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Rice bodies in the wrist joint

Published:August 03, 2016DOI:https://doi.org/10.1016/j.ejim.2016.07.014

      1. Case presentation

      A 71-year-old-female with HIV since 2005, presented to us in the clinic with a lesion on the dorsal aspect of her right wrist, which she had for the past 3 years. Her latest CD4 count in November was 225 cells/mL with undetectable viral load. She was on abacavir, lamivudine and ritonavir-boosted atazanavir. The lesion was non-tender with normal overlying skin and it was non-mobile. It measured at about 1 cm in width. However, 6 months later, the lesion had significantly changed with a new lesion seen lateral to the initial lesion. Both lesions were red in colour and tender to touch (Fig. 1A ). The lesions now covered the whole length of her wrist and interfered with her daily activities (i.e. putting on clothes). Of note, she was afebrile at this time. She was also anorexic and she associated this loss of appetite to her new anti-retroviral treatment, atazanavir.
      Fig. 1
      Fig. 1A shows the lesions on the dorsal aspect of her right wrist. There were two swellings, with the new and smaller one formed on top of the previous swelling, with the former being redder in color. B shows the MRI image of the right wrist. C. The intra-op view of the excised lesions with rice bodies demonstrable in this picture (marked by forceps).
      What is the diagnosis?

      2. Diagnosis

      MRI and surgical excision of the lesions revealed the presence of multiple rice bodies in the wrist joint space (Fig. 1B and C). Rice bodies can develop due to mycobacterial infections and other non-infectious causes notably rheumatoid arthritis [
      • Berg E.
      • et al.
      On the nature of rheumatoid rice bodies: an immunologic, histochemical, and electron microscope study.
      ,
      • Watanabe S.
      • et al.
      Case of rheumatoid arthritis with the inflamed subdeltoid bursa containing 923 rice bodies—with special reference to the development of rice bodies.
      ]. The lesion was subsequently aspirated, which yielded 3 mL of yellowish thick fluid. Mycobacterium tuberculosis complex (MTBC) was detected in the fluid aspirate using a nested multi target polymerase chain reaction (PCR) assay (Seeplex MTB Nested ACE Detection, Seegene Inc., Seoul, Korea). Acid-fast bacilli were not observed and MTBC was not isolated from both liquid Mycobacteria Growth Indicator Tube (MGIT) culture and solid Lowenstein-Jensen culture. Interestingly, Mycobacterium intracellulare was identified instead from liquid MGIT culture of the same fluid aspirate, using the Genotype Mycobacterium CM line probe assay (Hain Lifescience, Nehren, Germany). We diagnosed and treated her as a mixed mycobacterial synovial infection and she was commenced on standard antituberculosis regimen as well as azithromycin for 9 months. She also underwent debulking of the lesions and after a few months into the treatment, the size of the lesions subsided and healed well.

      Funding information

      High Impact Research MoE Grant UM.C/625/1/HIR/MOHE/MED/31 (No. H-20001-00-E000070).

      Conflict of interest statement for all authors

      There is no conflict of interest for all the authors involved in this manuscript
      We would like to verify that all the authors had access to the data and everyone contributed significantly in writing of the manuscript;

      References

        • Berg E.
        • et al.
        On the nature of rheumatoid rice bodies: an immunologic, histochemical, and electron microscope study.
        Arthritis Rheum. 1977; 20: 1343-1349
        • Watanabe S.
        • et al.
        Case of rheumatoid arthritis with the inflamed subdeltoid bursa containing 923 rice bodies—with special reference to the development of rice bodies.
        Ryumachi. 1983; 23: 206-211