NDT Advance Access originally published online on November 18, 2006
Nephrology Dialysis Transplantation 2007 22(3):971-972; doi:10.1093/ndt/gfl651
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A painful hand in a kidney transplant recipient
Email: pmunoz{at}micro.hggm.esSir,
A 58-year-old Caucasian woman reported 1-month progressive pain and swelling of the wrist and metatharsal region (Figure 1). She had received a renal transplantation 6 years previously and was on cyclosporine A and mycophenolate. Her daughter had latent tuberculosis 15 years earlier. Imaging techniques of the wrist were suggestive of tenosynovitis. Fine-needle aspiration yielded 0.3 ml of liquid with inflammatory properties. Standard stains and cultures, 16S rRNA gene PCR and mycobacteria PCR were negative. TST, chest radiographs, abdominal ultrasonography and cultures for mycobacteria were also negative.
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After 2 weeks of empirical antibiotic treatment without clinical improvement, a synovial biopsy was performed, from which Mycobacterium tuberculosis was recovered. Eventually, M. tuberculosis also grew from the earlier synovial fluid. Surgical debridement was performed and the diagnosis was histologically confirmed. Treatment with isoniazid, ethambutol and levofloxacin has been satisfactory.
Infectious tenosynovitis is an uncommon disorder that may result from puncture wounds or lacerations. Infection in the closed space of the hand can lead to severe limitation of motion, due to tendon disruption. Reports of tuberculous tenosynovitis after organ transplantation are very rare. We found only one other case of M. tuberculosis tenosynovitis in a heart transplant patient [1], two by M. kansasii and two by non-identified mycobacteria [2–5]. However, in other populations, tuberculosis is a common cause of tenosynovitis. It spreads haematogenously from a secondary infection site, such as lung or abdomen. Precipitating factors include trauma (30%), work-related tendon stress and local glucocorticoid injections.
Definite diagnosis must rely on deep structures culture, since granulomatous inflammation alone may have another aetiology. The sensitivity of synovial fluid culture for M. tuberculosis is 79% and reaches 94% for synovial tissue culture. Molecular techniques allow a rapid diagnosis (<6 h) directly from the samples. The false negative result in our case may be due to low inoculum of the sample. Other foci of tuberculous disease should be excluded in all patients with synovitis.
A combination of medical and surgical treatment increases the chances of satisfactory functional outcomes. Significant interaction of rifampin with immunosuppressive agents may occur in the transplant population. If disseminated disease and suspicion of multi-drug resistant tuberculosis (MDR-TBC) are absent, we recommend [6] isoniazid, ethambutol and pyrazinamide. In the presence of disseminated disease or in geographic areas of MDR-TBC, the addition of a fourth drug is recommended. Triple therapy is usually maintained for the initial 2 months, followed by a combination of isoniazid and ethambutol for periods of up to 18 months, in situations in which rifampin cannot be part of the therapy. Surgery is essential and safe in the transplant population with tenosynovitis. Rehabilitation therapy improves the functional outcome but recurrences are common and prolonged follow-up should therefore be provided.
1Department of Clinical Microbiology and Infectious Diseases
2Department of Nephrology
Hospital General Universitario
"Gregorio Marañón"
University of Madrid
Madrid, Spain
Acknowledgements
We would like to thank Mr. Lawrence Baron for his assistance with the English wording. This work is partly supported by the study group of infection in transplant patients (GESITRA) and by Red Española de Infección y Trasplante. (RESITRA-G03/75). ISCIII. Ministerio de Sanidad y Consumo.
Conflict of interest statement. None declared.
References
- Le Meur A, Arvieux C, Guggenbuhl P, Cormier M, Jolivet-Gougeon A. (2005) Tenosynovitis of the wrist due to resistant Mycobacterium tuberculosis in a heart transplant patient. J Clin Microbiol 43:988–990.
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- Sanger JF, Strampfl DA, Franson TR. (1987) Recurrent granulomatous synovitis due to Mycobacterium kansasii in a renal transplant recipient. J Hand Surg 12:436–441.[Medline]
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- Vivekanad J, Ashiq H, Nahar U. (2003) Tubercular tonsillitis and tenosynovitis in a renal transplant recipient. Transplantation 76:269–270.[CrossRef][Web of Science][Medline]
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