Medical Mystery: What caused this woman’s wrist to swell?
Her wrist had swelled to the point where her fingers turned blue. She lost the ability to grip objects as her fingers would not flex or extend. Her hand was numb as well.
A very pleasant 63-year-old woman visited me with her daughter around December 2016. Her daughter was recently engaged, they were planning a wedding, and the woman wanted more than anything to relieve her ailing hand.
She recounted that over the past year she had developed an unexplained swelling in her wrist. She saw several physicians about the problem and the ultimate consensus was that she was suffering from rheumatoid arthritis. She was given very powerful medicines to quell the inflammation in her wrist.
But over the course of a year, her condition worsened. Her wrist had swelled to the point where her fingers turned blue. She lost the ability to grip objects as her fingers would not flex or extend. Her hand was numb as well. A follow up MRI from a few months prior to her visit to my office had shown a non-specific edema (swelling) within her carpal bones.
Several types of arthritis may affect the wrist joints. Rheumatoid arthritis is an inflammatory form of arthritis where the body’s immune system essentially attacks itself. It can be very destructive and disfiguring if left untreated. However, modern medical therapies aimed at suppressing the immune system are very successful in preventing deformities caused by rheumatoid arthritis.
On the other hand, these powerful immunosuppressant drugs come at a price. A suppressed immune system provides an opportunity for rare and unusual infections to take hold in an otherwise healthy person.
So, was the woman really suffering from arthritis, or had the immunosuppressant drugs caused an entirely different problem?
My suspicion was that an atypical infection had spread from her wrist. I biopsied the swollen tissue in her wrist and sent it for growth on a special culture medium to identify if any bacteria were present.
The culture helped us identify a rare infection called mycobacterium avium, which is a slow-growing bacteria related to tuberculosis.
Mycobacteria are found commonly in the soil, water, and dust, but a normally functioning immune system usually has no problem defending against them. However, once an infection has been established, mycobacteria are notoriously difficult to cure. They have a high rate of recurrence. They are resistant to most antibiotics. They can even be lethal.
When the biopsy confirmed the presence of mycobacteria, we developed a new care plan.
To start, I ordered an updated MRI to plan for an aggressive surgical excision of the diseased tissue. Unfortunately, the imaging had revealed that the infection spread across the woman’s wrist into all eight carpal bones, all five metacarpal bones, and both forearm bones (radius and ulna). Infection of the bone is called “osteomyelitis,” which is also notoriously difficult to cure, even with typical bacteria.
Atypical infections often require several surgeries to clear diseased tissue. Sometimes even with aggressive surgery, infection in the bones or deep spaces may lead to amputation or death. This woman had fifteen infected bones. I told her family that she was at high risk for losing her hand.
I worked with an infectious disease specialist who devised a three-drug cocktail aimed at killing mycobacterium.
At the first surgery, I tried to spare her bones and joints and removed only the non-vital soft tissue from her hand to her forearm. But this was not enough to kill the bacteria.
During a follow up surgery I removed all eight carpal bones, and parts of the metacarpals, radius, and ulna. In the space where I had removed the bones, I placed a cement block to preserve the height of the woman’s hand. The cement was laced with additional antibiotics that would slowly absorb into the local tissue to further kill the infection.
Her daughter’s wedding was planned for one week after that surgery. The woman was self-conscious about the scar, so we gave her a flesh-colored bandage to place over the stitches for the photos. But more importantly, her numbness resolved and she recovered the use of her fingers within days.
The woman remained on antibiotics for one year after the surgery. At this point we were confident we had cured the infection, but we still had to address the large structural defect in her wrist.
Ultimately, I reconstructed the wrist by harvesting a bone graft from her hip. The bone graft was secured with a steel plate and screws to permanently provide stability to her wrist — just in time for her to hold her newborn grandchild.
Richard Tosti, M.D., is an assistant professor of orthopaedic surgery at the Sidney Kimmel Medical College at Thomas Jefferson University and a hand, wrist, elbow, and microvascular surgeon at Philadelphia Hand to Shoulder Center.