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Document Details :
Title: Iets meer aan de hand?
Author(s): COOLS T, VAN CAESBROECK D, VAN DEN HEUVEL M, VAN ROEY G
Journal: Tijdschrift voor Geneeskunde
Volume: 67 Issue: 6 Date: 2011
Atypical hand wounds
A 46-year-old woman, who lived in India until 2006, with a negative medical history, presented with chronic wounds on her proximal left index finger, thumb and metacarpal bones II and III of the right hand. Systemic anamnesis revealed severe anorexia and weight loss. Lab results indicated inflammation (CRP: 4 milligrams/deciliter). Serologic, tumoral and auto-immune screening were negative. The culture of superficial wound specimens showed a multisensitive Group A Streptococus. The bone marrow puncture was normal. Standard radiography of the hands revealed diffuse bone destruction. A CT scan showed multiple pathologically diffuse abdominal and axillar adenopathies. An ileocolonoscopy revealed a focal aphthoid sigmoiditis.
Because of the atypical presentation with constitutional symptoms in an India-born patient, extrapulmonary tuberculosis (tbc) was considered, namely osteoarticular tbc (multifocal tuberculous dactylitis/osteomyelitis, osteitis cystica tuberculosa multiplex, and tuberculous arthritis), tuberculous colitis and mesenterial tuberculous lymfadenitis. The diagnosis was confirmed by a positive tuberculin skin test (TST) and a granulomatous inflammation of the joint fluid, the axillary glands and sigmoid biopsies, although the Ziehl-Neelsen stain and the mycobacterial cultures remained negative. Tuberculostatic therapy was initiated with a positive clinical evolution: ethambutol and pyrazinamide (2 months), and rifampicin and isoniazid (9 months).
Osteoarticular tbc represents 2% of the cases of active tbc. Half of the cases is due to extraspinal tbc: arthritis (60%) and osteomyelitis (48%). The clinical presentation is indolent without pathognomonic clinical, biochemical and radiological signs. TST is useful, with a 90% sensitivity for osteoarticular tbc. Other efficient tests like the Quantiferon- TB test and the polymerase chain reaction are not used in routine clinical practice. Staining and cultures of tissue specimens remain the golden standard. Treatment is primarily non-surgical, similar to the 6-month drug regimen used for active pulmonary tbc. In severe cases, a 9-month scheme is advised.