title: A Rare Diagnosis: Recognizing and Managing Fungal Tenosynovitis of the Hand and Upper Extremity.
abstract: OBJECTIVE
  Fungal infections involving the tenosynovium of the upper extremity are uncommon and are often misdiagnosed. This study evaluates the epidemiology, diagnosis, treatment, and outcomes of patients with fungal tenosynovitis of the upper extremity over a 20-year period.
  
  
  METHODS
  A retrospective review of all culture-confirmed cases of fungal tenosynovitis of the upper extremity treated between 1990 and 2013 at a single institution was performed. Clinical data included patient and epidemiologic risk factors, causative fungal organism, surgical management, antimicrobial regimen, recurrence rates, and outcomes.
  
  
  RESULTS
  There were 10 patients (9 female, 1 male) who met the inclusion criteria. The mean patient age was 60 years (range, 47-76 y). Identified pathogens included Histoplasmacapsulatum (7), Coccidioides posadasii/immitis (2), and Cryptococcus neoformans (1). Eight patients were on immunosuppressant medications at the time of diagnosis. The most common clinical presentation was subacute localized pain, swelling, and erythema consistent with tenosynovitis. The diagnosis was delayed by a median of 6 months (range, 0-48 mo). The most helpful diagnostic imaging studies included magnetic resonance imaging and ultrasound. All patients were treated with extensive surgical synovectomy and debridement. Seven patients were treated by a single surgery, whereas 3 required multiple consecutive debridements (2, 7, and 10 surgeries). The mean course of initial antimicrobial therapy was 8.2 months (range, 3-12 mo). Clinical recurrence was noted in 3 patients (30%) during a median follow-up period of 46 months (range, 7-250 mo). Both patients with Coccidioides infection incurred recurrence.
  
  
  CONCLUSIONS
  Although uncommon, surgeons and clinicians should consider a diagnosis of fungal tenosynovitis among immunocompromised patients with signs of mild tenosynovitis and should consider operative debridement and biopsy. Although the majority of patients were successfully treated with surgical debridement and antimicrobial therapy, a recurrence rate of 30% highlights the need for close post-treatment follow-up.
  
  
  METHODS
  Therapeutic V.
authors.affiliation: Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Maureen A
authors.initials: MA
authors.lastname: O'Shaughnessy
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Aaron J
authors.initials: AJ
authors.lastname: Tande
authors.affiliation: Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.
authors.forename: Shawn
authors.initials: S
authors.lastname: Vasoo
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Enzler
authors.affiliation: Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Elie F
authors.initials: EF
authors.lastname: Berbari
authors.affiliation: Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN. Electronic address: Shin.Alexander@mayo.edu.
authors.forename: Alexander Y
authors.initials: AY
authors.lastname: Shin
mesh_terms: D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D003646:Debridement; D003952:Diagnostic Imaging; D005260:Female; D006801:Humans; D016867:Immunocompromised Host; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000175:diagnosis* / Q000382:microbiology* / Q000628:therapy*; D012189:Retrospective Studies; D013717:Tenosynovitis / Q000175:diagnosis* / Q000382:microbiology* / Q000628:therapy*; D016896:Treatment Outcome; D034941:Upper Extremity / Q000382:microbiology*
chemical_list: D000935:Antifungal Agents
keywords: Fungal; infection; tenosynovitis; upper extremity