非结核分枝杆菌感染所致腕管综合征

Carpal tunnel syndrome caused by nontuberculosis mycobacteria infection

目的探讨非结核分枝杆菌(nontuberculosis mycobacteria,NTM)感染所致腕管综合征的临床特点、鉴别诊断及相应治疗方案。方法回顾性分析自2014年6月至2017年6月诊治的7例NTM感染导致的腕管综合征患者。行腕管切开、正中神经松解术治疗,术中均发现滑膜异常增生,标本送普通细菌、真菌及分枝杆菌培养和病理检查。分析病例的诱发因素、临床发病特点、鉴别诊断、培养结果、治疗经过及随访预后。结果有明确诱因3例(鱼虾等刺伤史),其余4例无明确诱因。均有手麻及不同程度疼痛,表现为急性疼痛4例。有明显感染迹象4例,3例未见红肿等表现。细菌培养结果:海分枝杆菌感染5例、偶发分枝杆菌1例、浅黄分枝杆菌1例。肌电图提示正中神经腕管受压中度5例,重度2例。术前4例有服用抗分枝杆菌药物史。4例术中对腕管和前臂及受累手指进行了彻底病灶清除,3例仅行腕管切口正中神经松解及局限病灶清除。术后所有患者的神经受压症状均明显缓解,尤其是疼痛。术后6例患者经抗分枝杆菌治疗2~3个月后痊愈,1例行局限切开的患者在术后2个月时感染复发,经再次手术清创后痊愈。术后6例手功能恢复良好,1例抓握功能轻度受限。结论NTM感染导致的腕管综合征可能与特发性腕管综合征表现相似,临床需要仔细鉴别。如果没有明显的感染表现,急性不能缓解的疼痛可能提示感染。手术适用于神经卡压症状明显且保守治疗不能缓解的患者,术后需要抗分枝杆菌药物治疗2~3个月。

Objective To investigate the clinical features, differential diagnosis and treatment of carpal tunnel syndrome caused by nontuberculosis mycobacteria (NTM) infection. Methods Seven patients with carpal tunnel syndrome caused by NTM infection were retrospectively analyzed from June 2014 to June 2017. Carpal tunnel incision and median nerve release were performed. Synovial dysplasia was found during the operation. Samples were sent for culture and pathological examination of common bacteria, fungi and mycobacterium. The inducing factors, clinical features, differential diagnosis, culture results, treatment process and follow-up prognosis were analyzed. Results There were 3 cases with definite inducement (history of stabbing wounds such as fish and shrimp), and the other 4 cases had no definite inducement. All the patients had hand anesthesia and pain in different degrees, which manifested as acute pain in 4 cases. There were 4 cases with obvious signs of infection and 3 cases without signs of redness and swelling. Bacterial culture results: mycobacterium marinum infection in 5 cases, mycobacterium fortuitum in 1 case, mycobacterium lentiflavum in 1 case. EMG showed that median nerve carpal tunnel was compressed moderately in 5 cases and severely in 2 cases. 4 patients had a history of taking anti-mycobacterium drugs before operation. 4 cases underwent thorough debridement of the carpal tunnel, forearm and affected fingers, and 3 cases underwent median nerve release and local debridement through carpal tunnel incision. The symptoms of nerve compression, especially pain, were relieved in all the patients after the operation. 6 patients recovered after 2 to 3 months of anti-mycobacterium treatment, and 1 patient who underwent limited incision relapsed 2 months after the operation, and recovered after reoperation. Postoperative hand function recovered well in 6 cases and slightly limited in 1 case. Conclusion Carpal tunnel syndrome caused by NTM infection may be similar to idiopathic carpal tunnel syndrome, which needs to be differentiated carefully. If there is no obvious manifestation of infection, acute pain that cannot be alleviated may indicate infection. Surgery is suitable for patients with obvious symptoms of nerve entrapment that cannot be alleviated by conservative treatment. Antimycobacterium drugs are needed for 2 to 3 months after the operation.