Atypical Mycobacterial Infections of the Upper Extremity

Abstract

Atypical mycobacterial infections of upper extremity synovial-lined structures are often misdiagnosed and unrecognized. Despite an increasing incidence, lack of physician awareness of these pathogens may result in considerable delay in diagnosis and management, potentially leading to permanent disability. The authors conducted a literature review and analyzed 31 cases of penetrating atypical mycobacterial infection to better understand the clinical characteristics and to evaluate their posttreatment complication rate compared with available literature. Medical records for culture-positive cases of tenosynovial or intra-articular atypical mycobacterial infections of the upper extremity that were treated were retrospectively reviewed. Treatment outcomes were analyzed against published case reviews and case series. Thirty-one cases of penetrating atypical mycobacterial infection were identified. Mycobacterium marinum (n=11) was the most common organism and was associated with aquatic exposure. Twenty-eight cases received empiric treatment, 17 of which received contraindicated treatment. Patients saw an average of 5 physicians prior to receiving an accurate diagnosis, and the mean time to diagnosis was 10 months. All cases received antibiotic treatment in addition to surgical management. Twenty cases (68%) failed treatment outcomes. Delay in diagnosis and inappropriate management of atypical mycobacterial infections may lead to a treatment failure rate that is higher than what has been reported in the literature. Mycobacterium avium and M fortuitum had significantly higher failure rates than other organisms. A high index of suspicion is required to make a diagnosis and prevent residual disability. [Orthopedics. 2018; 41(3):e383-e388.].

Recurrent Nontuberculous Mycobacterial Tenosynovitis

“…5 Often, the diagnosis of mycobacterial infection within a joint or tendon is missed or delayed because of the indolent course, lack of clinical suspicion, misinterpretation of biopsies, and lack of mycobacterial cultures performed. [6][7] The most commonly involved location for nontuberculous mycobacterial infection within the musculoskeletal system is the hand and wrist because of the relative abundance of synovium and the increased risk for inoculation through penetrating trauma. 2,6,8 Patients usually present with swelling, drainage, or a palpable mass.…”

“…1,2,9 Combined surgery and antimycobacterial therapy are needed for treatment as synovectomy cannot remove all of the infected tissue but can decrease the overall disease burden, giving the pharmacologic therapy a better chance to eradicate the residual infection. 1,6,7,9 AFB staining from synovial biopsy is often negative, with a diagnostic yield ranging from 0% to 60%, and initial histopathology evaluation may reveal granulomatous inflammation. 6,9,11 Given the appropriate clinical history, the presence of granulomatous synovial inflammation, and negative fungal cultures, antimycobacterial therapy should be started immediately after surgery and prior to receiving definitive mycobacterial culture results, which may take several weeks.…”

“…5,6 Prolonged therapy of at least 6 months and up to 2 years is recommended, with tailoring of pharmacologic treatment after culture results demonstrate drug sensitivities given the high rate of drug resistance among nontuberculous mycobacteria. 1,2,6,7 However, even with thorough debridement and prolonged appropriate medical therapy, infection may recur and require repeated debridement for infection control. 1 Treatment is more likely to fail in cases of articular infection and osteomyelitis and can lead to persistent patient disability or even amputation.…”

Nontuberculous mycobacterial infections of the lower extremities: A 15-year experience

“…Given the high cure rate in our cohort, ascertaining whether the shorter interval from symptom presentation to diagnosis was related to outcome may be difficult. In a retrospective review of 31 cases of atypical mycobacterial infections of the upper extremity (mean diagnostic delay, 10 months), delays and inappropriate management resulted in a higher risk of treatment failure of up to 68%, especially in patients with M. avium and M. fortuitum , compared with patients with M. marinum [44]. Follow-up ranged from 1 month to 9 years for those who had medical treatment alone or medical treatment combined with surgery.…”

Mycobacterial Tenosynovitis After Sea Urchin Spine Injury in an Immunocompromised Patient

“…Mycobacterial tenosynovitis of the hand has been specifically reported in the literature, usually associated with puncture wounds and exposure to sea water and fish [ 9–12 ]. Due to the indolent nature of mycobacterial infection, onset of symptoms is typically gradual and delay in diagnosis and surgical treatment, often by months, is common [ 13 ]. Retention of spine fragments is known to cause painful skin nodules with foreign-body granulomatous reaction as well as arthritis and synovitis [ 14 ].…”