Rheumatoid or tubercular: Flexor tenosynovitis of the wrist with rice bodies

Abstract

Rice bodies are formed mainly in tenosynovitis and bursitis of rheumatoid or tubercular origin. It rarely presents with compressive ulnar neuropathy. A 35-year-old female presented with painful swelling in the volar aspect of the left wrist and incomplete flexion of the little finger. The laboratory tests revealed ESR 10 mm/1^st hr and C-reactive protein, rheumatoid factor, and anti-cyclic citrullinated peptide tests were negative. Thickened and distended ulnar bursa with rice bodies was seen on magnetic resonance imaging (MRI). Thorough drainage, debridement, and synovectomy were done. Epithelioid cell granulomas with multinucleated giant cells on microscopy and the strongly positive Mantoux test prompted us to start anti-tubercular treatment. The wound healed uneventfully with good recovery of range of motion of the little finger at one-year follow up. Rice bodies can be a diagnostic dilemma in the absence of classical signs of their rheumatoid or tubercular origin.

Keywords: Millet or melon seed bodies; rheumatoid; rice bodies; tenosynovitis; tubercular.

Figure 1

Preoperative image of the volar aspect of the left wrist joint in (a) dorsiflexion and (b) neutral position

Figure 2

Preoperative X-ray of left wrist (a) and (b) lateral view of left wrist showing the soft tissue shadow (red arrow)

Figure 3

a) T2W TSE image in a coronal plane at the level of the carpal tunnel shows a well-defined fluid intensity collection seen distending the ulnar bursa, continuing along with the flexor group of tendons, and containing oval-shaped hypointense foci (red arrow), suggestive of tenosynovitis with rice bodies secondary to mycobacteria. The collection is also extending to mid palmar and thenar spaces. b) Fat-suppressed T1-weighted post-contrast (b. 1) axial and (b. 2) sagittal images reveal avid synovial enhancement (yellow arrows) of the ulnar and radial bursae engulfing flexor tendons. c) Short tau inversion recovery (STIR) sagittal image demonstrates numerous hypointense foci, consistent with rice bodies within a markedly distended ulnar bursa (blue arrows). d) A fat-suppressed T2-weighted axial image at the level of the proximal wrist reveals distension of the palmar bursae by a horseshoe-shaped abscess containing rice bodies (white arrow). Ulnar and radial bursae are thickened with entrapment of flexor digitorum profundus (red arrows), flexor digitorum superficialis (yellow arrows), and flexor pollicis tendons (green arrowhead) by the abscess

Figure 4

Intraoperative images showing the a) superficial sac, b) pearl-sized rice bodies, c) thick bursa engulfing the tendon itself, d) deep and much larger sac emerging under the tendon, which becomes clearer on e) retraction of tendon and f) dorsiflexion of the wrist

Figure 5

Photomicrographs. a) Microscopic image shows granulomas on scanner view (arrow)(H&E). b) Low power image shows epithelioid cell granuloma (H&E). c) High power image shows granuloma with multinucleated giant cells (inset) some of them are Langhans type (arrow) (H&E). d) Microscopic image showing synovial hyperplasia with fibrin deposition (H&E)

Figure 6

At six months the incision at the wrist/hand (a) and (b) healed well under the cover of anti-tubercular treatment (ATT)

Figure 7

At one year, the scar at the wrist/hand has faded and good function of the hand is maintained, with a near-normal range of motion (a-f), and without any recurrence