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Isolated Histoplasma Tenosynovitis in a Patient on Adalimumab

      A 42-year-old woman presented with a 3-week history of left hand swelling and pain, with a “shooting” sensation up her arm. Medical history was remarkable for Crohn disease on adalimumab and azathioprine. Physical examination was notable for erythema and tenderness on the palmar aspect of the left hand (Figure 1). Magnetic resonance imaging (MRI) identified flexor tenosynovial enhancement with surrounding inflammation (Supplemental Figure 1, available online at http://www.mayoclinicproceedings.org). Urgent flexor tenosynovectomy of digits 2 through 5 with left carpal tunnel release was performed. Pathologic evaluation of synovium noted necrotizing granulomas (Supplemental Figure 2) with Gömöri methenamine-silver stain positive yeast (Figure 2). Synovial cultures grew Histoplasma capsulatum. Chest radiograph was unremarkable. Histoplasma antigen was not detected in blood or urine; however, the sensitivity of these tests is not established in localized extrapulmonary infection. The patient was started on itraconazole therapy; at 1-month follow-up, she was doing well. These images demonstrate the importance of considering histoplasmosis when evaluating subacute tenosynovitis in the immunosuppressed patient. To our knowledge, this is the first patient that we are aware of who was diagnosed with histoplasma tenosynovitis when on adalimumab.
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      Figure 1Palmar surface of hand before surgical irrigation and debridement.
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      Figure 2Ovoid, 2-4 micrometer yeasts (arrows) highlighted on Gömöri methenamine-silver stain (original magnification ×600).

      Supplemental Online Material

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      Supplementary Figure 1Axial T1FS MRI of left hand with contrast, demonstrating diffuse subcutaneous edema with subcutaneous enhancement along the flexor tendons.
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      Supplementary Figure 2Granulomatous inflammation, including multinucleated giant cells (arrowhead) and areas of necrosis (arrow), with hematoxylin and eosin stain (original magnification ×200).