Tuberculosis Presenting as Carpal Tunnel Syndrome : A

Case Report with Review of Literature

Arvind G Kulkarni*, Vidyanand V Prabhu**
Abstract
We present a case of tuberculosis presenting as carpal tunnel syndrome. Though it is not unusual, the aim is to draw attention that tuberculosis should be considered in the differential
diagnosis on finding nonspecific tenosynovitis during carpal tunnel release and should be excluded by performing a biopsy.

Introduction

uberculosis is not one of the most

common causes of carpal tunnel
syndrome. However a high index of suspicion
should be kept in mind especially in
developing countries like India on finding
unexplained proliferative tenosynovitis
during surgery. The aim of this article is to
draw attention to this fact and recommend
biopsy in every patient presenting with carpal
tunnel syndrome due to chronic nonspecific
tenosynovitis.
Case Report
A 60 year old lady came to our outpatient with
chief complaints of gradually progressive increasing
paraesthesia and numbness in the median nerve
innervated territory of the left hand since one month.
The symptoms were more intense at night and were
typically relieved with vigorous shaking of the hand.
On examination, there was wasting of the left thenar
eminence and swelling on the anterior aspect of the
wrist, suggestive of tenosynovitis of the flexor tendons.
There was hypoaesthesia in the radial three and half
fingers. There was no evidence of any motor
weakness. Phalens test, Tinels sign and Nicolles test
were positive and correlated well with median nerve
compression. There was neither any history nor

*Senior Registrar; **Lecturer, Department of

Orthopaedics, Dr. RN Cooper Hospital, Vile Parle,
Mumbai.
Reprinted from : BHJ 2002; 44 (1) : 102-3
Bombay Hospital Journal, Special Issue, 2009

Fig. 1 : Histopathology showing central caseoid

necrosis surrounded by giant cells along with
monocytes and macrophages typical of
tuberculosis.
clinical finding suggestive of rheumatoid arthritis.
History and clinical findings were not suggestive of
any other pathology either.
Nerve conduction studies showed delayed
conduction and diminished amplitude confirming
median nerve compression at the wrist. ESR of the
patient was 30 mm at the end of one hour. Surgery in
the form of carpal tunnel release was performed. At
surgery, flexor tendons looked grey and were swollen
proximal and distal to the tunnel with constriction in
the region underneath the flexor retinaculum
117

(dumbbell shaped), compressing the median nerve

which was also similarly constricted. After the carpal
tunnel release, tenosynovectomy of all the involved
tendons was done and a specimen for biopsy was sent.
Histopathology revealed tuberculosis which is shown
in the figure. Patient was started on antituberculous
treatment. The symptoms reduced in 1-1.5 months
and after 6 months the patient is completely better.
Retrospectively, the patient does not give any past
history of tuberculosis or recent history of loss of
weight or appetite, fever etc.

Discussion
Carpal tunnel syndrome secondary to
tuberculous tenosynovitis has been
described. 1-4 If untreated it results in caseoid
necrosis and destruction of flexor tendon
apparatus.4 In almost all cases, the diagnosis
was made post-operatively after suspicious
tenosynovial material was sent for and
confirmed with biopsy. The pre-operative
diagnosis was either rheumatoid arthritis or
nonspecific tenosynovitis. The aim of this
article is to highlight the fact that

118

tuberculosis should be kept in mind as a

possibility in the presence of proliferative
tenosynovitis causing carpal tunnel syndrome,
especially in a developing country like India
and biopsy should always be done to rule out
the same.
References
1. Langa V, Pogner MA, Hoffman S, et al. Carpal
tunnel syndrome secondary to tuberculous
tenosynovitis. Bulletin of the Hospital for Joint
Diseases Orthopaedic Institute 1986; 46 (2) :
137-42.
2. Lee KE. Tuberculosis presenting as carpal tunnel
syndrome. Journal of Hand Surgery - American
1985; 10 (2) : 242-5.
3. Bush DC, Schneider LH. Tuberculosis of the hand
and wrist. Journal of Hand Surgery - American
1984; 9 (3) : 391-8.
4. Mark G, Gartmann J, Reudi T. Carpal tunnel
syndrome in tuberculous tenosynovitis of the hand
(German).
Schweizerische
Medizinische
Wochenschrift. Journal Suisse de Medecine 1984;
114 (13) : 448-51.

Bombay Hospital Journal, Special Issue, 2009