Imaging Findings

1. Plain radiographs (X-ray) show soft tissue swelling around the proximal phalanx region of the right middle finger, with no clear evidence of bony destruction or obvious fracture. The articular surface appears largely intact, but there is a noted bulge in the local soft tissue. Minor osteoporosis may be present in the surrounding bone.

2. MRI reveals multiple well-defined, round or oval signal lesions of varying sizes within the tendon sheath of the right middle finger. On T1-weighted imaging, they appear isointense to slightly hypointense; on T2-weighted imaging, they are predominantly isointense to mildly hypointense. The tendon sheath wall shows thickening and low signal, suggesting chronic inflammatory hyperplasia of the sheath. There is no obvious tendon rupture or significant bony erosion, though mild local erosion and synovial thickening cannot be ruled out.

Taking into account these imaging findings and the patient’s history of tuberculosis, it is highly suggestive of multiple “Rice bodies” within the tendon sheath of the right middle finger, consistent with tuberculous tenosynovitis.

Possible Diagnoses

• Tuberculous Tenosynovitis: The patient has a history of pulmonary tuberculosis, presents with a painless local swelling that has progressively enlarged over the past year, and imaging reveals classic rice bodies and tendon sheath thickening, consistent with tuberculous infection.
• Rheumatoid Arthritis: Rheumatoid arthritis can also present with tenosynovitis and synovial hyperplasia, sometimes with rice body-like structures. However, it usually involves more widespread areas and is often accompanied by distinct articular erosions and tendon damage.
• Other Non-Specific Chronic Tenosynovitis: Generally, such conditions can show chronic inflammatory thickening but rarely exhibit multiple synovial rice bodies. They also do not align well with the patient’s history of tuberculosis.

Final Diagnosis

Based on the patient’s previous history of pulmonary tuberculosis, clinical presentation (gradually enlarging painless swelling and limited mobility), imaging findings (rice body formation and tendon sheath thickening), and microbiological culture results (isolation of Mycobacterium tuberculosis), the most likely diagnosis is:

Tuberculous Tenosynovitis (with Rice Body Formation).

Treatment and Rehabilitation Plan

1. Pharmacotherapy: Reinforced anti-tuberculosis treatment is generally recommended (a standard anti-tuberculous regimen such as isoniazid, rifampin, ethambutol, and pyrazinamide combined). The course typically lasts at least 6–9 months, possibly extended according to the patient’s condition and any drug resistance.

2. Surgical Intervention: In cases with abundant rice bodies, marked thickening of the tendon sheath, or where Stage II/III disease is present (localized necrosis, significant functional impairment), surgical debridement of the lesion and rice bodies along with pathological examination may be considered. Prolonged anti-tuberculosis therapy afterward helps reduce recurrence.

3. Rehabilitation Training and Exercise Prescription: During anti-tuberculosis therapy and post-surgery, gradual finger exercise is advised:

• F (Frequency): Perform gentle active joint exercises 2–3 times daily initially, gradually increasing to 3–5 times per day depending on the condition.
• I (Intensity): Start with a level that does not cause significant pain or discomfort, using low resistance and low-intensity movements. As the condition stabilizes, slowly increase the range of motion and resistance (for example, using light finger resistance bands).
• T (Time): Each exercise session should last about 5–10 minutes, followed by rest to avoid fatigue or tendon sheath irritation. Later, sessions can be extended to 15–20 minutes based on tolerance.
• T (Type): Focus on joint mobility exercises (e.g., finger flexion and extension, gentle grip ball exercises), and flexibility exercises can be done in warm water to reduce pain and stiffness. Strengthening exercises targeting hand grip can be added in later stages.
• V (Volume): Adjust the total amount of exercise according to post-operative recovery and pain levels, ensuring it does not exacerbate sheath irritation or cause recurrence of inflammation.
• P (Progression): Progress from simple passive and active movements to assisted exercises or low-resistance grip training. Monitor improvements in joint range of motion and grip strength, and advance every 2–4 weeks based on rehabilitation assessments.

Close monitoring of the surgical site and affected finger is essential during rehabilitation. In case of redness, swelling, pain, or any other discomfort, seek medical evaluation promptly to rule out post-operative infection or recurrence of tuberculosis.

Disclaimer: This report provides a clinical reference analysis and cannot replace in-person consultation or the actual diagnosis and treatment advice of a professional physician. If you have any concerns or changes in your condition, please consult a specialist promptly.