It was the worst pain she had ever felt, the 57-year-old woman told Dr. Mark Vitale. He was a hand surgeon in Greenwich, Conn. — part of the same practice she had visited earlier that year for pain in her hips. But this wrist pain was so much worse.
Five days earlier, she noticed a little soreness in her right wrist, especially on the pinkie side. She didn’t remember injuring it, but since the pandemic hit she had been on the computer more than ever. That first day she thought it must be an overuse injury. But then it just kept getting worse. Now it was excruciating. And swollen. Her right wrist and hand dwarfed those on the left. Her fingers were puffy and tingled with pricks of invisible pins and needles. She was right-handed, and now she couldn’t turn a doorknob or open a jar with that hand. She could barely hold her cellphone. Driving was a nightmare. She tried Tylenol and ibuprofen, but the only thing that seemed to help was ice. She hadn’t been able to sleep much, because she couldn’t find an ice pack that would last all night.
She was healthy and active. She had no real medical problems. Where, she asked the surgeon, did this come from?
A Course of Steroids
Vitale examined the woman’s wrist carefully. The joint between the two bones of the forearm (ulna and radius) and those on the pinkie side of the wrist was exquisitely tender. The swelling was greatest on the palm side of the wrist, where there was a tender lump, maybe the size of a hard-boiled egg sliced lengthwise. Her fingers, especially the index, middle and ring finger, were slightly swollen when compared with those on the left hand. There was no redness, and none of the areas were hot. An X-ray done in the office was normal.
Vitale agreed with the woman’s self-diagnosis: This was probably an overuse injury of the tendons that allow the hand to grip. He gave her a splint and a Medrol dose pack — a six-day course of a steroid called methylprednisolone. She was to take six tablets the first day and then reduce the dose by one tablet a day for the next five days.
The woman returned the following week. At first the steroids seemed miraculous. But by Day 3 the pain and swelling were back, even worse than before. Vitale was concerned. Tendinitis usually improves with steroids and rest, but her wrist and hand clearly had not. The wrist was now diffusely swollen. And the fingers looked like sausages. It didn’t look like an infection — it wasn’t hot or red — but that was still a possibility. It seemed more likely to the surgeon that this was a systemic joint disease. She had a history of pain in both hips, and the doctor she’d seen for that found inflammation in the parts of the pelvic girdle known as the sacroiliac joints. These joints are often involved in diseases that affect the whole body, like ankylosing spondylitis or psoriatic arthritis. Vitale decided to give her another Medrol dose pack to help with the pain and inflammation and send her for an M.R.I. and some blood tests. If these tests didn’t show evidence of an infection, he would refer her to a rheumatologist.
Second Doctor, Second Diagnosis
The M.R.I. showed only what Vitale already knew: inflammation and swelling in the joint where the ulna and radius came together at the wrist and at the tendons that pull the fingers into a grip. The blood tests were unremarkable. Vitale called the patient with the news. She should see a rheumatologist. He recommended Dr. Lana Bernstein.
The woman called Bernstein’s office, but the doctor wouldn’t be able to see her for weeks. She took the appointment but couldn’t imagine living with this pain for that long, so she saw another rheumatologist who could see her a lot sooner. That rheumatologist diagnosed something called pseudogout. In this disorder, a calcium compound created in the body is deposited in joints, causing pain and swelling. The rheumatologist prescribed a hefty dose of prednisone and another anti-inflammatory drug, colchicine, which is used to treat gout as well as pseudogout. The medications helped with the pain but not the swelling. So the woman saw Bernstein to get a second opinion.
Lana Bernstein had a friendly, no-nonsense manner and just a hint of an Eastern European accent. The patient told her about the pain and swelling and the treatment with multiple courses of steroids and now colchicine. Thanks to those medications, the wrist was less painful, but the hand and wrist were still swollen and using that hand to do just about anything was impossible. Bernstein examined her right hand. The swelling was impressive.
“What’s this?” Bernstein asked, pointing to a red lesion on the side of the patient’s thumb. The patient had burned it a couple of months earlier, and it had been healing very slowly. It became infected and took two rounds of antibiotics to start to clear up.
Bernstein reviewed the tests obtained by Vitale. All the blood tests were normal. And the imaging showed only the swelling and fluid around the tendons and joint. This could be an inflammatory arthritis; there were some that didn’t show up in blood tests. But seeing that lesion got Bernstein worrying that it could be an infection. And there was one infection that she was particularly concerned about.
“Have you cleaned a fish lately?” the doctor asked. The question surprised the patient. Yes, she had. Months earlier, before all this had started, her daughter had ordered three branzinos from the market. Normally the patient’s husband, an avid fisherman, would have cleaned them, but he had just had shoulder surgery. So he coached from the sidelines as she scaled and cleaned them. It was a mess. By the time she was done, there were fish scales and drops of her blood everywhere. But the fish cooked just beautifully.
Bernstein nodded. Around the patient’s thumb were several tiny bumps that seemed to line up going from the tip of her thumb toward her wrist. Bernstein recognized this as a sign of a rare infection, caught from fish — often while scaling them. Indeed, this infection, caused by a cousin of tuberculosis, mycobacterium marinum (M.M.), is sometimes called fish handlers’ disease. Bernstein had seen it once before, years earlier. The organism enters the body through a cut or scrape in the skin. Once in, it grows slowly, then travels the body by way of the lymphatic system, which is why the disease’s characteristic nodules and ulcers often appear in the lines formed by the underlying lymph vessels. Bernstein suspected that the infection in the thumb had spread to the patient’s hand and wrist — and that the steroids the patient took contributed to the infection’s atypical swelling rather than the usual nodules.
Still, this was a rare disease; there were maybe three cases per million people in a year. Unusual joint diseases were much more likely. Bernstein ordered some specialized blood tests and an ultrasound of the wrist to see if there was fluid that could be tapped. If this was an infection, the bug could often be grown from these fluids. And she referred the patient to yet another doctor, Gavin McLeod, a specialist in infectious diseases.
McLeod saw the patient that weekend. He wasn’t certain that this was mycobacterium marinum, but it was a persuasive story. He stopped the prednisone and colchicine. These medications stop inflammation by slowing down the work of the white blood cells. And he put the woman on two antibiotics to fight M.M. Best to get started on the treatment for this infection even before the diagnosis was made.
The culture did finally grow M.M. It has been a slow recovery, and she’s still not fully there. Her wrist became much uglier before it started to get better. She will probably have to take antibiotics for several more months to get completely rid of the bug, but she’s hopeful for a time when she’ll finally have her right hand back.
Recently the patient asked McLeod what would have happened if Bernstein hadn’t asked her about the fish. Would they have ever figured it out? Eventually, probably, McLeod replied thoughtfully. The cultures would have shown it. But, he agreed, it was a good thing she asked.