Download Qin, Jing Abstract - New England Hand Society

A Case of Spontaneous Flexor Tenosynovitis From Endometritis
Authors: Jing Bai Qin MD, Richard Montilla MD, Douglas M. Rothkopf MD,
Division of Plastic Surgery, University of Massachusetts Medical School,
Worcester, MA
Presenter: Jing Bai Qin MD
Contact person: Jing Bai Qin MD, [email protected], (617)
396-4133
Background and Literature Review
Infection is the most common cause of flexor tenosynovitis of the hand. The
most prevalent organism found in pyogenic tenosynovitis is Staphylococcus
aureus through introduction of bacteria into a wound. Rarely, hematogenous
seeding of the tendon sheath can occur in the absence of known traumatic
injury to the hand. Only isolated cases of hematogenous inoculation of
bacteria causing flexor tenosynovitis have been reported. Neisseria
gonorrhoeae is known to be able to spread systemically from genital
infection or pharyngitis to the hand. Patients with pulmonary infections from
coccidioidomycosis and nontuberculous mycobacteria can develop systemic
infection leading to pyogenic tenosynovitis in rare cases. In the AIDS
population, disseminated candidiasis occasionally may lead to Candida
tenosynovitis and Prototheca wickerhamii algaemia is the cause of one
patient’s hand flexor tenosynovitis. There are no reports of a disseminated
endometrial pathogen causing hand flexor tenosynovitis. We present the
only reported case of spontaneous Group B Streptococcus flexor
tenosynovitis in the hand seeding from infectious endometritis.
Case Presentation
The patient is an 18-year-old female who presented to the hospital for
spontaneous vaginal delivery of her first child. During the delivery, the
patient sustained a second degree perineal laceration down to the perineal
muscles and fascia that was repaired. Following her delivery, the patient had
persistent post-partum hemorrhage and intractable pain in her pelvis with a
retained uterine hematoma. On post-partum day one, the patient developed
fever, chills, tachycardia, and leukocytosis. On pelvic exam, her lower
uterine fundus was boggy and tender, leading to a diagnosis of endometritis.
On post-partum day two, the patient developed pain in her right palm and
the volar aspect of her middle finger without a history of trauma.
Subsequently she had worsening erythema, edema and pain along the
middle finger tendon sheath and elevated ESR and CRP concerning for
tenosynovitis. She underwent surgical drainage and gross purulence was
found upon division of the A1 pulley. Intraoperative irrigation of the tendon
sheath with a counter incision at the A5 pulley was accomplished.
Intraoperative cultures were positive for Group B Streptococcus. The patient
was treated with IV vancomycin, flagyl, and ceftazidime for one day and
transitioned to an oral course of cephalexin with complete resolution of her
symptoms.
Conclusions
Group B Streptococcus is an unusual pathogen found in flexor tenosynovitis,
but it is a frequent pathogen in endometritis. Although hematogenous
spread of bacteria is theoretically possible from anywhere, this is the first
reported case of flexor tenosynovitis secondary to endometritis. Clinicians
need to be aware of possible hematogenous spread of endometritis
pathogens to the flexor tendon sheath.
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