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surrounding edema at the site of a cat scratch or bite. A similar lesion is seen at the regional lymph nodes. The course of the disease is benign and self-limiting, and treatment is symptomatic. The incubation period is 1 to 2 weeks, and symptoms last 1 to 3 weeks, although lymphadenopathy lasts 6 weeks and occasionally years. Atypical Mycobacterial Infections The incidence of tuberculosis of the hand has diminished at a rate commensurate with the decline in pulmonary tuberculosis. 20,101,102 In its place, however, are infections caused by atypical mycobacteria, which increase yearly. 103–105 The three major atypical mycobacteria involved in hand infection are Mycobacterium marinum, 106–109 Mycobacterium kansasii, 110–112 and Mycobacterium terrae. 113–115 M. marinum is the most common mycobacterial species to infect the hand. It lives in warm water environments and has been cultured from contaminated swimming pools, fish tanks, piers, boats, and stagnant water. It is endogenous to fresh and saltwater marine life. M. marinum survives best at 31°C, and for that reason, it produces infections on the extremities rather than deep body cavities. 103–108 Infections with M. marinum occur after a break in the integrity of the skin, often from an insignificant abrasion on the dorsum of the hand or over the interphalangeal or metacarpophalangeal joints of the fingers. Infection of the hand progresses through a spectrum of indolent skin ulcers through subcutaneous granulomas with sinus tracts, tenosynovitis (flexor and extensor), and septic arthritis or osteomyelitis. 116,117 Treatment of superficial disease can be successful with chemotherapy alone, both minocycline and co-trimoxazole having been shown to be effective. 118,119 The largest study to date, from Hong Kong, suggests that chemotherapy alone might also be applicable to more extensive disease. 118 Generally, deeper disease treatment also requires surgery with radical synovectomy and more specific antimycobacterial therapy with rifampicin and ethambutol for up to 2 years. Early clinical diagnosis of mycobacterial infections is made only with a high index of suspicion. When mycobacterial infection is suspected, cultures should SRPS Volume 10, Issue 25, 2009 be performed at both 31 and 37°C; otherwise, M. marinum infections can be missed. Positive cultures for mycobacterial strains take at least 6 weeks for identification; therefore, treatment can be instituted on the basis of granulomas shown by histological examination or on the basis of acid-fast bacilli seen on a smear. Viral Infections Herpes Simplex Virus Herpes simplex virus (HSV) infection of the hand can be caused by a primary or recurrent infection with either HSV-1 or HSV-2. It tends to occur in three distinct patient subgroups. The first and largest group is adolescents with genital herpes, who tend to be infected with HSV-2. The remaining groups tend to be infected with HSV-1. The second group is children with oral gingivostomatitis, 120,121 and the third group is adult health care professionals—including dentists, anesthesiologists, surgeons, and nurses—who deal directly with potentially infected oral and respiratory secretions. 122 Herpetic infection of the hand typically involves the fingers or thumb in the vast majority of cases. 123 The infection initially declares itself with a prodromal phase of approximately 72 hours’ duration, with severe pain or tingling in the affected digit, and then erythema and swelling. This is called herpetic whitlow. During the ensuing hours to days, vesicles appear and coalesce, often around the eponychium and lateral nail fold. It is at that stage that the viral infection is most likely to be mistaken for a bacterial felon or paronychia. However, the pulp usually is not tense, as it would be in a case of bacterial felon. Associated lymphangitis can be present. The whole process takes approximately 2 weeks and then resolves in another 7 to 10 days. Reactivation of latent virus occurs in only approximately 20% of hand patients. 124 It is not normally as severe as the primary infection and lasts for 7 to 10 days. It is possible to confirm the diagnosis by conducting laboratory investigations, including viral cultures. The Tzanck smear is relatively inexpensive and rapid. 125 Although not as sensitive as viral cultures, it is a useful adjunct in diagnosis, especially if performed early in the course of the disease, during the vesicular or pustular stages. 11
SRPS Volume 10, Issue 25, 2009 The treatment of herpetic infections of the hand is primarily nonsurgical. Rest, elevation, and antiinflammatory analgesia are the mainstays of treatment. For immunocompromised patients, aggressive therapy with intravenously administered acyclovir might be warranted in an attempt to prevent a life-threatening viremia. 126,127 Infections in Immunocompromised Patients Immunocompromised patients can develop hand infections from opportunistic organisms. The management of hand infections in immunocompromised patients is identical, irrespective of the underlying causes. Many of the fungi, viruses, and mycobacteria can be cultured only under very exacting laboratory conditions. Diagnosis almost certainly requires formal surgical tissue biopsy. Treatment is dictated by the organism cultured, but considering that many of the unusual organisms can take several weeks to grow, therapy must be instituted “on spec.” If a fungal origin is most likely, intravenously administered amphotericin B is the first line treatment. Similarly, for a viral origin, of which herpes simplex is the most likely, acyclovir is intravenously administered. Finally, if a mycobacterial species is suspected, triple-agent therapy (rifampicin, ethambutol, isoniazid) is instituted. Diabetes Mellitus C. albicans infections of the nails are common in diabetics, so much so that a random blood glucose level should be obtained as a baseline for any patient presenting with an infection of the nail complex. The same has been suggested by some groups for a first presentation with flexor tenosynovitis. 128 Infections can commence from relatively simple injuries (e.g., felons and suppurative flexor tenosynovitis occurring after fingerstick blood test for glucose levels). 63,129 Microbiology often shows a mixed flora, and S. aureus, so commonly encountered in “normal” patients with suppurative hand infections, often is grossly outweighed by gram-negative organisms. 130 Diabetics often present with advanced disease (bone, tendon, or deep space infection), which can also reflect a peripheral neuropathy as a causative factor. 130–133 Finally, many undergo amputation, either to control 12 infection or because the function in the remaining part is so poor as to be a hindrance or danger to the patient. Treatment of hand infections in diabetics must be early and aggressive if useful function is to be maintained and amputation avoided. 130–133 Obvious abscesses must be drained and appropriate specimens obtained for aerobic and anaerobic cultures. Radiographs should be obtained and supplemented with bone scans, if indicated. Broad-spectrum intravenous antibiotic cover should be instituted and appropriately modified after cultures are returned. Rehabilitation should be aggressive and instituted as soon as the acute manifestations of the infection are on the wane. TUMORS Several authors offer excellent reviews of the spectrum of hand neoplasms, including their incidence, causes, anatomic distribution, and management, which almost always involves surgical remova1. 134–140 Only the more common hand tumors are discussed herein. The overwhelming majority of hand masses are benign, and true neoplasms are rare in the hand (Table 2). Soft-Tissue Tumors Ganglia Ganglia are the most common benign tumors in the hand. 141–143 Although trauma is commonly thought to be implicated in the development of ganglia, a traumatic antecedent has been documented in only a small percentage of patients. The pathogenesis is thought to be mucoid degeneration of fibrous connective tissue in joint capsules or tendon sheaths occurring idiopathically or secondary to injury or irritation. Ganglia are two to three times more common in women than in men. The usual clinical presentation is that of a mass with or without pain. Occasionally, occult ganglia present as paresthesias or weakness from nerve compression. 144–147 Ganglia sometimes even arise within tendon 148 or bone. 149 Dorsal wrist ganglia—The dorsum of the wrist accounts for 70% of all ganglia in the hand and wrist. In the dorsum of the wrist, the ganglion usually overlies the scapholunate ligament. Clay and Clement 150 noted the pedicle of the ganglion to arise from that site in 76% of patients. The cause of dorsal wrist ganglia is
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