title: A typically atypical tenosynovitis.
abstract: A 68-year-old woman developed tenosynovitis of the right second digit without a history of injury or animal bites. Apart from high titer anti-nuclear antibodies, serological studies were unremarkable. Tuberculin test and interferon gamma release assay were both negative. Several immunosuppressive therapies led only to partial relief of symptoms. Of note, clinical symptoms worsened significantly after introduction of adalimumab therapy. Tenosynovectomy was performed revealing a granulomatous inflammatory process. Seven weeks later, Mycobacterium malmoense could be cultured from the surgical specimen. A four drug antibiotic regimen was started and immunosuppressive therapy discontinued resulting in complete clinical remission. Our case highlights non-tuberculous mycobacterial (NTM) tenosynovitis as an important differential diagnosis of atypical arthritis. A negative tuberculin skin test as well as negative Ziehl-Neelsen stain does not argue against NTM infection. In fact, mycobacterial culture for extended periods remains the gold standard for diagnosis.
authors.affiliation: Department of Internal Medicine 3 and Institute for Clinical Immunology, University of Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany.
authors.forename: Enijad
authors.initials: E
authors.lastname: Sahinbegovic
authors.forename: Gunther
authors.initials: G
authors.lastname: Arco
authors.forename: Alexander
authors.initials: A
authors.lastname: Cavallaro
authors.forename: Stephan
authors.initials: S
authors.lastname: Söder
authors.forename: Christoph
authors.initials: C
authors.lastname: Schörner
authors.forename: Georg
authors.initials: G
authors.lastname: Schett
authors.forename: Thomas
authors.initials: T
authors.lastname: Harrer
authors.forename: Jochen
authors.initials: J
authors.lastname: Zwerina
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005260:Female; D005384:Finger Joint / Q000382:microbiology / Q000473:pathology* / Q000601:surgery; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D009161:Mycobacterium / Q000302:isolation & purification; D009165:Mycobacterium Infections, Nontuberculous / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D000074402:Synovectomy; D013583:Synovial Membrane / Q000382:microbiology / Q000473:pathology*; D013710:Tendons / Q000382:microbiology / Q000473:pathology* / Q000601:surgery; D013717:Tenosynovitis / Q000175:diagnosis* / Q000188:drug therapy / Q000601:surgery; D017211:Treatment Failure; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D005938:Glucocorticoids; D007166:Immunosuppressive Agents