An Unusual Case of Tuberculosis Infection of the Hand with Peritonitis

Summary

A 19-year-old male presented with rare co-occurring tuberculosis (TB) hand osteomyelitis and peritonitis. Initially misdiagnosed as an enchondroma, the diagnosis was confirmed by histopathology, acid-fast staining, and FISH. Combined surgical debridement and 12-month antitubercular therapy led to full recovery without sequelae, highlighting TB's atypical presentations and multidisciplinary management.

Abstract

Tuberculosis (TB), primarily a pulmonary disease, manifests extrapulmonary involvement in 20% of cases, though concurrent infections in distant sites like the hand and abdomen are exceedingly rare. This report presents an exceptionally rare case of concurrent tuberculosis osteomyelitis of the hand and peritoneal tuberculosis in a 19-year-old male-an unusual dual presentation not commonly documented in the literature. The patient had an 8-month history of progressive right little finger swelling, initially misdiagnosed as an enchondroma, and subsequently developed acute abdominal pain and ascites, with computed tomography (CT) revealing diffuse peritoneal thickening and peritonitis. Ascitic analysis showed exudative fluid with elevated CA-125, and an interferon-gamma release assay (IGRA) was positive, prompting TB suspicion. Histopathology of debrided hand tissue revealed granulomatous inflammation with necrosis, and Mycobacterium tuberculosis was confirmed by acid-fast staining and fluorescence in situ hybridization (FISH). Treatment combined surgical debridement, bone grafting, and vacuum-assisted drainage for the hand lesion with a 12-month HRZE regimen. Abdominal TB resolved with medical therapy alone. The patient achieved complete recovery with restored finger function and no recurrence over 2 years. This case underscores TB's protean manifestations, emphasizing diagnostic challenges in paucibacillary disease and the utility of IGRA and molecular confirmation (FISH). Clinicians should maintain high suspicion for TB in atypical osteolytic lesions or idiopathic serositis, particularly in endemic regions, to ensure timely multidisciplinary management.

Introduction

Tuberculosis (TB) remains a global epidemic. In 2023, an estimated 10.8 million people developed TB, and there were approximately 1.25 million deaths, making it once again the leading cause of death from a single infectious agent, according to the WHO Global Tuberculosis Report¹. The incidence has risen over the last decade as worldwide travel has become more common and the number of immunocompromised patients has climbed.

After lung and lymph nodes, osteoarticular TB is the third most common site of TB and accounts for 10% to 20% of all extrapulmonary TB cases^2,3<....

Protocol

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the First Affiliated Hospital, Zhejiang University School of Medicine. Written informed consent was obtained from the patient for participation in and publication of this study. All procedures involving the handling of tissue samples suspected of containing Mycobacterium tuberculosis were performed under Biosafety Level 2 (BSL-2) laboratory conditions, adhering to national and institutional biosafety regulations.

1. Initial clinical assessment

1. Comprehensive patient history was obtained, focusi....

Results

Clinically, the wound had healed by 2 weeks postoperatively, at which time the sutures were removed. The final results of the therapy included radiologic evidence of remineralization, sinus healing, and trabecular repair, as well as the elimination of local symptoms, pain-free mobility, and no increase in repeated blood counts or ESR. The outcome satisfied the patient. The patient experienced no recurrence of infection in the hand or abdomen during the 2-year follow-up and healed well with normal function of the finger (.......

Discussion

Extrapulmonary tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis that affects organs outside the lungs⁷. It can impact practically every organ system, including the lymph nodes, genitourinary tract, central nervous system, bones/joints, abdomen (intra-abdominal organs, peritoneum), and pericardium. Microbiologic evidence is essential for diagnosis and therapy, and tissue biopsy is usually necessary, but extrapulmonary lesions are paucibacillary, and sampling,.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
CT Scanner (64-slice)	GE Healthcare	LightSpeed VCT	For chest and abdominal imaging with contrast
Digital Radiography System	Siemens Healthineers	SOMATOM go.Now	Used for AP and lateral radiographs of the hand
ELISA Reader	Bio-Rad	iMark Microplate Reader	Measurement of IGRA interferon-gamma levels
Fluorescence in situ Hybridization (FISH) Kit	Abbott Molecular	06N38-020	Probe-based detection of M. tuberculosis in tissue
Histopathology Staining Reagents	Leica Biosystems	N/A	H&E staining of biopsy tissue
IGRA Test Kit	Qiagen	QuantiFERON-TB Gold Plus	Interferon-gamma release assay for TB screening
Microscope (Fluorescence)	Zeiss	Axio Imager 2	For visualization of FISH fluorescence signals
Microscope (Light)	Olympus	BX43	Used for histopathology and Ziehl–Neelsen examination
Vacuum Sealing Drainage (VSD) System	Smith & Nephew	RENASYS	Negative pressure wound therapy, –80 to –125 mmHg
Ziehl–Neelsen Stain Kit	Sigma-Aldrich	ZN-100	Acid-fast staining for M. tuberculosis