In May 2008, a 72 year old lady presented to the rheumatologist with a 6-month history of progressive painful swelling of both of her wrists. The pain, had started insidiously, and gradually worsened with time. This was associated with pins and needles affecting the digits in the median nerve distribution. There was no associated history of fever, loss of weight/appetite, night sweats, malaise or fatigue. There was no history of trauma, other joint involvement or morning stiffness. The patient had no significant past medical history.
Physical examination revealed bilateral volar wrist swellings, extending across the wrist crease. Each of the swelling was non-tender, firm in consistency, approximately 8 cm × 6 cm in size and non-compressible. It was mobile at right angles to the plane of the wrist joint but not longitudinally. There was wasting of thenar eminence especially the abductor pollicis with positive Tinel's and Phalen's test consistent with median nerve neuropathy. There was terminal restriction of dorsiflexion and palmarflexion of the wrist.
Laboratory tests were normal except for an elevated erythrocyte sedimentation rate (50 mm/h). Rheumatoid factor was negative. Wrist joint radiographs showed no erosive changes. Ultrasound of the wrists showed significant echogenic fluid surrounding flexor tendons suggestive of tenosynovitis. The tendons were intact with normal appearance of the neurovascular bundles. There was no significant Doppler flow. With these features a diagnosis of sero-negative inflammatory arthritis was made and the patient was started on Methotrexate.
The patient was referred six months later to our hand surgery department as there was no respite in her symptoms despite being on Methotrexate and two previous local corticosteroid injections. The patient underwent sequential subtotal synovectomy of her wrists using an extended volar approach. The flexor tendons were encased with fibronous tissue which was debrided. During the operation, multiple rice bodies among the flexor tendons with adherent synovitis were found. The median nerve was decompressed with external neurolysis. Immobilization with a splint was carried out in initial two post-operative weeks for patient comfort and wound healing. Thereafter no splint was used. The patient underwent both surgeries under the cover of Methotrexate. Methotrexate was administered before and continued following surgery under rheumatologist supervision.
Synovial histology revealed several areas of fibrinoid necrosis, bounded by a layer of pallisaded histiocytes but no epitheloid granulomata or germinal centre (). There were no epithelioid granulomata or giant cells. The rice bodies consisted of fibrino-necrotic material. Special stains for fungi (DPAS-Diastase resistant periodic acid Schiff) and acid fast bacilli (Ziehl–Neelsen) were negative ().
Amorphous, necrotic material (right) separated from inflamed synovium (left) by a rather pale zone of histiocytes.
Amorphous, pink, necrotic material (bottom) bounded by a layer of vaguely pallisaded histiocytes. (Stains for mycobacteria and fungi were negative.)
The patient's initial post-operative period was uneventful with primary healing of the wounds. Symptoms of median neuropathy improved. However, five months following the index operation, the symptoms recurred with reappearance of the wrist swellings and paraesthesia. A re-synovectomy of both the wrists was undertaken using the extended volar approach. The median nerve was identified and protected using loupe magnification. Recurrent synovitis in the carpal tunnel and around the flexor tendons was removed with radical debridement and debulking of the fibro-osseous canal. This time, there was yellowish altered synovial fluid with pellet like rice bodies encasing the flexor tendons ().
Yellowish discharge of altered synovial fluid with pellet like rice bodies following synovectomy.
Following re-synovectomy the patient regained her pre-operative range of movement with resolution of symptoms at one year follow-up.