Tubercular Compound Palmar Ganglion Presenting with Chronic Wrist Swelling and Flexor Dysfunction: A Case Report

Tubercular tenosynovitis involving the flexor compartments of the hand, specifically manifesting as a compound palmar ganglion, is a rare form of extrapulmonary tuberculosis (TB). It constitutes a small fraction of musculoskeletal TB cases and is frequently misdiagnosed as rheumatoid arthritis or non-specific synovitis due to its insidious onset and lack of systemic symptoms. This case report is important as it highlights a massive presentation of this condition that persisted for years due to delayed diagnosis. It underscores the necessity of considering a tubercular etiology in chronic hand swellings to prevent severe complications such as tendon rupture and permanent hand dysfunction. While this report describes a single patient, it aligns with the existing rare literature to provide a clear management framework for surgeons in endemic regions.

A 45-year-old female of Indian ethnicity presented with a 3-year history of gradually progressive swelling over her left hand and little finger, accompanied by an inability to flex the wrist and fifth digit. She had previously received conservative symptomatic treatment without relief. Clinical examination revealed a non-tender, spongy swelling over the hypothenar eminence and wrist. Magnetic resonance imaging (MRI) revealed extensive tenosynovitis of the fifth flexor compartment containing numerous "rice bodies," which are characteristic of chronic inflammation. The patient underwent open surgical excision of the mass. Histopathological examination of the excised tissue confirmed the diagnosis by revealing caseating granulomas and Langhans giant cells. She was subsequently treated with a 12-month course of antitubercular chemotherapy (ATT) and achieved full functional recovery without recurrence. Given the rapid clinical improvement, standard first-line chemotherapy was used successfully as a surrogate for drug sensitivity.

This case illustrates that compound palmar ganglion should remain a high-priority differential diagnosis for chronic, unexplained wrist swelling and flexor dysfunction, particularly in endemic regions. The clinical impact of this report lies in reinforcing the diagnostic utility of MRI in identifying "rice bodies" and the absolute necessity of histopathological confirmation. Early surgical excision combined with prolonged ATT is the definitive management strategy to restore hand function and prevent the significant morbidity associated with delayed diagnosis.