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编号:11304581
Tenosynovitis Due to Mycobacterium marinum
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     A healthy 60-year-old woman presented with a painful left hand. She noted that she had pulled a splinter from her left thumb while on vacation three months previously. She reported no history of exposure to fish tanks, sea water, or fresh water. Despite two courses of treatment with antimicrobial agents and nonsteroidal antiinflammatory drugs, the initial inflammation and tenderness of her thumb had gradually progressed to diffuse swelling, tenderness, and stiffness of her entire left hand, wrist, and forearm. On examination, the patient appeared healthy and had a temperature of 37.1°C. Her left hand was diffusely swollen, and her fingers were in a semiflexed position. The center of her palm was warm and puffy, and her volar forearm proximal to her left wrist had a red, raised, inflamed area that measured 7 by 5 cm (Panel A, arrow). There was no palpable epitrochlear or axillary adenopathy. Her white-cell count was 8700 per cubic millimeter. A T1-weighted magnetic resonance image with fat suppression, obtained after the administration of gadolinium (Panel B), showed enhancement of areas of soft-tissue thickening and swelling around the synovial tendon sheaths, predominantly in the carpal tunnel (central white area); adjacent collections of fluid (long arrows); and cross sections of the flexor tendons (short arrows) and metacarpals (arrowheads); the inset shows a normal wrist. Aspiration of the fluid that was collected from the area of the flexor tendons proximal to the wrist yielded 0.5 ml of pus. Kinyoun staining was positive for long, thin, acid-fast bacilli with a beaded appearance (Panel C). The patient was admitted to the hospital for débridement and therapy. A skin test for tuberculosis with the use of purified protein derivative was positive, with an induration of 20 mm at 48 hours. Subsequently, the organism was identified as Mycobacterium marinum. The patient was successfully treated with rifampin, ethambutol, azithromycin, and trimethoprim–sulfamethoxazole.

    Roxann Powers, M.D.

    Melanie Fisher, M.D.

    West Virginia University

    Morgantown, WV 26506