Tenosynovitis Secondary To Candida Magnoliae In An Immunocompetent Host: Candida Magnoliae Tenosynovitis
J Lane, M Lee, J Stephens
candida magnoliae, fungus, infectious diseases, medicine, tenosynovitis
J Lane, M Lee, J Stephens. Tenosynovitis Secondary To Candida Magnoliae In An Immunocompetent Host: Candida Magnoliae Tenosynovitis. The Internet Journal of Internal Medicine. 2000 Volume 3 Number 1.
Candida magnoliae has been rarely reported in clinical specimens. Furthermore, fungal tenosynovitis requiring surgical intervention is uncommon. The differential diagnosis for this type of nonpyogenic inflammation is diverse and should include fungal and acid fast bacilli as causes. We report a case of fungal tenosynovitis in an immunocompetent host secondary to C. magnoliae
A previously healthy 9-year-old boy presented with swelling, pain, and decreased mobility of his left ring finger. The swelling was present for 3 to 4 weeks with no history of trauma or fever. The child was reported to often climb a magnolia tree at his home. He had no pain except with light contact. The child had no significant medical or surgical history.
Physical examination revealed a well-developed, well-nourished child who was alert but in mild distress. Vital signs were normal. Neurological, cardiovascular, pulmonary, and abdominal examinations yielded normal findings. Examination of the left fourth finger revealed swelling primarily over the distal end of the middle phalanx. There was no erythema, tenderness, or warmth of the finger. There was limited isolated movement in his finger at the middle and distal phalanx. Radial pulses were present and there were no signs of trauma.
Laboratory studies revealed a leukocyte count of 8,300/µl, with 57 % neutrophils, 31 % lymphocytes, 9 % monocytes, 2 % eosinophils, and 1 % basophils. His hemoglobin and hematocrit were 12.7 mg/dl and 35.7 %, respectively. Platelet count was 252,000 /µl. The erythrocyte sedimentation rate was 12 mm/hr and C-reactive protein less than 0.4 mg/dl. Rheumatoid factor, antistreptolysin, and antinuclear antibody screens were also normal.
Plain radiographs of the finger showed soft tissue swelling at the distal interphalangeal joint and middle phalanx of the fourth ray (Figure 1).
Magnetic resonance imaging of the involved finger revealed abnormal signal on T1 and T2 weighted images within the epiphysis of the distal phalanx of the fourth ray extending completely into the middle phalanx (Figures 2-4).
The abnormal signal intensity was within surrounding soft tissue that displaced the flexor digitorum profundus tendon and extensor retinacular ligament. A 3 mm focal area of low signal intensity dorsal to the flexor digitorum profundus tendon at the level of the distal aspect of the middle phalanx was also seen. Three phase bone scan also demonstrated increased activity in the distal aspect of the fourth digit (Figure 5). These radiographic findings were suggestive of osteomyelitis or septic arthritis.
The child underwent surgical irrigation and debridement of the left fourth finger. He was taken to the operating room where a standard Kocher incision and arthrotomy was performed. Frank pus was aspirated; however, exploration of the middle and distal interphalangeal joints revealed no signs of chondral or osseous damage. Intraoperative tissue biopsy, bone biopsy, and synovial sampling were obtained and submitted for gram stain, culture, and sensitivity. Gram stain of both the tissue and synovial sample revealed few leukocytes and no organisms. Both tissue and synovial samples were negative for acid fast bacilli and on routine cultures. Bone biopsy was normal. Both the solid tissue biopsy and synovial sample demonstrated chronic synovitis with periarticular edematous fibrovascular connective tissue. The synovium had a chronic inflammatory process characterized by synovial cell hyperplasia, vascular proliferation, and infiltration by lymphocytes and plasma cells. There was no histopathologic evidence of pyogenic abscess formation, granulomatous formation, hemosiderin deposition, or foreign body. Periodic acid schiff and acid fast bacilli stains were negative. Fungal cultures of both the tissue and synovium revealed growth of
The patient underwent an uneventful postoperative course. He remained afebrile and had decreased swelling of his finger. He was able to flex and extend approximately 30° at the distal interphalangeal joint without any pain. Subsequent plain films of the left hand showed residual soft tissue swelling with destruction of epiphysis of terminal phalanx and distal metaphysis of middle phalanx and dorsal dislocation of the terminal phalanx (Figure 6).
A regimen of fluconazole was considered if the patient did not continue to improve; however, complete resolution was achieved without any clinical or radiographic evidence of recurrence.
This is the first reported case of
Joshua E. Lane, M.D.
The Medical College of Georgia
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