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it mimics a number of other clinical conditions such as ganglion , de quervan s disease , carpal tunnel syndrome , granulomatous gout , neurofibroma , and haemangioma .
we present case of 58-year - old male patient with swelling over thenar region of left hand where the initial fine needle aspiration cytology ( fnac ) report suggested diagnosis of ganglion / synovial cyst , but the patient did not improve with conservative treatment .
fnac was repeated which showed granulomatous inflammation consistent with the clinical diagnosis of tuberculosis and antitubercular therapy for 9 months was given .
swelling disappeared and normal range of movements was attained in adjacent joints at final follow - up of 12 months from initiation of antitubercular treatment ( att ) .
the literature on the management of tubercular tenosynovitis has mostly incorporated surgical method as one of the first - line treatments .
we report an unusual case , where the tenosynovitis of wrist completely responded within 12 months of att without any need of surgical treatment .
tuberculosis ( tb ) can affect any organs / systems of the human body and have variable presentation in each system . the musculoskeletal system is involved in approximately 10% of all extrapulmonary involvements .
tb tenosynovitis of the wrist and hand is an unusual condition [ 2 , 3 ] . the major dilemma in diagnosing these uncommon presentations is the presence of the non - specific clinical signs which can be misleading as they mimic a number of other clinical conditions such as ganglion , de quervain s disease , carpal tunnel syndrome , and granulomatous gout [ 4 , 5 , 6 ] .
we report an unusual case of tubercular tenosynovitis of the left hand in a 58-year - old male who had been treated as ganglion .
the purpose of this report is to highlight the importance of radiological and histopathological investigations in these  suspicious  cases .
further , there is only handful of literature available which highlights the management of tubercular tenosynovitis with anti - tubercular therapy only without operative treatment .
we present a case of 58-year - old male patient who presented to the outpatient department of the author s tertiary level institute with swelling over thenar region of the left hand .
he was a fully independent , nonsmoker , right handed , asthmatic patient on inhalational corticosteroids since 5 years .
he visited a local orthopedician who advised him to get fine needle aspiration cytology ( fnac ) of the swelling .
fnac report suggested the diagnosis of ganglion / synovial cyst and conservative treatment was started , but the swelling did not decrease in size , rather gradually increased in size and became painful with other signs of inflammation .
when the patient presented to the author s institute , there was a single , soft , fluctuant swelling of 5 cm  4 cm over left thenar region with ill - defined margins , erythematic overlying skin .
there was diffuse edema over the volar surface of the left wrist and distal forearm associated with erythema and tenderness .
there was no history of fever , trauma , joint pain , rashes , prolonged cough , decreased appetite , weight loss as well as no known or traceable history of contact with tb .
clinical photograph showing- ( left ) pretreatment lesion - single , soft , fluctuant swelling over left thenar region with ill - defined margins , erythematic and discolored overlying skin .
it revealed a large peripherally enhancing cystic lesion containing multiple loose bodies involving thenar eminence of left palm .
tenosynovitis of flexor carpi radialis was also seen , and a small cystic lesion ( 0.9 cm  0.5 cm  0.4 cm ) was seen superficial to flexor retinaculum laterally .
underlying carpal bones revealed focal area of altered signal intensity , with no evidence of joint effusion ( fig .
fnac was repeated which showed granulomatous inflammation with caseation , consistent with the clinical diagnosis of tb ( fig .
3 ) and the sample was sent for culture . the patient was started on antitubercular therapy with four first - line drugs ( isoniazid , rifampicin , pyrazinamide and ethambutol ) for 4 months followed by biotherapy ( isoniazid , rifampicin ) for 5 months .
complete blood count revealed elevated white blood cell count of 14.8  10/l with a high neutrophil differential count of 90% but low lymphocyte differential count of 5% .
erythrocyte sedimentation rate was also elevated ( 50 mm / h ) . magnetic resonance imaging wrist and hand showing a large peripherally enhancing cystic lesion containing multiple loose bodies involving the flexor tendons of forearm and thenar eminence of left palm .
the patient was compliant to the treatment and did not have any major adverse drug effects .
swelling disappeared and normal range of movements was attained in adjacent joints at final follow - up of 12 months from initiation of antitubercular treatment ( fig .
1 ) . supervised physiotherapy for fingers and wrist was initiated especially in the initial treatment phase to prevent adhesions and contractures and improve functional results .
mycobacterium tb infection is mostly seen in patients with impaired cell - mediated immunity , which may be disseminated readily resulting in high mortality rates .
the known predisposing factors include age > 60 years , malnutrition , alcohol abuse , low socioeconomic status , history of or exposure to tb , immunosuppression from any cause , and intake of corticosteroids .
the two theories regarding the pathogenesis of tb tenosynovitis direct inoculation and hematogenous dissemination from a primary focus .
infection appears to start in the synovium and then gradually spread to the tendons and even the bones .
tb tenosynovitis selectively targets the wrist and volar aspect of the hand , where it accounts for 5% of cases of osteoarticular tb .
the main setback remains the difficulty in diagnosing the disease because of non - specific clinical signs that point to a number of other possibilities such as other mycobacterial infections , pyogenic and fungal infections , brucellosis , foreign body tenosynovitis , sarcoidosis , rheumatoid arthritis ( ra ) , gouty arthritis , de quervain s disease , and ganglion [ 3 , 4 , 6 ] .
tb tenosynovitis may appear in different forms as a result of the long duration of the disease , the varying resistance of the individual , and the varying virulence of the organism .
patients with tubercular tenosynovitis usually present with an insidious , slow - growing , sausage - like mass along the inflamed tendon with minimal or no pain ; sometimes may present with discharging sinus and carpal tunnel syndrome .
this explains the presentation of our case , who initially presented to outpatient department with slow growing , insidious , painless swelling and later ( after being treated as ganglion only ) developed pain , increased size of swelling , and other signs of inflammation .
further , plain radiograph of the left hand showed only a large soft tissue mass on the thenar aspect of the hand with no bony involvement .
mri discovered a large peripherally enhancing cystic lesion containing multiple loose bodies with focal area of altered signals in underlying carpal bones ( fig .
finally , repeat fnac was performed which showed granulomatous inflammation consistent with tb ( fig .
mri may show thickening of the synovial membrane , increased vascularity and fluid within the tendon sheath , reactive inflammation and swelling around the tendon .
in contrast to acute suppurative tenosynovitis , where synovial sheath fluid is the predominant feature , relatively little synovial sheath fluid is characteristic of tb pathology [ 3 , 7 ] .
multiple rice bodies are composed of amorphous material surrounded by collagen and fibrin with unknown etiology .
although this is a rare occurrence related to ra , rice bodies can also be seen in systemic lupus erythematosus , seronegative arthritis , infectious arthritis ( tb , atypical mycobacterial infection ) , and nonspecific arthritis .
the literature on the management of tubercular tenosynovitis has mostly incorporated surgical method as one of the first - line treatment .
surgical debridement is controversial [ 9 , 10 ] tuli states that surgical debridement should be performed in patients who do not respond to four or five months of chemotherapy .
furthermore , surgery may cause adhesions especially in palmar side of hand so antitubercular therapy should be tried first .
only a few studies are available which managed the disease with antitubercular therapy ( att ) alone without the primary surgical procedure .
we report an unusual case , where the tenosynovitis of wrist completely responded within 12 months of att without any need of surgical treatment ( fig .
although rare , orthopedicians must consider tb tenosynovitis of wrist and hand as a differential , where patient presents even with an innocent mass lesion at the wrist .
the patient should undergo a thorough clinical , radiological and histopathological examination , to diagnose the tubercular tenosynovitis .
early diagnosis and instigation of att with or without surgical procedure gives good functional results .
tubercular tenosynovitis of hand is a rare presentation which can mimic many other clinical conditions due to which it can be easily misdiagnosed and mistreated .
once diagnosed , it can be treated with antitubercular chemotherapy without the need of surgical treatment .
introduction : tuberculosis tenosynovitis of the wrist and hand is an unusual condition . 
 it mimics a number of other clinical conditions such as ganglion , de quervan s disease , carpal tunnel syndrome , granulomatous gout , neurofibroma , and haemangioma.case report : we present case of 58-year - old male patient with swelling over thenar region of left hand where the initial fine needle aspiration cytology ( fnac ) report suggested diagnosis of ganglion / synovial cyst , but the patient did not improve with conservative treatment . 
 fnac was repeated which showed granulomatous inflammation consistent with the clinical diagnosis of tuberculosis and antitubercular therapy for 9 months was given . 
 swelling disappeared and normal range of movements was attained in adjacent joints at final follow - up of 12 months from initiation of antitubercular treatment ( att).conclusion : the literature on the management of tubercular tenosynovitis has mostly incorporated surgical method as one of the first - line treatments . 
 we report an unusual case , where the tenosynovitis of wrist completely responded within 12 months of att without any need of surgical treatment .