JKSSH Journal of the Korean Society for Surgery of the Hand J Korean Soc Surg Hand 1598-3889 2234-0998 The Korean Society for Surgery of the Hand 10.12790/jkssh.2015.20.3.119 jkssh-20-119 Original Article Diagnosis and Treatment for Deep Nontuberculous Mycobacteria Infection of the Hand and Wrist ParkHo Youn 1 YoonJun O 2 ParkJin-Woong 2 YoonJaeyoun 2 KimJim Sam 2 Department of Orthopedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University, Uijeongbu, Korea Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Correspondence to: Jim Sam Kim Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea TEL: +82-2-3010-3950 FAX: +82-2-488-7877 E-mail: micro@amc.seoul.kr 09 2015 11 09 2015 203 119 126 11062015 14082015 27082015 27082015 Copyright © 2015 Korean Ophthalmological Society 2015 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Purpose:

The purpose of this study was to present a systematic treatment method for nontuberculous mycobacteria (NTM) infection of the hand and wrist to gain better clinical outcomes.

 Methods:

10 patients of deep NTM infection of the hand and wrist were reviewed. Extensive debridement was performed in all cases. When biopsy result suggested mycobacterial infection such as granulomatous inflammation, empirical tuberculosis medication was started. After culture confirmed NTM growth, the species was identified and in vitro sensitivity test was performed. Then medication was switched according to the results. Functional outcomes of the hand and wrist were measured by total active motion of the fingers and by range of motion of the wrist respectively.

 Results:

Diagnosis was tenosynovitis in seven patients, infective arthritis and osteomyelitis combined with tenosynovitis of the wrist in three patients. Two patients had recurred skin ulcer during follow-up period and undergone second debridement. After second operation, no patient had a persistent discharging sinus and all patient were completely healed during follow-up period. Functional outcome of the eight patients who had NTM infection of their hand was excellent in two, good in four, fair in one, poor in one. Mean range of motion of the two patients who had osteomyelitis of their wrist was dorsiflexion 20°, volar flexion 15°, radial deviation 0°, ulnar deviation 15°.

 Conclusion:

Our standardized treatment protocol can be helpful for treatment of deep NTM infection of the hand and wrist.

 Hand and wrist Nontuberculous mycobacteria infection Treatment algorithm References GriffithDEAksamitTBrown-ElliottBAAn official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseasesAm J Respir Crit Care Med2007175367416 von ReynCFArbeitRDHorsburghCRSources of disseminated Mycobacterium avium infection in AIDSJ Infect.20024416670 YoonHJKwonJWYoonYCChoiSHNontuberculous mycobacterial tenosynovitis in the hand: two case reports with the MR imaging findingsKorean J Radiol2011127459 MazisGASakellariouVIKontosFZervaLSpyridonosSGRecurrent fluctuant mass of the wrist and forearm associated with chronic tenosynovitis by Mycobacterium kansasiiOrthopedics201134400 LeeWJKangSMSungHNon-tuberculous mycobacterial infections of the skin: a retrospective study of 29 casesJ Dermatol20103796572 WoodsGLClinical and Laboratory Standards InstituteSusceptibility testing of mycobacteria, nocardiae and other aerobic actinomycetes tmvpdltm tkrwp: approved standardWayne, PAClinical and Laboratory Standards Institute2011 StricklandJWGlogovacSVDigital function following flexor tendon repair in Zone II: A comparison of immobilization and controlled passive motion techniquesJ Hand Surg Am1980553743 MazonAGil-SetasAAlfaroJIdigorasPDiagnosis of tuberculous arthritis from the isolation of Mycobacterium tuberculosis in blood agar and chocolate agarEnferm Infecc Microbiol Clin2000185278 WolinskyENontuberculous mycobacteria and associated diseasesAm Rev Respir Dis197911910759 WallaceRJ JrSwensonJMSilcoxVAGoodRCTschenJAStoneMSSpectrum of disease due to rapidly growing mycobacteriaRev Infect Dis1983565779 FalkinhamJO3rdEpidemiology of infection by nontuberculous mycobacteriaClin Microbiol Rev19969177215 WallaceRJ JrSwensonJMSilcoxVABullenMGTreatment of nonpulmonary infections due to Mycobacterium fortuitum and Mycobacterium chelonei on the basis of in vitro susceptibilitiesJ Infect Dis198515250014 WolinskyEGomezFZimpferFSporotrichoid Mycobacterium marinum infection treated with rifampin-ethambutolAm Rev Respir Dis19721059647 AubryAChosidowOCaumesERobertJCambauESixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolatesArch Intern Med2002162174652 CheungJPFungBWongSSIpWYReview article: Mycobacterium marinum infection of the hand and wristJ Orthop Surg (Hong Kong)20101898103 ChowSPStroebelABLauJHCollinsRJMycobacterium marinum infection of the hand involving deep structuresJ Hand Surg Am1983856873 Figures and Tables

Algorithm of our standardized treatment of NTM infection of the hand and wrist. TB, tuberculosis; NTM, nontuberculous mycobacteria; AFB, acid fast bacillus; ROM, range of motion.

Extensive debridement was performed. (A) The medical photograph shows infective tissue around the flexor tendon of the ring finger. (B) The infective tissue was massively removed preserving the A2 pulley. (C) Biopsy material was sent for histology and culture study.

A 47-year-old patient with chronic infective arthritis and osteomyelitis combined with tenosynovitis of the finger joint. This patient had taken steroids for a long period because of lupus disease. (A) Preoperative X-rays shows severely destructed finger joint of the middle finger. (B) Postoperative X-ray shows massive removal of infective bone.

A 73-years-old patient with chronic infective arthritis and osteomyelitis combined with tenosynovitis of the wrist joint. This patient had taken steroids for a long period because of lupus disease. (A) Preoperative X-rays shows diffuse osteopenia and bony erosion at the wrist joint. (B) Magnetic resonance imaging shows synovial proliferation wrist joint, involvement of the flexor and extensor tendons, and carpal bone erosion. (C) Extensive debridement including synovectomy and Darrach operation was performed. Postoperative X-rays at the final follow-up shows decreased swelling and consolidation of the remaining carpal bones.

Clinical characteristics of ten cases

Case Age (yr)/sex Underlying disease Precipitating factors Duration of symptoms (mo) Affected site MRI/US finding Pathology Culture AFB PCR TB/NTM Medication/duration (mo) Outcomes
1 46/male None None 12 Ring finger, Rt F. TS G/N:+/- M. intracellulare - -/- RFP+EMB+clari/12 Healed
2 74/male None Excision of ganglion 24 Wrist~palm, Rt F. TS G/N: +/- M. marinum - -/0 INH+EMB+CIPR/13 Healed
3 58/male None Fishbone 8 Index finger, Rt F. TS G/N:+/+ M. marinum - -/0 RFP+EMB+clari/12 Healed
4 48/female SLE None 12 Middle linger, Rt Finger joint IA, OM, F. E. T G/N: +/+ M. intracellulare + -/0 RFP+EMB+clari/34 Wound Revision
5 74/male None Steroid injection 3 Index finger, Lt F. TS G/N: +/- M. marinum - -/0 RFP+EMB+clari/12 Healed
6 54/male None Wire 2 Little finger, Rt F. TS Acute, chronic Inflammation M. abscessus - 0/0 Clari+amik+CIPR/5 Healed
7 77/male None CTR 36 Wrist joint, Rt Wrist joint IA, OM, F. E. TS G/N: +/+ M. marinum - -/0 RFP+EMB+clari/9 Healed
8 66/male SLE CTR 7 Palm: 2-5th fingers, Rt F. TS G/N:+/- M. intracellulare - -/0 EMB+clari+levo/15 Healed
9 73/male None Acupuncture 2 Wrist joint, Rt Wrist joint IA, OM, F. E. TS Acute inflammation with N M. intracellulare - -/0 RFP+EMB+clari/12 Wound revision
10 41/female None Excision of ganglion 12 Wrist joint, Lt E.TS G/N: +/- M. chelonae - -/- Clari+amik+moxi/12 Healed

MRI/US, magnetic resonance imaging/ultrasound; AFB, acid fast bacillus; PCR TB/NTM, polymerase chain reaction tuberculosis/nontuberculous mycobacteria; Rt, right; F., flexor; TS, tenosynovitis; G/N, chronic granulommatous inflammation/necrosis; RFP, Rifampin; EMB, ethambutol; clari, clarithromycin; INH, isoniazid; Lt, left; IA, infective arthritis; OM, osteomyelitis; E., extensor; CIPR, ciprobay; amik, amikacin; levo, levofloxacin; moxi, moxifloxacin; -, negative; +, positive; 0, was not performed.