  |
|
|
|
|
|||
| Journal of the New Zealand Medical Association,
02-May-2003, Vol 116 No 1173
|
|||
|
Acute extensor hallucis longus tenosynovitis caused by
gonococcal infection
Shihab Faraj and Derek Stanley-Clarke
We report here an unusual case of acute septic extensor
hallucis tendon tenosynovitis caused by
Neisseria gonorrhoeae, not associated
with arthropathy, septic arthritis or other manifestation of disseminated
gonococcal infection. To our knowledge there has been no such case reported
before.
Case reportShe gave a history of gradual deterioration of pain and
discomfort in the right foot one week after arrival from a trip to a Pacific
Island, eventually becoming unable to bear weight on it. There was no history of
trauma, gout or systemic arthritis.
The patient had vaginal and cervical swabs undertaken by her
general practitioner for gonorrhoea six months prior to her presentation and
these were repeated one week before her presentation; both sets of results came
back negative.
Examination findings revealed that she was afebrile with no
skin rash and the pertinent findings were restricted to her right
foot.
The dorsum of the right foot was red, warm and swollen. The
swelling extended to the ankle joint area. The patient experienced marked
tenderness along the extensor tendon sheath, particularly the extensor hallucis
longus (EHL) tendon. Pain was induced mainly by passive plantar flexion of the
big toe. The ankle joint movement was relatively restricted.
Blood tests showed a white blood count of 12.2 E9/l, an ESR
of 70 mm/hr and normal serum uric acid.
A radiograph of the foot revealed moderate soft-tissue
swelling around the ankle and dorsal aspect of the foot. There was no bone or
joint involvement.
Ultrasound examination of the right foot demonstrated
subcutaneous oedema of the dorsal aspect of the foot and a moderate amount of
fluid around the EHL tendon, but the tendon itself appeared normal in size and
moved freely. No ankle joint effusion was seen on the scan (Figure 1).
A provisional diagnosis of acute EHL tenosynovitis was made.
To confirm the diagnosis and the nature of the tenosynovitis, a needle
aspiration was performed under ultrasound guidance. A small amount of fluid was
aspirated and sent for culture and sensitivity. This came back with heavy growth
of Neisseria gonorrhoeae sensitive to
ciprofloxacin.
The patient was treated successfully with oral ciprofloxacin
then referred to the sexually transmitted diseases clinic for further
management.
Figure 1. Coronal section of ultrasound examination of
extensor hallucis longus of both sides showing the fluid inside the right tendon
sheath
 DiscussionDisseminated gonococcal infection
can produce an inflammatory reaction in the joints and synovial membranes. It is
usually associated with polyarthropathy, affecting the wrist and the knee
joints.1,2 The ankle, shoulder, elbow and small
joints of the fingers and toes can also be
involved.3
Keiseler,3
Harris,4 and Colin and
Weissman5 described inflammation of the
extensor tendon of the hand, but in all these cases joints were
involved.
Schaefer et al reported a case of acute flexor gonococcal
tenosynovitis of the middle finger with symptomatic gonococcal pharyngitis in a
15-year-old boy.6
Ultrasound is a quick and effective way to differentiate
between joint infection and infected tendon in the ankle or wrist areas where
fluid accumulation is the clue to the infected site.
Intervention ultrasound yields accurate placement of the
needle tip and subsequent aspiration of the tendon sheaths or joint
spaces.7,8
Author information:
Shihab Faraj, Orthopaedic Registrar; Derek Stanley-Clarke, Orthopaedic
Consultant, Rotorua Public Hospital, Rotorua
Correspondence: Dr
Shihab Faraj, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland. Fax:
(09) 533 6555; email: faraj@wave.co.nz
References:
|
|
|
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|