Case Series of Non-specific Volar Wrist Swellings in Malaysia

We collected a series of 5 patients with non-specific volar wrist swellings which were not ganglions. These swellings were of a mean 4x4cm in measurement with a vague history. The dilemma is deciding on a correct diagnosis in clinic to ensure the relevant investigations are performed and to adequately inform patients who are worried and anxious about the swelling. Symptom presentations were pain (n=4), carpal tunnel syndrome symptoms (n=3) and triggering of the middle finger (n=1). The mean age was 54.8 years and mean duration to surgery was 15 months. All had the swelling on their dominant wrist and underwent surgical excision. Finally, two swellings were tuberculosis (TB), one was gout and two were tenosynovitis.

Two of our cases were diagnosed as tuberculous tenosynovitis based on histopathological examination (HPE) showing Langhans giant cells and one with positive tuberculosis polymerase chain reaction. The third case had a HPE showing scattered small and large amorphous cotton wool-like eosinophilic deposits surrounded by numerous multinucleated giant cells. This patient has a history of gout with no proper follow up. The last two cases were diagnosed to be chronic tenosynovitis with all cultures negative and HPE showing fibrocollagenous and fibrofatty tissue composed of lobules of mature adipocytes.

We need to be highly suspicious of cases that present with harmless looking non specific volar wrist swellings. Even with no history of TB contact and rheumatoid arthritis (RA), their diagnosis cannot be ruled out. Presence or absence of rice bodies could be a red herring as it could be present in either TB, RA and Systemic Lupus Erythematosus. As tuberculosis is endemic in Malaysia, it remains as the top diagnosis.