Letter to the Editor
Rice Bodies in Tuberculous Tenosynovitis of Wrist
Cuerpos de arroz en la tenosinovitis tuberculosa de la muñeca
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Edema migratorio y solapamiento de dermatomiositis edematosa y vesiculoampollosa" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "313" "paginaFinal" => "314" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Edema and dermatomyositis. Migratory edema and edematous and vesiculobullous dermatomyositis overlap" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 900 "Ancho" => 1200 "Tamanyo" => 117913 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a: Placa eritematoedematosa con vesiculoampollas en superficie en miembro superior derecho. b. 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(B) T2W Coronal images show well defined fluid intensity collection anterior to the wrist joint along the flexor tendon sheath suggestive of tenosynovitis. Multiple layered hypointense loose bodies like rice grain are seen within it (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Rice body formation is an uncommon inflammatory process occurring in joints and tendon sheaths in systemic disorders.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> Since their first description in 1895 in a patient with tuberculosis, these have been described in various rheumatic diseases including rheumatoid arthritis, juvenile idiopathic arthritis, and seronegative inflammatory arthritis, in infections with atypical mycobacteria, and in subacromial bursitis.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">2–5</span></a> Generally involving shoulder and knee joints, we describe here a rare case report of a patient with isolated wrist tenosynovitis with rice bodies on magnetic resonance imaging (MRI) who was diagnosed as tuberculosis based on results of microbiologic investigations.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 50-year-old lady came with progressive pain and isolated swelling of the right wrist of 9 months duration. Physical examination revealed an oblong swelling on the volar aspect of wrist extending into the forearm. Attempted active flexion at the wrist was painful though passive range of movement was normal. Laboratory investigations showed raised erythrocyte sedimentation rate of 50<span class="elsevierStyleHsp" style=""></span>mm/h. Radiograph of the wrist was normal. MRI revealed well-defined fluid intensity collection along the flexor tendon sheath with presence of hypointense-layered lucencies within suggestive of tenosynovitis with rice bodies (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). The adjacent bone and soft tissues were normal. Fluid obtained by ultrasound-guided aspiration from the tenosynovial swelling was positive for Acid Fast Bacilli. Culture grew <span class="elsevierStyleItalic">Mycobacterium Tuberculosis</span> and hence, diagnosis of tuberculosis was reached. The patient did not have diabetes and was not on any immunosuppressive drugs. Serology for Human Immunodeficiency Virus (HIV) was non-reactive. The patient responded to six months of anti-tuberculous therapy with complete resolution of pain and swelling.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Rice bodies are called so due to their resemblance to grains of polished white rice on gross examination. The pathogenesis of rice body formation is unclear, but is likely related to shedding of the infarcted synovial tissue into the joint.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> These are formed by fibrin deposits on a nidus of sloughed synovium or inflamed tissue, as evidenced by rim of fibroblasts and inflammatory cells on a nidus of collagen. Types 1, 2 as well as small amounts of type 5 collagen have been demonstrated on histopathological sections.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">2,6,7</span></a> Rice bodies can be detected on both ultrasonography and MR imaging. Ultrasonography of tendon sheath may show low-level internal echoes or an apparent soft tissue mass, however, may fail to delineate individual rice bodies, particularly if these are too small.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> Therefore, MRI is considered the imaging modality of choice for rice bodies which appear iso- or hypointense to skeletal muscle on T1- and T2-weighted images.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Rice bodies are known to occur commonly in rheumatic conditions such as rheumatoid arthritis (RA), juvenile idiopathic arthritis, seronegative inflammatory arthritis, and also osteoarthritis.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">2–4,9</span></a> Pigmented villonodular synovitis (PVNS) and synovial osteochondromatosis form the primary differential diagnoses. In a patient with isolated tenosynovitis, infection is highly likely, and mycobacteria are most often implicated. Rice body formation has been seen with tenosynovitis due to Mycobacterium tuberculosis, and nontuberculous mycobacteria (NTM), including <span class="elsevierStyleItalic">Mycobacterium marinum</span>, <span class="elsevierStyleItalic">Mycobacterium kansasii</span>, rapid growing mycobacterium, <span class="elsevierStyleItalic">Mycobacterium avium</span> and <span class="elsevierStyleItalic">Mycobacterium intracellulare</span>.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> The laboratory should always be informed of the possibility of NTM, as these can be differentiated on culture. Treatment includes mycobacterial therapy and tenosynovectomy to avoid complications such as tendon rupture.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> However, rarely, as in our case, resolution has been reported with antitubercular therapy without any surgical treatment.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In a patient with early polyarthritis yet negative autoantibodies, rice body formation could be a salient marker to underlying RA. In established RA, it is important to know that these solid masses are treatable; as resolution has been described with intraarticular steroids and/or disease modifying anti-rheumatic drugs in most cases without sequelae. This can obviate a surgical procedure, which although initially successful, is associated with recurrence in one-third of patients. Half of those with recurrence require re-operation.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> Lastly, rice bodies are rare in the wrist. If not identified and treated they can progress to compressive neuropathy and tendon ruptures.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1735 "Ancho" => 2500 "Tamanyo" => 232654 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) T2W FAT SAT sagittal image show a well defined fluid intensity collection seen along the flexor tendon sheath with presence of hypointense layered rice grain (white arrow) shaped within it suggestive of tenosynovitis with multiple loose bodies. (B) T2W Coronal images show well defined fluid intensity collection anterior to the wrist joint along the flexor tendon sheath suggestive of tenosynovitis. Multiple layered hypointense loose bodies like rice grain are seen within it (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rice body formation without rheumatic disease or tuberculosis infection: a case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.L. Forse" 1 => "B.L. Mucha" 2 => "M. Lauren Zabala Santos" 3 => "E.H. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 3 | 1 | 4 |
| 2024 Octubre | 83 | 46 | 129 |
| 2024 Septiembre | 113 | 34 | 147 |
| 2024 Agosto | 142 | 58 | 200 |
| 2024 Julio | 130 | 45 | 175 |
| 2024 Junio | 112 | 56 | 168 |
| 2024 Mayo | 106 | 36 | 142 |
| 2024 Abril | 93 | 35 | 128 |
| 2024 Marzo | 123 | 39 | 162 |
| 2024 Febrero | 85 | 31 | 116 |
| 2024 Enero | 104 | 23 | 127 |
| 2023 Diciembre | 81 | 40 | 121 |
| 2023 Noviembre | 118 | 24 | 142 |
| 2023 Octubre | 165 | 27 | 192 |
| 2023 Septiembre | 194 | 33 | 227 |
| 2023 Agosto | 94 | 21 | 115 |
| 2023 Julio | 112 | 35 | 147 |
| 2023 Junio | 103 | 34 | 137 |
| 2023 Mayo | 96 | 26 | 122 |
| 2023 Abril | 104 | 16 | 120 |
| 2023 Marzo | 149 | 46 | 195 |
| 2023 Febrero | 115 | 29 | 144 |
| 2023 Enero | 125 | 20 | 145 |
| 2022 Diciembre | 146 | 43 | 189 |
| 2022 Noviembre | 123 | 44 | 167 |
| 2022 Octubre | 180 | 41 | 221 |
| 2022 Septiembre | 166 | 52 | 218 |
| 2022 Agosto | 244 | 58 | 302 |
| 2022 Julio | 114 | 39 | 153 |
| 2022 Junio | 84 | 33 | 117 |
| 2022 Mayo | 114 | 60 | 174 |
| 2022 Abril | 132 | 56 | 188 |
| 2022 Marzo | 137 | 63 | 200 |
| 2022 Febrero | 121 | 49 | 170 |
| 2022 Enero | 132 | 57 | 189 |
| 2021 Diciembre | 139 | 44 | 183 |
| 2021 Noviembre | 131 | 50 | 181 |
| 2021 Octubre | 201 | 58 | 259 |
| 2021 Septiembre | 176 | 52 | 228 |
| 2021 Agosto | 147 | 54 | 201 |
| 2021 Julio | 166 | 55 | 221 |
| 2021 Junio | 165 | 63 | 228 |
| 2021 Mayo | 168 | 90 | 258 |
| 2021 Abril | 321 | 125 | 446 |
| 2021 Marzo | 243 | 57 | 300 |
| 2021 Febrero | 171 | 36 | 207 |
| 2021 Enero | 154 | 39 | 193 |
| 2020 Diciembre | 132 | 40 | 172 |
| 2020 Noviembre | 159 | 26 | 185 |
| 2020 Octubre | 122 | 22 | 144 |
| 2020 Septiembre | 112 | 40 | 152 |
| 2020 Agosto | 110 | 20 | 130 |
| 2020 Julio | 99 | 30 | 129 |
| 2020 Junio | 64 | 34 | 98 |
| 2020 Mayo | 94 | 29 | 123 |
| 2020 Abril | 90 | 21 | 111 |
| 2020 Marzo | 97 | 17 | 114 |
| 2020 Febrero | 110 | 42 | 152 |
| 2020 Enero | 103 | 31 | 134 |
| 2019 Diciembre | 94 | 31 | 125 |
| 2019 Noviembre | 69 | 13 | 82 |
| 2019 Octubre | 103 | 23 | 126 |
| 2019 Septiembre | 61 | 24 | 85 |
| 2019 Agosto | 60 | 16 | 76 |
| 2019 Julio | 104 | 32 | 136 |
| 2019 Junio | 125 | 13 | 138 |
| 2019 Mayo | 165 | 66 | 231 |
| 2019 Abril | 33 | 119 | 152 |
| 2019 Marzo | 26 | 16 | 42 |
| 2019 Febrero | 1 | 0 | 1 |
| 2019 Enero | 4 | 2 | 6 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 0 | 4 | 4 |
| 2018 Agosto | 0 | 11 | 11 |
| 2018 Julio | 0 | 5 | 5 |
| 2018 Marzo | 0 | 14 | 14 |
| 2018 Febrero | 0 | 26 | 26 |
| 2018 Enero | 0 | 11 | 11 |
| 2017 Diciembre | 0 | 13 | 13 |
| 2017 Noviembre | 0 | 31 | 31 |
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