NE Hand Society



A Case of Spontaneous Flexor Tenosynovitis From EndometritisAuthors: Jing Bai Qin MD, Richard Montilla MD, Douglas M. Rothkopf MD, Division of Plastic Surgery, University of Massachusetts Medical School, Worcester, MAPresenter: Jing Bai Qin MDContact person: Jing Bai Qin MD, baijing.qin@, (617) 396-4133Background and Literature ReviewInfection is the most common cause of flexor tenosynovitis of the hand. The most prevalent organism found in pyogenic tenosynovitis is Staphylococcus aureus through introduction of bacteria into a wound. Rarely, hematogenous seeding of the tendon sheath can occur in the absence of known traumatic injury to the hand. Only isolated cases of hematogenous inoculation of bacteria causing flexor tenosynovitis have been reported. Neisseria gonorrhoeae is known to be able to spread systemically from genital infection or pharyngitis to the hand. Patients with pulmonary infections from coccidioidomycosis and nontuberculous mycobacteria can develop systemic infection leading to pyogenic tenosynovitis in rare cases. In the AIDS population, disseminated candidiasis occasionally may lead to Candida tenosynovitis and Prototheca wickerhamii algaemia is the cause of one patient’s hand flexor tenosynovitis. There are no reports of a disseminated endometrial pathogen causing hand flexor tenosynovitis. We present the only reported case of spontaneous Group B Streptococcus flexor tenosynovitis in the hand seeding from infectious endometritis. Case Presentation The patient is an 18-year-old female who presented to the hospital for spontaneous vaginal delivery of her first child. During the delivery, the patient sustained a second degree perineal laceration down to the perineal muscles and fascia that was repaired. Following her delivery, the patient had persistent post-partum hemorrhage and intractable pain in her pelvis with a retained uterine hematoma. On post-partum day one, the patient developed fever, chills, tachycardia, and leukocytosis. On pelvic exam, her lower uterine fundus was boggy and tender, leading to a diagnosis of endometritis. On post-partum day two, the patient developed pain in her right palm and the volar aspect of her middle finger without a history of trauma. Subsequently she had worsening erythema, edema and pain along the middle finger tendon sheath and elevated ESR and CRP concerning for tenosynovitis. She underwent surgical drainage and gross purulence was found upon division of the A1 pulley. Intraoperative irrigation of the tendon sheath with a counter incision at the A5 pulley was accomplished. Intraoperative cultures were positive for Group B Streptococcus. The patient was treated with IV vancomycin, flagyl, and ceftazidime for one day and transitioned to an oral course of cephalexin with complete resolution of her symptoms. Conclusions Group B Streptococcus is an unusual pathogen found in flexor tenosynovitis, but it is a frequent pathogen in endometritis. Although hematogenous spread of bacteria is theoretically possible from anywhere, this is the first reported case of flexor tenosynovitis secondary to endometritis. Clinicians need to be aware of possible hematogenous spread of endometritis pathogens to the flexor tendon sheath.ReferencesBarrick EF. Acute gonococcal flexor tenosynovitis in a woman with asymptomatic gonorrhea. J Hand Surg Am. 1983 Mar;8(2):224-5. Krieger LE, Schnall SB, Holtom PD, Costigan W. Acute gonococcal flexor tenosynovitis. Orthopedics. 1997 Jul;20(7):649-50.Mateo L, Rufí G, Nolla JM, Alcaide F. Mycobacterium chelonae tenosynovitis of the hand. Semin Arthritis Rheum. 2004 Dec;34(3):617-22. Ogiela DM, Peimer CA. Acute gonococcal flexor tenosynovitis- case report and literature review. J Hand Surg Am. 1981 Sep;6(5):470-2. Pascual JS, Balos LL, Baer AN. Disseminated Prototheca wickerhamii infection with arthritis and tenosynovitis. J Rheumatol. 2004 Sep;31(9):1861-5. Rosenfeld N, Kurzer A. Acute flexor tenosynovitis caused by gonococcal infection. A case report. Hand. 1978 Jun;10(2):213-4. Schaefer RA, Enzenauer RJ, Pruitt A, Corpe RS. Acute gonococcal flexor tenosynovitis in an adolescent male with pharyngitis. A case report and literature review. Clin Orthop Relat Res. 1992 Aug;(281):212-5. Townsend DJ, Singer DI, Doyle JR. Candida tenosynovitis in an AIDS patient: a case report. J Hand Surg Am. 1994 Mar;19(2):293-4.Yuan RT, Cohen MJ. Candida albicans tenosynovitis of the hand. J Hand Surg Am. 1985 Sep;10(5):719-22. Zenone T, Boibieux A, Tigaud S, Fredenucci JF, Vincent V, Chidiac C, Peyramond D. Non-tuberculous mycobacterial tenosynovitis: a review. Scand J Infect Dis. 1999;31(3):221-8. ................
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