Flexor Tenosynovitis Caused by Mycobacterium heraklionense

Abstract

Mycobacterium heraklionense is a rare etiology of serious hand infection with only 2 cases having been reported in literature to date to our knowledge. We describe the case of a 58-year-old woman with persistent swelling and stiffness in her right index finger. Advanced imaging studies in addition to serial surgical debridement with tissue cultures helped to confirm the diagnosis of flexor tenosynovitis caused by M. heraklionense. In this case report, we highlight the clinical evaluation, operative treatment, and antimicrobial therapy leading to the successful care of this disease presentation. Due to its rarity and potential to cause substantial hand infection, M. heraklionense should be included in the differential diagnosis as the cause for chronic flexor tenosynovitis to appropriately minimize morbidity.

Keywords: Flexor tenosynovitis; Mycobacterium heraklionense; Tendon sheath infection.

Figure 1

Preoperative clinical photograph showing the initial presentation, with fusiform swelling, stiffness, and erythema of right index finger. A Frontal view and B side view of involved digit.

Figure 2

Preoperative advanced magnetic resonance imaging of the A sagittal T2-weighted fat suppresion and B axial proton density fat suppresion sequences of the patient’s hand showing fluid within the flexor sheath of the index finger. Over 3 mm of separation of the flexor tendons from the phalanx at the proximal phalanx indicates pulley injury or attenuation.

Figure 3

Intraoperative clinical photograph showing A before and B after debridement with removal of inflammatory tissue from flexor tendon sheath.

Figure 4

Pathology imaging of debrided inflammatory tissue, demonstrating granulomatous inflammation with giant cells, Hematoxylin-eosin stain; magnification 100–400x, A low power and B high power.

Figure 5

Postoperative clinical photograph of the patient, demonstrating reduced swelling and the patient’s A full extension but B still limited maximal index finger flexion at 15 months after the initial presentation.