A tuberculous midpalmar abscess of the hand due to reactivation of previous pulmonary tuberculosis.

Dear Editor, A 45-year-old renal transplant recipient presented with a 2-week history of progressive painful mid-palmar swelling in his right hand and intermittent low-grade pyrexia. There was no history of trauma. He had been on transplant-related immunosuppression (cyclosporin and prednisolone) for 10 years, and had a significant past history of pulmonary tuberculosis treated 20 years ago without previous reactivation. Initial physical examination (Fig. 1) revealed oedema of the right hand with central palmar swelling and redness. There was warmth and tenderness of the mid-palm and the middle finger along the flexor sheath from the level of the A1 pulley to the proximal phalanx. The middle finger was not swollen or flexed, but passive extension was painful. Radiographs showed only soft tissue swelling. Suppurative flexor tenosynovitis with midpalmar space extension was provisionally diagnosed. Emergent surgical exploration revealed unhealthy synovium around the middle finger flexors about the A1 pulley, without suppuration of tendon sheath or midpalmar space. This was debrided and sent for histology, bacterial, fungal and mycobacterial cultures and microscopy. Postoperatively, he improved with intravenous antibiotics and was discharged on oral amoxicillinclavulanate. Tissue bacterial cultures and blood cultures were negative, and fungal and mycobacterial cultures were pending at the time of discharge. Two weeks later, he developed purulent discharge from the surgical wound along with severe pain and swelling of the hand and digits. The mid-palm was tense, tender, erythematous, and all fingers were flexed and painful on passive extension. He spiked temperatures of 40 degrees Celsius. The total white had risen to 13.50 x 10 (9)/L and erythrocyte sedimentation rate (ESR) was elevated at 86. Histology from the earlier debridement showed a chronic inflammatory infiltrate with Langhan’s giant cells. ZiehlNielsen staining showed acid-fast bacilli. However, his chest X-ray done for the prior surgery did not show any obvious features of post-primary tuberculosis such as cavitation. At repeat debridement there was an extensive midpalmar space abscess, with frank purulence and caseating necrosis of the subcutaneous fat. Necrotic tissue encased the common palmar digital nerves and vessels, superficial arch and flexor tendons. Radical debridement of all necrotic tissue left a significant defect exposing the neurovascular A Tuberculous Midpalmar Abscess of the Hand Due to Reactivation of Previous Pulmonary Tuberculosis