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Mycobacterium terrae tenosynovitis
Pathology (1990), 22, pp. 106-107
Case Report MYCOBACTERIUM TERRAE TENOSYNOVITIS KULA T. KARTHIGASU,* DOMINIC v. SPAGNOLO**AND BETHL.
GOWt
*Department of Clinical Microbiology, Sir Charles Gairdner Hospital, and **Department of Histopathology, Sir Charles Gairdner Hospital, Nedlands, tMycobacteria Reference Laboratory, State Health Laboratories, Queen Elizabeth 11 Medical Centre, Nedlands, Western A ustralia
Summary Atypical mycobacteria causing extra-pulmonarydisease in man are well documented.' These infections are manifested by the presence of ulcers, abscesses and lymphadenitis. Mycobacteriurn marinurn is particularly noted for infections involving the Of lesser note synovium, tendon sheaths, bursae and is Mycobacteriorn terrae (radish bacillus): a nonchromogenalso associated with tenosynovitis. We are not aware of any previous report of the association of M. terrae with synovitis in Australia.' This case report describes a culture-proven case of tenosynovitis caused by M. terrae.
Key words: Mycobacterium terrae, synovitis Accepted 1 August, 1989
CASE REPORT This 63-year-old lady, an avid gardener, noticed a swelling and felt discomfort over the left wrist over an eight-month period. There was no history of abrasions or puncture wounds. At presentation, she gave a history of recent rapid increased swelling, numbness on the palmar aspect of her left hand and associated weakness of the little finger. On examination, there was a 5 cm x 6 cm swelling over the volar aspect. Paresthesia was detected over the ulnar border of the hand, and weakness and minimal wasting over the ulnar and median nerve distribution. An initial diagnosis of a cystic compound ganglion was made. EMG and nerve conduction studies showed partial denervation of thenar, hypothenar and the first interosseus of the left ulnar and median nerve, thought to be related to the swelling. A large fluid-filled myxoid mass was dissected and excised from amongst the tendons.
PATHOLOGY The specimen received in the laboratory consisted of several irregular pieces of soft tissue, the largest measuring 7 x 4 x 1.5cm. Some of the fragments had a firm and smooth border of white fibrous tissue on one aspect, while on the other surface there were irregular nodular and filiform excrescences of soft, yellow, gelatinous material. Histological examination revealed granulomatous synovitis occurring in a thickened, hyperplastic synovium thrown into papillary processes, many of which were
covered by an exuberant fibrinous exudate. There was marked synoviocyte hyperplasia. The stroma contained many epithelioid granulomata and a variable infiltrate of lymphocytes, histiocytes, some neutrophil polymorphs and occasional plasma cells. The granulomata ranged in appearance from loose collections of epithelioid histiocytes, to larger, well-formed, circumscribed granulomata which contained multinucleate Langhans' giant cells. Most granulomata were non-necrotizing, but a few had necrotic centres. A cluster of acid and alcohol-fast bacilli was found in one of the fdiform processes, surrounded by degenerate inflammatory cells. Single bacilli were rarely seen (Fig. 1). Stains for fungi and other organisms were negative. MICROBIOLOGY Although acid-fast bacilli were not seen on direct microscopy of tissue and fluid, Mycobacterium terrae was cultured. The organism was identified as Mycobacterium terrae on the basis of cultural and biochemical tests (See Table 1). Fungal and routine cultures were negative.
Pigment production in dark Pigment production in light Niacin Nitrate reduction Catalase (column of foam >45 mm) Tween 80 hydrolysis Tellurite reduction (3 day) Arylsulfatase (3 day) Arylsulfatase ( 2 weeks) 5% NaCl tolerance Urease Growth at room temperature Growth at 30°C Growth at 37°C Growth at 42°C
negative negative negative positive positive positive negative negative positive negative negative positive positive positive negative
MYCOBACTERIUMTERRAE TENOSYNOVITIS
107
Fig. 1 Top left: Fibrinous exudate (bottom right) along synovial surface with palisading histiocytes in subjacent stroma including many epithelioid cells which at one point (top left) form a loose granuloma. (H&E x 160) Right: A non-necrotizing granuloma in deep synovial stroma. Several Langhans’ giant cells are present. (H&E x400) Bottom left: A colony of beaded, slender, acid-fast bacilli surrounded by histiocytes predominantly. (H&E x 1600)
and house dust, is not commonly isolated from patients in Australia.6 We know of only one reported case of this,’ in which the organism was sensitive to ethambutol but resistant to cycloserine, isoniazid, para-aminosalicylic acid, rifampicin and streptomycin. Suitable chemotherapeutic regimes for M. terrae infection are not clear.8 Surgery alone as appropriate therapy for hand infections has been a d ~ o c a t e d .This ~ patient did not have any chemotherapy, given previous reports on the doubtful outcome of ethambutol treatment.’ Chest x-ray was normal without evidence of tuberculosis, and the patient was Mantoux-positive. Cell-mediated immunity was normal. At last follow-up, one year after surgery, a small nodule was noted. Recurrence of this infection is common and a trial of chemotherapy may be indicated in this case. The organism was sensitive to ethambutol and prothionamide but resistant to steptomycin, isoniazid, rifampicin, para-aminosalicylic acid, kanamycin and moderately resistant to cycloserine.
ACKNOWLEDGEMENTS We wish to acknowledge permission from Mr. B.A.R. Stokes, Neurosurgeon, Sir Charles Gairdner Hospital to present this case.
Address for correspondence:K.T.K., Department of Clinical Microbiology, Sir Charles Gairdner Hospital, Nedlands 6009,Western Australia.
References 1. Blacklock ZM, Dawson DJ. Atypical mycobacteria causing nonpulmonary disease in Queensland. Pathology 1979; 11: 283-7. 2. Beckman EN, Pankey GA, McFarland GB. The histopathology of Mycobacterium marinum. Am J Clin Pathol 1985; 83: 457-62.
3. Collins RJ, Chow SP, Ip FK, Leung YK. Synovial involvement by Mycobacterium marinum. A histopathological study of 25 cultureproven cases. Pathology 1988; 20: 340-5. 4. Huskisson EC, Doyle DV, Fowler EF, Shaw EJ. Sausage digit due to radish bacillus. Ann Rheum Dis 1981; 40: 90-1. 5 . Halla JT, Gould JS, Hardin JG. Chronic tenosynovial hand infection from Mycobacterium terrae. Arthritis Rheum 1979; 22: 1386-90.
6. Dawson DJ. Potential pathogens among strains of mycobacteria isolated from house-dusts. Med J Aust 1971; 1: 679-81.
7. Love GL, Melchior E. Mycobacterium terrae tenosynovitis. J Hand Surg 1985; 10: 730-2. 8. Kuze F et al. Chronic pulmonary infection caused by Mycobactenum terrae. Am Rev Resp Dis 1983; 128: 561-5.
9. May CD et al. Mycobacterium terrae tenosynovitis: chronic infection in a previously healthy individual. Southern Med J 1983; 76: 1445-7.
Case Report MYCOBACTERIUM TERRAE TENOSYNOVITIS KULA T. KARTHIGASU,* DOMINIC v. SPAGNOLO**AND BETHL.
GOWt
*Department of Clinical Microbiology, Sir Charles Gairdner Hospital, and **Department of Histopathology, Sir Charles Gairdner Hospital, Nedlands, tMycobacteria Reference Laboratory, State Health Laboratories, Queen Elizabeth 11 Medical Centre, Nedlands, Western A ustralia
Summary Atypical mycobacteria causing extra-pulmonarydisease in man are well documented.' These infections are manifested by the presence of ulcers, abscesses and lymphadenitis. Mycobacteriurn marinurn is particularly noted for infections involving the Of lesser note synovium, tendon sheaths, bursae and is Mycobacteriorn terrae (radish bacillus): a nonchromogenalso associated with tenosynovitis. We are not aware of any previous report of the association of M. terrae with synovitis in Australia.' This case report describes a culture-proven case of tenosynovitis caused by M. terrae.
Key words: Mycobacterium terrae, synovitis Accepted 1 August, 1989
CASE REPORT This 63-year-old lady, an avid gardener, noticed a swelling and felt discomfort over the left wrist over an eight-month period. There was no history of abrasions or puncture wounds. At presentation, she gave a history of recent rapid increased swelling, numbness on the palmar aspect of her left hand and associated weakness of the little finger. On examination, there was a 5 cm x 6 cm swelling over the volar aspect. Paresthesia was detected over the ulnar border of the hand, and weakness and minimal wasting over the ulnar and median nerve distribution. An initial diagnosis of a cystic compound ganglion was made. EMG and nerve conduction studies showed partial denervation of thenar, hypothenar and the first interosseus of the left ulnar and median nerve, thought to be related to the swelling. A large fluid-filled myxoid mass was dissected and excised from amongst the tendons.
PATHOLOGY The specimen received in the laboratory consisted of several irregular pieces of soft tissue, the largest measuring 7 x 4 x 1.5cm. Some of the fragments had a firm and smooth border of white fibrous tissue on one aspect, while on the other surface there were irregular nodular and filiform excrescences of soft, yellow, gelatinous material. Histological examination revealed granulomatous synovitis occurring in a thickened, hyperplastic synovium thrown into papillary processes, many of which were
covered by an exuberant fibrinous exudate. There was marked synoviocyte hyperplasia. The stroma contained many epithelioid granulomata and a variable infiltrate of lymphocytes, histiocytes, some neutrophil polymorphs and occasional plasma cells. The granulomata ranged in appearance from loose collections of epithelioid histiocytes, to larger, well-formed, circumscribed granulomata which contained multinucleate Langhans' giant cells. Most granulomata were non-necrotizing, but a few had necrotic centres. A cluster of acid and alcohol-fast bacilli was found in one of the fdiform processes, surrounded by degenerate inflammatory cells. Single bacilli were rarely seen (Fig. 1). Stains for fungi and other organisms were negative. MICROBIOLOGY Although acid-fast bacilli were not seen on direct microscopy of tissue and fluid, Mycobacterium terrae was cultured. The organism was identified as Mycobacterium terrae on the basis of cultural and biochemical tests (See Table 1). Fungal and routine cultures were negative.
Pigment production in dark Pigment production in light Niacin Nitrate reduction Catalase (column of foam >45 mm) Tween 80 hydrolysis Tellurite reduction (3 day) Arylsulfatase (3 day) Arylsulfatase ( 2 weeks) 5% NaCl tolerance Urease Growth at room temperature Growth at 30°C Growth at 37°C Growth at 42°C
negative negative negative positive positive positive negative negative positive negative negative positive positive positive negative
MYCOBACTERIUMTERRAE TENOSYNOVITIS
107
Fig. 1 Top left: Fibrinous exudate (bottom right) along synovial surface with palisading histiocytes in subjacent stroma including many epithelioid cells which at one point (top left) form a loose granuloma. (H&E x 160) Right: A non-necrotizing granuloma in deep synovial stroma. Several Langhans’ giant cells are present. (H&E x400) Bottom left: A colony of beaded, slender, acid-fast bacilli surrounded by histiocytes predominantly. (H&E x 1600)
and house dust, is not commonly isolated from patients in Australia.6 We know of only one reported case of this,’ in which the organism was sensitive to ethambutol but resistant to cycloserine, isoniazid, para-aminosalicylic acid, rifampicin and streptomycin. Suitable chemotherapeutic regimes for M. terrae infection are not clear.8 Surgery alone as appropriate therapy for hand infections has been a d ~ o c a t e d .This ~ patient did not have any chemotherapy, given previous reports on the doubtful outcome of ethambutol treatment.’ Chest x-ray was normal without evidence of tuberculosis, and the patient was Mantoux-positive. Cell-mediated immunity was normal. At last follow-up, one year after surgery, a small nodule was noted. Recurrence of this infection is common and a trial of chemotherapy may be indicated in this case. The organism was sensitive to ethambutol and prothionamide but resistant to steptomycin, isoniazid, rifampicin, para-aminosalicylic acid, kanamycin and moderately resistant to cycloserine.
ACKNOWLEDGEMENTS We wish to acknowledge permission from Mr. B.A.R. Stokes, Neurosurgeon, Sir Charles Gairdner Hospital to present this case.
Address for correspondence:K.T.K., Department of Clinical Microbiology, Sir Charles Gairdner Hospital, Nedlands 6009,Western Australia.
References 1. Blacklock ZM, Dawson DJ. Atypical mycobacteria causing nonpulmonary disease in Queensland. Pathology 1979; 11: 283-7. 2. Beckman EN, Pankey GA, McFarland GB. The histopathology of Mycobacterium marinum. Am J Clin Pathol 1985; 83: 457-62.
3. Collins RJ, Chow SP, Ip FK, Leung YK. Synovial involvement by Mycobacterium marinum. A histopathological study of 25 cultureproven cases. Pathology 1988; 20: 340-5. 4. Huskisson EC, Doyle DV, Fowler EF, Shaw EJ. Sausage digit due to radish bacillus. Ann Rheum Dis 1981; 40: 90-1. 5 . Halla JT, Gould JS, Hardin JG. Chronic tenosynovial hand infection from Mycobacterium terrae. Arthritis Rheum 1979; 22: 1386-90.
6. Dawson DJ. Potential pathogens among strains of mycobacteria isolated from house-dusts. Med J Aust 1971; 1: 679-81.
7. Love GL, Melchior E. Mycobacterium terrae tenosynovitis. J Hand Surg 1985; 10: 730-2. 8. Kuze F et al. Chronic pulmonary infection caused by Mycobactenum terrae. Am Rev Resp Dis 1983; 128: 561-5.
9. May CD et al. Mycobacterium terrae tenosynovitis: chronic infection in a previously healthy individual. Southern Med J 1983; 76: 1445-7.