A 53-year-old Sri Lankan male with a background history of diabetes and hypertension for 14 years presented with left side (non dominant) isolated hand swelling for a 7-month duration. Its progressive enlargement was associated with pain and restriction of movements. There were no other small or large joint symptoms. He did not have episodes of fever, and he maintained good physical well-being in terms of appetite and weight. He did not give any past history of chronic productive cough, pulmonary tuberculosis, or any contact history.
On examination, there was a swelling near the wrist joint and carpal region both volar and dorsal aspects (Figure 1). The area was not warm, and mild tenderness was elicited. Flexion extension and circumduction movements were reduced. Distal neurovascular examination was unremarkable. His ESR was 98 mm/hr with full blood count and other biochemical investigations within the normal range. Initial digital X-ray of the hand showed destructive type lytic lesions involving mainly the carpal bones and bases of the 2nd to 5th metacarpals with sparing of the radiocarpal and distal radioulnar joints (Figure 2). His chest X-ray was normal. He underwent a magnetic resonance (MR) scan of the hand which showed multiple destructive lesions in the carpal bones, surrounding focal fluid collections with narrowing of the intercarpal and carpometacarpal joints (Figure 3). Flexor muscle tendons were intact. Upon initial assessment with basic investigations and imaging, a conclusive diagnosis was not achieved. A decision was made to go ahead with a synovial biopsy, and an intraoperative caseous material was noted. After the new finding, other investigations in relation to caseous necrosis were carried out. His Mantoux test was positive with 12 mm of induration. Serological assessment for melioidosis was negative. Histology sample showed multiple Langhans type of giant cell associated with caseating granulomas, and the Xpert MTB/RIF test was positive. He was started on antituberculosis treatment with hand physiotherapy and occupational therapy. He was improved in terms of pain and swelling with antituberculosis treatment without any significant side effects of the treatment, and his culture was also positive for Mycobacterium tuberculosis.