The Journal of Rheumatology
Volume 40, no. 6
Infectious Tenosynovitis in a Patient with Dermatopolymyositis and Vasculitis
CLARISSA CANELLA, MARCELO PACHECO, FLAVIA COSTA and EDSON
MARCHIORI
J Rheumatol 2013;40;949
http://www.jrheum.org/content/40/6/949
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The Journal of Rheumatology is a monthly international serial edited by Earl D.
Silverman featuring research articles on clinical subjects from scientists working
in rheumatology and related fields.
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Images in Rheumatology
Infectious Tenosynovitis in a Patient with
Dermatopolymyositis and Vasculitis
CLARISSA CANELLA, MD, Clínica de Diagnóstico por Imagem; Serviço de Radiologia e Diagnóstico por Imagem da Universidade Federal do Rio de
Janeiro – UFRJ; MARCELO PACHECO, MD, Serviço de Reumatologia do Hospital dos Servidores do Estado; FLAVIA COSTA, MD, Clínica de
Diagnóstico por Imagem; Serviço de Radiologia e Diagnóstico por Imagem da UFRJ; EDSON MARCHIORI, PhD, Serviço de Radiologia e Diagnóstico
por Imagem da UFRJ, Rio de Janeiro, Brazil. Address correspondence to Dr. C. Canella, Clinica de Diagnóstico por Imagem, Avenida das Americas 4666,
sala 325, Rio de Janeiro, RJ 22630010, Brazil. E-mail: clacanella@yahoo.com.br. J Rheumatol 2013;40:949; doi:10.3899/jrheum.121434
Flexor tendon sheath infection calls for appropriate
antimicrobial and surgical therapy to overcome complications such as deep abscesses, septic arthritis, and
osteomyelitis.
A 33-year-old woman with dermatopolymyositis and
vasculitis for 1 year was diagnosed by typical rash
(heliotrope rash, Gottron’s sign), symmetric proximal
muscle weakness, elevated serum skeletal muscle enzymes,
electromyographic abnormalities, and interstitial lung
disease. She started intravenous (IV) methylprednisolone 1
g/day for 3 days, followed by monthly IV cyclophosphamide and oral prednisone 1 mg/kg/day. After 2 months,
the right fourth finger exhibited painful erythematous
bullous lesions (Figure 1a, arrows). She did not present any
systemic symptoms. Laboratory examinations showed white
blood cell count 4900 and C-reactive protein 0.07 mg/dl.
Sagittal (Figure 1b) and axial (Figure 1c) T1-weighted,
gadolinium-enhanced magnetic resonance imaging (MRI)
scans with fat saturation sequences showed extensive fluid
collection with peripheral contrast enhancement of the
fourth flexor tendon synovial sheath, indicating abscess
(Figure 1b, 1c, arrows). Following fluid drainage 3 days
after MRI, infectious tenosynovitis was confirmed and
multisensitive Staphylococcus aureus was isolated. After 4
months of treatment, bullous lesions were completely
resolved, without any sequela.
Tenosynovitis has been described in adult-onset
dermatopolymyositis involving the hand, especially in
patients with skin ulcers and calcinosis, and can cause
recurrent extensor tendon rupture1. Causes of flexor tendon
sheath infection (most commonly S. aureus, Streptococcus
species) must be diagnosed, and appropriate medical or
surgical treatment undertaken, to avoid poor clinical
outcomes1,2,3. Treatment involves antimicrobial therapy,
immobilization, edema control, and appropriate surgical
therapy to prevent complications such as deep abscesses,
septic arthritis, and osteomyelitis2,3.
REFERENCES
1. Nakamura S, Nakagawa J. Recurrent extensor tendon rupture in
adult-onset dermatomyositis: a case report. Clin Rheumatol
2005;24:409-10.
2. Draeger RW, Bynum DK Jr. Flexor tendon sheath infections of the
hand. J Am Acad Orthop Surg 2012;20:373-82.
3. Turecki MB, Taljanovic MS, Stubbs AY, Graham AR, Holden DA,
Hunter TB, et al. Imaging of musculoskeletal soft tissue infections.
Skeletal Radiol 2010;39:957-71.
Figure 1. A. The right fourth finger exhibited erythematous bullous lesions (arrows). B and C. Magnetic resonance imaging scans
showed extensive fluid collection with peripheral contrast enhancement of the fourth flexor tendon synovial sheath, indicating
abscess (arrows).
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Canella, et al: Infectious tenosynovitis
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