A man aged 50 years was admitted to the rheumatology department with symptoms of right wrist volar pain, swelling, redness, and palmar pain, which had started in 2011. He had no comorbidities. Laboratory tests revealed C-reactive protein (CRP): 18 mg/L, erythrocyte sedimentation rate (ESR): 24 mm/h, and white blood cells (WBC): 6460 x 103 mm3. A diagnosis of seronegative arthritis was made and deltacortril 4 mg 1*1 and salazoyprin 500 mg 1*1 was administered. During the follow-up period, pain was relieved but redness and swelling remained. In 2013, an wrist X-ray was performed (Fig. 1), which revealed soft tissue density increase, soft tissue swelling, and periarticular osteoporosis. Magnetic resonance imaging (MRI) (Fig. 2) showed millimetric and nodular images in flexor group tendon sheath in T2A series and wrist images were consistent with synovitis. The patient was referred to our department. On March 19th, 2013, right wrist synovitis resection and flexor retinaculum release was performed. Multiple rice bodies around the wrist flexor tendons were seen during the operation (Fig. 3, Fig. 4). Specimens were sent to microbiology and aerobic-anaerobic cultures and liquid media remained sterile. The patient's symptoms regressed after the operation. However, in the postoperative 6th month, symptoms of right hand volar pain, swelling, and redness started. Laboratory tests and MRI findings showed recurrence. The patient underwent surgery again on November 11th, 2014, using the same incision line. There were multiple rice bodies again (Fig. 3). Flexor tendons were widely debrided. Perioperative specimens were sent to pathology and microbiology. A tuberculosis culture was analysed in addition. Pathologic examination showed granulomatous synovitis and the microbiologic examination in Lowenstein Jensen medium revealed M. tuberculosis. There was no history of lung tuberculosis. After thorough debridement, antituberculosis therapy was administered and maintained for twelve months.
After completion of antituberculosis therapy, there was no wrist pain and redness. Wrist range of motion was full. Laboratory tests revealed CRP: 1 mg/L, ESR: 2 mm/h, and WBC: 6600 x 103 mm3. Wrist X-ray in the control visit (Fig. 5) showed that soft tissue density decreased and swelling disappeared. Wrist MRI (Fig. 6) revealed that synovitis findings were fully recovered.