A 31-year-old right-hand-dominant male presented to the emergency department with acute right wrist pain after lifting a box for an upcoming move. The patient was originally from Afghanistan and 7 years prior to presentation had moved to the United States. The patient was diagnosed with a right wrist ligamentous sprain and discharged from the emergency department with anti-inflammatories per patient report. The patient moved from Florida to Canada and continued to have right wrist pain. One month later, the patient presented to an emergency department in Canada with continued right wrist pain. At that visit, he was diagnosed with primary osteoarthritis, instructed to continue anti-inflammatories, follow up as an outpatient with his family provider, and was again discharged from the emergency department. The patient moved back to the United States and subsequently reported to our emergency department with continued right wrist pain for greater than 3 months and new onset fluctuance at the volar aspect of the right wrist. Laboratory tests and vital signs were obtained, as shown in Figure 1.
The emergency department provider obtained radiographs of the right wrist (Figure 2). X-rays revealed diffuse destruction and osteopenia of the proximal as well as distal carpal rows with scattered cystic changes of the distal radius, ulna, and carpal bones. Orthopedics was subsequently consulted for evaluation and treatment.
On physical examination, there was an area of fluctuance appreciated on the volar aspect of the right wrist. It was erythematous and had developed desquamation of the skin around the lesion (Figure 3).
The patient had pain with small arcs of motion of the right wrist and held his wrist in a guarded position. The patient appeared to be hyper reflexive in his upper extremities, but otherwise was neurovascularly intact about his entire right upper extremity with no other upper motor neuron signs. At this time, the differential diagnosis included infectious arthropathy of the wrist and carpus (bacterial: aggressive vs indolent, or fungal), non-infectious inflammatory arthropathy, neuropathic joint, or neoplastic process. Further testing was performed to rule out potential diagnoses in our differential.
A magnetic resonance image (MRI) with intravenous (IV) contrast was obtained to further characterize the lesion and its involvement (Figure 4). Enhancement was noted diffusely about the wrist and carpus on T2-weighted imaging with a subcutaneous fluid collection communicating with the radiocarpal joint.
The patient underwent aspiration of the right wrist. The fluid appeared grossly purulent and was sent to the lab for cytology, gram stain, culture, and crystal analysis.
Supplemental imaging obtained included a chest radiograph for concern of possible pulmonary M. tuberculosis and MRI of the cervical spine to rule out a syrinx which could have caused a neuropathic joint and accounted for his hyperreflexia. The chest radiograph was negative for any acute or indolent pulmonary disease and the MRI of the cervical spine did not show a syrinx.
Given the work-up obtained in conjunction with his history, our differential was narrowed to infectious arthropathy of the wrist and carpus likely secondary to an indolent bacteria or fungi. The patient was admitted to the hospital for septic arthritis of the wrist and carpus and was taken to the operating room for an irrigation and debridement (I&D) of his right wrist. During the I&D extensive purulent material, synovitis, severe bony erosion, and significant cartilage loss were encountered. No "rice bodies" were found. Specimens were obtained and sent to pathology for further analysis. A need for future debridement was evident and as such the patient was packed open and sent to the floor on broad spectrum IV antibiotics (vancomycin, cefepime, and metronidazole). Following the first I&D, the whole blood QuantiFERON TB gold test returned as positive and preliminary pathology showed for caseating granulomas (Figure 5). Of note, genetic analysis was not performed on the pathology specimens obtained.
Culture and sensitivity results of the aspiration returned positive for M. tuberculosis, and the antibiotic regimen was revised to rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) per sensitivities. The patient was reported to the Department of Health for directly observed therapy per protocol. Subsequently, the patient required two more open I&Ds. At the time of the third debridement, it was felt that the infection was resolving and that there was appropriate tension on the skin to attempt partial closure. The large volar fluctuance had created a sizable soft tissue defect that was not amenable to primary closure (Figure 6).
The patient's final procedure was a full-thickness skin grafting of the described defect. The graft was harvested from the proximal aspect of the patient's right upper extremity and primarily closed. The patient continued with follow-up care as an outpatient and was seen 2 months post-operatively. The skin graft was noted to have healed well and he was continuing RIPE therapy. Radiographs obtained from that follow-up appointment demonstrated severe degeneration of the right wrist and carpus with continued osteopenia (Figure 7). He continued to have substantial pain, decreased range of motion of the right wrist, and difficulty with completing activities of daily living. Ultimately, he was lost to follow-up approximately 2 months after discharge.