Hand Edema and Erythema in an Infant

An 8-month-old girl presented with acute onset of fever, increased irritability, redness and swelling, and pain in her left hand. The infant was previously healthy and her symptoms had occurred for 1 day prior to presentation. There was no obvious preceding trauma, insect bite, or alteration in skin integrity. On initial presentation, the girl was crying, tachycardic, and febrile. Physical examination results revealed that her left hand was moderately erythematous, warm, and displayed tense swelling localized to the dorsal aspect of the hand, extending to all 5 digits (Figure 1). Perfusion and sensation were intact, but there was tenderness to palpation of the left hand and wrist, and there was pain with wrist flexion. The infant was able to move her fingers without apparent discomfort. 

Laboratory tests were conducted, and results included a serum white blood cell count of 12.6 /µL with a left shift. C-reactive protein was 68 mg/L (normal range < 7 mg/L) and erythrocyte sedimentation rate was 23 mm/h. The results of a radiograph of her left hand revealed significant soft tissue swelling, predominantly along the dorsal aspect of the visualized distal forearm, wrist, and hand. No underlying osseous abnormality was identified.

The infant was diagnosed with cellulitis of the left hand and was treated with intravenous antibiotics. Blood cultures were negative for infection at 48 hours, and a wound culture obtained via incision and drainage showed no growth. The girl clinically improved over the next several days and was discharged home on oral antibiotics with complete resolution of symptoms at follow-up 3 days later.

However, 2 weeks later, she presented again with recurrent symptoms of left hand discoloration and swelling, but no pain. Physical examination results revealed a nontender reticular area of purple discoloration, and less edema than on initial presentation (Figure 2). She was afebrile and was restarted on antibiotics with a presumptive diagnosis of recurrent cellulitis. 

Ultrasonography of the left hand was conducted and revealed an extensor compartment tenosynovitis.  Magnetic resonance imaging of the left hand showed edema dorsally in the subcutaneous fat and within the fourth extensor tendon compartment, consistent with cellulitis and mild tenosynovitis of the fourth extensor compartment. A rheumatologist was consulted, and it was concluded that the infant had postinfectious/reactive tenosynovitis or early presentation of juvenile idiopathic arthritis. Antibiotics were discontinued after 2 days’ duration, and the girl improved on nonsteroidal anti-inflammatories (NSAIDs). At the 2-week follow-up, the patient was doing well with no symptoms other than some intermittent purple discoloration over the hand. She had no return of symptoms, and NSAIDs were discontinued 1 week later. At the 3-month follow-up, the results of her joint examination were unremarkable. The final diagnosis was reactive inflammatory tenosynovitis. 

DISCUSSION

In our patient, it was initially unclear whether her second presentation represented infectious tenosynovitis, early presentation of juvenile idiopathic arthritis, or reactive inflammatory tenosynovitis. Reactive tenosynovitis is most commonly seen in children aged 3 to 10 years but has rarely been reported in infants.¹ Maintaining a high index of suspicion for deep fascial space infections with prompt initiation of antibiotics and surgical consultation is imperative in the evaluation of such cases.

Because of the hand’s unique anatomy, a deep infection may spread rapidly and can present in several ways, including through tendons. The flexor tendons are contained within definite sheaths that can act as pathways for spread of infection.² Pyogenic flexor tenosynovitis is diagnosed with 4 classic signs: tenderness along the tendon sheath, digital swelling, semiflexed position, and pain on extension.³ Pyogenic flexor tenosynovitis requires urgent diagnosis and surgical care because a delay in diagnosis affects functional recovery. The condition can result in adhesions, tendon rupture, extension to other digits, and loss of digits.³ 

The extensor tendons do not lie within fixed tendon sheaths, so infection of these tendons is less likely.² However, deep dorsal fascial infection can cause significant swelling of the dorsum and pain with passive extension of the extensor tendons.¹ Cellulitis should raise suspicion of underlying osteomyelitis, septic arthritis, a retained foreign body, or abscess formation.² 

Fortunately, in our case, ongoing follow-up demonstrated complete resolution of symptoms, with no recurrence over 15 months. The outcome suggested that our patient indeed had reactive inflammatory tenosynovitis.

Karoline Korah, DO, is a pediatric resident at Lehigh Valley Health Network in Allentown, Pennsylvania.

Kris Rooney, MD, is an assistant professor of pediatrics at the University of South Florida College of Medicine in Tampa, Florida, and  an associate program director at Lehigh Valley Health Network Pediatric Residency Program in Allentown, Pennsylvania.

April Bingham, MD, is an assistant professor in the Department of Pediatrics, Division of Pediatric Rheumatology at Penn State Children’s Hospital in Hershey, Pennsylvania.

REFERENCES

1. Fabry G. Clinical practice: the hip from birth to adolescence. Eur J Pediatr. 2010;169(2):143-148.

2. Zenel J. A febrile infant who has hand edema and erythema. Pediatr Rev. 2000;21(9):321-323.

3. Luria S, Haze A. Pyogenic flexor tenosynovitis in children. Pediatr Emerg Care. 2011;27(8):740-741.