A Rare Diagnosis: Recognizing and Managing Fungal Tenosynovitis of the Hand and Upper Extremity

Maureen A. O'Shaughnessy, Aaron J. Tande, Shawn Vasoo, Mark J. Enzler, Elie F. Berbari, Alexander Y. Shin

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Purpose: Fungal infections involving the tenosynovium of the upper extremity are uncommon and are often misdiagnosed. This study evaluates the epidemiology, diagnosis, treatment, and outcomes of patients with fungal tenosynovitis of the upper extremity over a 20-year period. Methods: A retrospective review of all culture-confirmed cases of fungal tenosynovitis of the upper extremity treated between 1990 and 2013 at a single institution was performed. Clinical data included patient and epidemiologic risk factors, causative fungal organism, surgical management, antimicrobial regimen, recurrence rates, and outcomes. Results: There were 10 patients (9 female, 1 male) who met the inclusion criteria. The mean patient age was 60 years (range, 47-76 y). Identified pathogens included . Histoplasma . capsulatum (7), . Coccidioides posadasii/immitis (2), and . Cryptococcus neoformans (1). Eight patients were on immunosuppressant medications at the time of diagnosis. The most common clinical presentation was subacute localized pain, swelling, and erythema consistent with tenosynovitis. The diagnosis was delayed by a median of 6 months (range, 0-48 mo). The most helpful diagnostic imaging studies included magnetic resonance imaging and ultrasound. All patients were treated with extensive surgical synovectomy and debridement. Seven patients were treated by a single surgery, whereas 3 required multiple consecutive debridements (2, 7, and 10 surgeries). The mean course of initial antimicrobial therapy was 8.2 months (range, 3-12 mo). Clinical recurrence was noted in 3 patients (30%) during a median follow-up period of 46 months (range, 7-250 mo). Both patients with . Coccidioides infection incurred recurrence. Conclusions: Although uncommon, surgeons and clinicians should consider a diagnosis of fungal tenosynovitis among immunocompromised patients with signs of mild tenosynovitis and should consider operative debridement and biopsy. Although the majority of patients were successfully treated with surgical debridement and antimicrobial therapy, a recurrence rate of 30% highlights the need for close post-treatment follow-up. Type of study/level of evidence: Therapeutic V.

Original languageEnglish (US)
JournalJournal of Hand Surgery
DOIs
StateAccepted/In press - Feb 4 2016

Fingerprint

Tenosynovitis
Upper Extremity
Hand
Debridement
Coccidioides
Recurrence
Epidemiologic Factors
Histoplasma
Cryptococcus neoformans
Mycoses
Delayed Diagnosis
Immunocompromised Host
Diagnostic Imaging
Therapeutics
Erythema
Immunosuppressive Agents
Diagnostic Errors
Epidemiology
Magnetic Resonance Imaging

Keywords

  • Fungal
  • Infection
  • Tenosynovitis
  • Upper extremity

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine

Cite this

A Rare Diagnosis : Recognizing and Managing Fungal Tenosynovitis of the Hand and Upper Extremity. / O'Shaughnessy, Maureen A.; Tande, Aaron J.; Vasoo, Shawn; Enzler, Mark J.; Berbari, Elie F.; Shin, Alexander Y.

In: Journal of Hand Surgery, 04.02.2016.

Research output: Contribution to journalArticle

O'Shaughnessy, Maureen A. ; Tande, Aaron J. ; Vasoo, Shawn ; Enzler, Mark J. ; Berbari, Elie F. ; Shin, Alexander Y. / A Rare Diagnosis : Recognizing and Managing Fungal Tenosynovitis of the Hand and Upper Extremity. In: Journal of Hand Surgery. 2016.
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AU - Vasoo, Shawn

AU - Enzler, Mark J.

AU - Berbari, Elie F.

AU - Shin, Alexander Y.

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N2 - Purpose: Fungal infections involving the tenosynovium of the upper extremity are uncommon and are often misdiagnosed. This study evaluates the epidemiology, diagnosis, treatment, and outcomes of patients with fungal tenosynovitis of the upper extremity over a 20-year period. Methods: A retrospective review of all culture-confirmed cases of fungal tenosynovitis of the upper extremity treated between 1990 and 2013 at a single institution was performed. Clinical data included patient and epidemiologic risk factors, causative fungal organism, surgical management, antimicrobial regimen, recurrence rates, and outcomes. Results: There were 10 patients (9 female, 1 male) who met the inclusion criteria. The mean patient age was 60 years (range, 47-76 y). Identified pathogens included . Histoplasma . capsulatum (7), . Coccidioides posadasii/immitis (2), and . Cryptococcus neoformans (1). Eight patients were on immunosuppressant medications at the time of diagnosis. The most common clinical presentation was subacute localized pain, swelling, and erythema consistent with tenosynovitis. The diagnosis was delayed by a median of 6 months (range, 0-48 mo). The most helpful diagnostic imaging studies included magnetic resonance imaging and ultrasound. All patients were treated with extensive surgical synovectomy and debridement. Seven patients were treated by a single surgery, whereas 3 required multiple consecutive debridements (2, 7, and 10 surgeries). The mean course of initial antimicrobial therapy was 8.2 months (range, 3-12 mo). Clinical recurrence was noted in 3 patients (30%) during a median follow-up period of 46 months (range, 7-250 mo). Both patients with . Coccidioides infection incurred recurrence. Conclusions: Although uncommon, surgeons and clinicians should consider a diagnosis of fungal tenosynovitis among immunocompromised patients with signs of mild tenosynovitis and should consider operative debridement and biopsy. Although the majority of patients were successfully treated with surgical debridement and antimicrobial therapy, a recurrence rate of 30% highlights the need for close post-treatment follow-up. Type of study/level of evidence: Therapeutic V.

AB - Purpose: Fungal infections involving the tenosynovium of the upper extremity are uncommon and are often misdiagnosed. This study evaluates the epidemiology, diagnosis, treatment, and outcomes of patients with fungal tenosynovitis of the upper extremity over a 20-year period. Methods: A retrospective review of all culture-confirmed cases of fungal tenosynovitis of the upper extremity treated between 1990 and 2013 at a single institution was performed. Clinical data included patient and epidemiologic risk factors, causative fungal organism, surgical management, antimicrobial regimen, recurrence rates, and outcomes. Results: There were 10 patients (9 female, 1 male) who met the inclusion criteria. The mean patient age was 60 years (range, 47-76 y). Identified pathogens included . Histoplasma . capsulatum (7), . Coccidioides posadasii/immitis (2), and . Cryptococcus neoformans (1). Eight patients were on immunosuppressant medications at the time of diagnosis. The most common clinical presentation was subacute localized pain, swelling, and erythema consistent with tenosynovitis. The diagnosis was delayed by a median of 6 months (range, 0-48 mo). The most helpful diagnostic imaging studies included magnetic resonance imaging and ultrasound. All patients were treated with extensive surgical synovectomy and debridement. Seven patients were treated by a single surgery, whereas 3 required multiple consecutive debridements (2, 7, and 10 surgeries). The mean course of initial antimicrobial therapy was 8.2 months (range, 3-12 mo). Clinical recurrence was noted in 3 patients (30%) during a median follow-up period of 46 months (range, 7-250 mo). Both patients with . Coccidioides infection incurred recurrence. Conclusions: Although uncommon, surgeons and clinicians should consider a diagnosis of fungal tenosynovitis among immunocompromised patients with signs of mild tenosynovitis and should consider operative debridement and biopsy. Although the majority of patients were successfully treated with surgical debridement and antimicrobial therapy, a recurrence rate of 30% highlights the need for close post-treatment follow-up. Type of study/level of evidence: Therapeutic V.

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