AJR 2003; 180:1455-1459
© American Roentgen Ray Society
Rice-Body Formation in Atypical Mycobacterial Tenosynovitis and Bursitis: Findings on Sonography and MR Imaging
C. L. F. Chau1,
J. F. Griffith2,
P. T. Chan3,
T. H. Lui,
K. S. Yu3 and
W. K. Ngai3
1 Department of Radiology, Ground floor, North District Hospital, New
Territories East Cluster, Fanling, New Territories, Hong Kong.
2 Department of Diagnostic Radiology and Organ Imaging, Ground floor, Prince of
Wales Hospital, New Territories East Cluster, Shatin, New Territories, Hong
Kong.
3 Department of Orthopaedics and Traumatology, First floor, North District
Hospital, Fanling, New Territories, Hong Kong.
Received August 5, 2002;
accepted after revision October 8, 2002.
Address correspondence to C. L. F. Chau.
Abstract
OBJECTIVE. This article describes rice bodies found in patients with
atypical mycobacterial tenosynovitis and bursitis, emphasizing the sonographic
and MR imaging appearances of these small bodies.
CONCLUSION. Rice bodies occur in patients with atypical
mycobacterial tenosynovitis and bursitis. When small, rice bodies are better
visualized on MR imaging than on sonography, allowing the radiologist to
consider appropriate diagnoses.
Introduction
Atypical mycobacterial tenosynovitis and bursitis are rare diseases.
Previous case reports of atypical mycobacterial tenosynovitis and bursitis
have focused mainly on the clinical and microbiologic aspects of these
entities [1,
2,
3]. To our knowledge, rice-body
formation in atypical mycobacterial tenosynovitis and bursitis has not been
previously reported. We reviewed the imaging findings of three cases of
atypical mycobacterial tenosynovitis and bursitis, highlighting the varying
appearances of rice bodies on sonography and MR imaging.
Materials and Methods
We reviewed the medical records of three patients with atypical
mycobacterial tenosynovitis and bursitis of the wrists and hands who were seen
from January 2000 to March 2002. All patients underwent radiography,
sonography, and MR imaging. All sonographic examinations were performed using
a 12–5 MHz linear array transducer (HDI 5000; Advanced Technology
Laboratories, Bothell, WA). MR imaging was performed on a 1.5-T unit (Signa
Horizon Echospeed; General Electric Medical Systems, Milwaukee, WI) using a
dedicated wrist coil.
The imaging findings were reviewed by two musculoskeletal radiologists.
Radiographs were evaluated for the presence of osseous involvement,
soft-tissue swelling, and calcification. Sonographic and MR imaging findings
were evaluated for thickening or inflammation of the tendon sheath or bursal
wall, tendon sheath effusion, calcification, and rice bodies.
Patients consisted of two men (ages, 50 and 69 years) and one woman (age,
71 years) whose average age was 65 years. All three patients complained of
swelling of the wrist with mild pain and stiffness. One patient had carpal
tunnel syndrome. The average duration of symptoms before presentation was 13
months (range, 12–15 months). Patients were not immunocompromised at the
onset of symptoms. One patient was subsequently treated with oral steroids and
a single steroid injection to the wrist.
Results
In all patients, radiography revealed softtissue swelling without
calcification or osseous abnormality. Both sonography and MR imaging revealed
moderately distended radial and ulnar bursae in the distal section of the
affected forearm (Figs. 1A,
1B,
2A,
2B,
2C,
2D,
2E,
3A,
3B,
3C,
3D). The deep component of the
ulnar bursa was predominately involved in all patients (Figs.
1A,
1B). The condition of the
bursal wall ranged from minimally to moderately thickened (Figs.
1B,
2B, and
2D). Distal to the bursae,
flexor tenosynovitis was found to extend through the carpal tunnel to the
digits (Fig. 2C). All three
patients had marginally thickened flexor tendons
(Fig. 1A). Rice bodies were
clearly identifiable on sonography in two patients (Figs.
1A,
1B and
2A,
2B,
2C,
2D,
2E). In the third patient, a
moderate amount of echogenic material was present in the distended bursa and
was particularly notable around the tendons (Figs.
3A and
3B). No rice bodies were
discernible on sonography in this patient although they were clearly revealed
on subsequent MR imaging (Figs.
3C and
3D). MR imaging showed that
there was no involvement of the bones or joints in any of the patients.
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Fig. 1A. —69-year-old man with 1-year history of swelling in left
wrist. Axial fast spin-echo T1-weighted MR image (TR/effective TE, 860/10.6;
echo-train length, 3) of wrist reveals markedly distended radial (single
asterisk), intermediate (double asterisks), and ulnar
(triple asterisks) bursae. Flexor tendons are marginally thickened.
Rice bodies are isointense relative to bursal fluid and muscle; tendons cannot
be differentiated from bursal fluid. (Intermediate bursa is normal variation,
providing communication between radial and ulnar bursa.)
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Fig. 1B. —69-year-old man with 1-year history of swelling in left
wrist. Axial fast spin-echo T2-weighted MR image (5220/101; echo-train length,
16) reveals multiple, slightly hyperintense rice bodies (short
arrows) in distended bursae. Bursal walls (long arrows) are
moderately and diffusely thickened. Little or no edema of surrounding soft
tissue is visible. Extensor tendons are normal.
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Fig. 2A. —71-year-old woman with 15-month history of swelling and
symptoms of carpal tunnel syndrome in right wrist. Clinical photograph of
wrist shows soft-tissue swelling distal (short arrow) and proximal
(long arrow) relative to flexor retinaculum (arrowhead).
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Fig. 2B. —71-year-old woman with 15-month history of swelling and
symptoms of carpal tunnel syndrome in right wrist. Longitudinal sonogram of
ulnar bursa reveals multiple large well-defined isoechoic rice bodies within
large bursal effusion. Bursal wall (arrows) is slightly
thickened.
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Fig. 2C. —71-year-old woman with 15-month history of swelling and
symptoms of carpal tunnel syndrome in right wrist. Sagittal fast spin-echo
T2-weighted fat-saturated MR image (TR/effective TE, 3840/105; echo-train
length, 12) reveals multiple rice bodies (arrows) in distended
radioulnar bursa and flexor tendon sheath proximal and distal relative to
flexor retinaculum. R = radius, C = capitate bone.
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Fig. 2D. —71-year-old woman with 15-month history of swelling and
symptoms of carpal tunnel syndrome in right wrist. Axial fast spin-echo
T2-weighted MR image (4000/105; echo-train length, 12) obtained distal
relative to carpal tunnel shows multiple slightly hyperintense rice bodies
(arrows) in distended bursae. Bursal wall is slightly thickened. Mild
edema is evident in adjacent muscle and soft tissues.
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Fig. 2E. —71-year-old woman with 15-month history of swelling and
symptoms of carpal tunnel syndrome in right wrist. Photograph acquired during
surgery reveals multiple white smoothly marginated rice bodies
(arrow) in dissected radioulnar bursae.
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Fig. 3A. —50-year-old man with left wrist swelling for 1 year.
Longitudinal (A) and transverse (B) sonograms of wrist show
low-level internal echoes (arrows) without acoustic shadowing in deep
portion of ulnar bursa (U, B) and surrounding flexor digitorum
superficialis and profundus (P) tendons. Some mass effect is evident. Discrete
rice bodies cannot be seen. R = radius.
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Fig. 3B. —50-year-old man with left wrist swelling for 1 year.
Longitudinal (A) and transverse (B) sonograms of wrist show
low-level internal echoes (arrows) without acoustic shadowing in deep
portion of ulnar bursa (U, B) and surrounding flexor digitorum
superficialis and profundus (P) tendons. Some mass effect is evident. Discrete
rice bodies cannot be seen. R = radius.
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Fig. 3C. —50-year-old man with left wrist swelling for 1 year. Axial
(C) and coronal (D) fast spin-echo MR images (TR/effective TE,
3800/105; echo-train length, 12) reveals multiple tiny hypointense rice bodies
(arrows) that almost completely fill radial and ulnar bursae. These
rice bodies are much smaller than those seen in Figures
1B and
2D. Bursal wall is slightly
thickened. P = flexor digitorium profundus tendons, R = radius, U = ulna.
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Fig. 3D. —50-year-old man with left wrist swelling for 1 year. Axial
(C) and coronal (D) fast spin-echo MR images (TR/effective TE,
3800/105; echo-train length, 12) reveals multiple tiny hypointense rice bodies
(arrows) that almost completely fill radial and ulnar bursae. These
rice bodies are much smaller than those seen in Figures
1B and
2D. Bursal wall is slightly
thickened. P = flexor digitorium profundus tendons, R = radius, U = ulna.
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Histologically, multinucleated giant cell granulomas were found in the
specimens of all patients. Results of Zielh-Neelsen stains for acid-fast
bacilli were negative. Organisms were identified on tissue culture as
Mycobacterium avium-intracelluare complex in two patients. In the
remaining patient, the organisms on the tissue culture were broadly
categorized as Runyon group III atypical mycobacterium (this group includes
Mycobacterium intracellulare, Mycobacterium gastri, and
Mycobacterium avium)
[4].
The findings on chest radiography were normal in two patients. One patient
had a small fibrocalcific focus, probably related to a previous tuberculosis
infection. No evidence of active pulmonary infection was found in any patient.
In all patients, the wrist and hands were the sole sites of infection. The
patients were treated with synovectomy and antituberculous chemotherapy. One
patient had poor drug compliance and stopped taking the antimycobacterial
medication after a short period. His symptoms recurred 5 months later.
Reexploration was required. Eventually, the treatment response in all patients
was satisfactory.
Discussion
Atypical mycobacteria have colonial characteristics different from those of
Mycobacterium tuberculosis
[5]. As the name implies,
atypical mycobacteria are less common than typical mycobacteria.
Musculoskeletal involvement occurs in 5–10% of patients with atypical
mycobacterial infection [5],
whichis commonly precipitated by trauma, such as surgery or penetrating
injury. The hand and wrist are the most frequent sites of atypical
mycobacterial infection. Occurrence in these sites is postulated to be related
to both the relative abundance of synovium in the region and the increased
risk for pathogen inoculation through minor penetrating injuries
[5]. At presentation,
concurrent atypical mycobacterial infection in pulmonary sites or in separate
sites in the bursa or tendon sheath is rare, especially in immunocompetent
patients. However, in immunocompromised patients, especially in patients with
AIDS, disseminated atypical mycobacterial infection with multiple organ
involvement is frequently found
[2,
6].
Although it is rare, atypical mycobacterial infection is an important
disease to recognize, given the increasing incidence of the disease because of
the spread of the AIDS epidemic and an increased virulence of the mycobacteria
[5].
Typically, diagnosis of atypical mycobacterial tenosynovitis is delayed;
the length of time between the onset of symptoms and diagnosis may be as long
as 1 year [5,
7]. Physical signs of acute
infection are usually not present. Blood tests are generally not helpful,
although the erythrocyte sedimentation rate and C-reactive protein level may
be elevated in some patients. Imaging studies play an important role in
establishing the diagnosis of tenosynovitis and in providing clues to the
possible presence of mycobacterial infection. Potentially harmful steroid
therapy can thus be avoided
[8].
The clinical and imaging appearances of tuberculosis tenosynovitis vary,
depending on duration of the disease, host resistance, and organism virulence
[9,
10]. To our knowledge,
rice-body formation in atypical mycobacterial tenosynovitis and bursitis has
not previously been reported. The rice bodies are composed of fibrin and are
identical to those present in mycobacterial tuberculous tenosynovitis.
Both sonography and MR imaging can reveal the presence of rice bodies.
However, if the rice bodies are small (as they were in the 50-year-old man in
our series, Figs. 3A,
3B,
3C,
3D), sonography may fail to
delineate the individual rice bodies and instead may give an impression of a
soft-tissue mass, debris, blood, or viscous fluid inside the bursa (Figs.
3A and
3B). Further evaluation on MR
imaging is recommended for patients believed to have tenosynovitis whose
sonographic findings show low-level internal echoes or an apparent soft-tissue
mass in the tendon sheath (Figs.
3C and
3D).
Inflammatory conditions often associated with rice-body formation are
rheumatoid arthritis; seronegative inflammatory arthritis; and tuberculous
joints, tenosynovitis, and bursitis
[11]. Rice bodies are
isointense on T1-weighted MR images and slightly hyperintense relative to
muscle on T2-weighted MR images
[12]. In all three patients,
the rice bodies were clearly visible on MR imaging.
Histologic examinations for all patients revealed a multinucleated giant
cells granulomatous infection, with associated fibrinous rice bodies.
Frequently, tissues infected by mycobacteria (typical or atypical) that are
examined with Ziehl-Neelsen stain do not result in positive findings. Tissue
culture is the most important means of identifying the offending pathogen,
although it may take months to obtain a positive result
[2]. Treatment is usually
started empirically on the basis of the clinical, radiologic, and histologic
findings. Patients usually respond to synovectomy and antimycobacterial
treatment.
In conclusion, rice bodies may be found in atypical mycobacterial
tenosynovitis. Both sonography and MR imaging can depict rice bodies, but MR
imaging is especially useful if the rice bodies are small.
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Abstract
Introduction
