 2014;18(1):a654. DOI: 10.4102/sajr.v18i1.654
2. Altaf W, Attarde D, Sancheti P. Tubercular compound palmar ganglion presenting as a severe carpal tunnel syndrome- a case report. J Clin Orthop Trauma 2020;11(Suppl. 5):S889–S891. DOI: 10.1016/j.jcot.2020.06.029
3. Das S. A Manual on Clinical Surgery, 13th edition. Kolkata: Dr Somen Das; 2018. p. 319.
4. Higuchi S, Ishihara S, Kobayashi H, et al. A mass lesion of the wrist: a rare manifestation of tuberculosis. Intern Med 2008;47(4):313–316. DOI: 10.2169/internalmedicine.47.0495
5. Baidoo PK, Baddoo D, Ocloo A, et al. Tuberculous tenosynovitis of the flexor tendons of the wrist: a case report. BMC Res Notes 2018;11(1):238. DOI: 10.1186/s13104-018-3343-4
6. Raine AJH, Ritchie HD. Bailey and Love’s Short Practice of Surgery, 17th edition. London: H. K. Lewis & Co. Ltd.; 1977. p. 220.
7. Adams R, Jones G, Marble HC. Tuberculous tenosynovitis. N Engl J Med 1940;223:706–708. DOI: 10.1056/NEJM194010312231803
8. Bickel WH, Kimbrough RF, Dahlin DC. Tuberculous tenosynovitis. JAMA 1953;151:31–35. DOI: 10.1001/jama.151.1.31
9. Fellander M. Tuberculous tenosynovitis of the hand treated by combined surgery and chemotherapy. Acta Chir Scand 1956;11:142–150. DOI: 10.13107/jocr.2250-0685.954
10. Bunnell S. Surgery of the Hand. Philadelphia: Lippincott; 1949.
11. Smith RJ, Leffert RD. Tuberculosis of the hand. In: Flynn JE (Ed). Hand Surgery, 3rd edition. 1982. Baltimore: Williams & Wilkins; pp. 724–730.
12. Lall H, Nag SK, Jain VK, et al. Tuberculous extensor tenosynovitis of the wrist with extensor pollicis longus rupture: a case report. J Med Case Rep 2009;3:142. DOI: 10.1186/1752-1947-3-142
13. Doraisamy N, Chandrasekhar M, Jebakumar J, et al. Tuberculous compound palmar ganglion. J Postgrad Med Edu Res 2017;51(1):28–29. DOI: 10.5005/JPMER-51-1-28
14. Cain A (Ed). The hand. In: Hamilton Bailey’s Demonstrations of Physical Signs in Clinical Surgery, 15th edition. Bristol: John Wright & Sons Ltd.; 1973. pp. 489–490.
15. Wali H, Al-Khuwaitir S, Hafeez MA. Compound palmar ganglion: a case report and literature review. Ann Saudi Med 1986;6(1):55–59. DOI: 10.5144/0256-4947.1986.55.
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