Presentation
The patient presented with swelling at the left base of the thumb, with no signs of cellulitis of the skin. There were no constitutional symptoms or respiratory complaints. A normal chest X-ray was obtained.
Patient Data
The frontal X-ray of the thumb demonstrates bony erosions at the base of the proximal phalanx of the thumb and around the carpometacarpal joint. There is adjacent soft tissue swelling, a finding typically seen in infectious or inflammatory arthropathy, including tuberculous arthritis.
There is clear destruction at the base of the thumb, with bone erosions, and bone marrow edema involving the opposing articular surfaces of the carpometacarpal bones eliciting high signal on STIR. There is associated mild joint effusion. Extensor tenosynovitis of the 2nd, 3rd and 4th compartments of the wrist with distension of their tendon sheath by fluid signal containing rice bodies.
This MRI of the left wrist demonstrates findings suggestive of tuberculous arthritis.
Case Discussion
Bone destruction and soft tissue swelling with rice bodies represent a chronic inflammatory process. The degree of erosion combined with soft tissue swelling suggests an aggressive infection, in keeping with the tuberculous involvement already suggested by the MRI findings and a positive TB culture.
Further management should involve continued antitubercular treatment, with close monitoring of both clinical and radiological progress. Surgical intervention might be considered for debridement or stabilization, depending on the functional impairment caused by the bone destruction.
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