Bilateral recurrent wrist flexor tenosynovitis and rice body formation in a patient with sero-negative rheumatoid arthritis: A case report and review of literature

Abstract

Introduction: Rice body formation has been traditionally observed in the joint and tendon sheaths of patients with tuberculosis. Few case reports exist that describe rice body formation in patients with rheumatoid arthritis. We describe a case report of bilateral recurrent wrist flexor tenosynovitis with rice body formation in a patient with sero-negative rheumatoid arthritis.

Presentation of case: This case report describes a 72 year old lady presenting with severe bilateral, flexor tenosynovitis of the wrists. Ultrasonography revealed significant echogenic fluid on the palmer aspect of wrist joint surrounding flexor tendons with intact neurovascular bundles and no bony erosion. Laboratory tests demonstrated elevated erythrocyte sedimentation rate (50 mm/h) and negative rheumatoid factor. A sequential subtotal flexor tenosynovectomy was carried out with decompression of the carpal tunnel. During the operation, multiple rice bodies among the flexor tendons with adherent synovitis were found. Histology revealed disrupted synovial tissue containing several areas of fibrinoid necrosis, bounded by a layer of vaguely pallisaded histiocytes but no epitheloid granulomata or germinal centre. A revision surgery with debulking of the fibro-osseous canal was undertaken following recurrence. The patient presently has complete resolution of symptoms at one year follow-up.

Discussion: The combined clinical, laboratory, ultrasound and histology findings of the patient indicated that the cause of the rice body formation was due to a sero-negative arthritis rather than tuberculosis.

Conclusion: Rice body formation can be caused by sero-negative arthritis. Bilateral wrist flexor tensosynovitis can recur within five months of a previous synovectomy in a patient with sero-negative arthritis.

Keywords: Flexor tenosynovitis; Rice bodies; Tenosynovectomy; Ultrasonography; Wrist.

Fig. 1

Amorphous, necrotic material (right) separated from inflamed synovium (left) by a rather pale zone of histiocytes.

Fig. 2

Amorphous, pink, necrotic material (bottom) bounded by a layer of vaguely pallisaded histiocytes. (Stains for mycobacteria and fungi were negative.)

Fig. 3

Yellowish discharge of altered synovial fluid with pellet like rice bodies following synovectomy.