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1 ORIGINAL ARTICLE pissn eissn J Korean Soc Surg Hand 2015;20(3): JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Diagnosis and Treatment for Deep Nontuberculous Mycobacteria Infection of the Hand and Wrist Ho Youn Park 1, Jun O Yoon 2, Jin-Woong Park 2, Jaeyoun Yoon 2, Jim Sam Kim 2 1 Department of Orthopedic Surgery, Uijeongbu St. Mary s Hospital, College of Medicine, The Catholic University, Uijeongbu, Korea 2 Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Received: June 11, 2015 Revised: [1] August 14, 2015 [2] August 27, 2015 Accepted: August 27, 2015 Correspondence to: Jim Sam Kim Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea TEL: FAX: micro@amc.seoul.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose: The purpose of this study was to present a systematic treatment method for nontuberculous mycobacteria (NTM) infection of the hand and wrist to gain better clinical outcomes. Methods: 10 patients of deep NTM infection of the hand and wrist were reviewed. Extensive debridement was performed in all cases. When biopsy result suggested mycobacterial infection such as granulomatous inflammation, empirical tuberculosis medication was started. After culture confirmed NTM growth, the species was identified and in vitro sensitivity test was performed. Then medication was switched according to the results. Functional outcomes of the hand and wrist were measured by total active motion of the fingers and by range of motion of the wrist respectively. Results: Diagnosis was tenosynovitis in seven patients, infective arthritis and osteomyelitis combined with tenosynovitis of the wrist in three patients. Two patients had recurred skin ulcer during follow-up period and undergone second debridement. After second operation, no patient had a persistent discharging sinus and all patient were completely healed during follow-up period. Functional outcome of the eight patients who had NTM infection of their hand was excellent in two, good in four, fair in one, poor in one. Mean range of motion of the two patients who had osteomyelitis of their wrist was dorsiflexion 20, volar flexion 15, radial deviation 0, ulnar deviation 15. Conclusion: Our standardized treatment protocol can be helpful for treatment of deep NTM infection of the hand and wrist. Keywords: Hand and wrist, Nontuberculous mycobacteria infection, Treatment algorithm 서론 비결핵항산균 (nontuberculous mycobacteria, NTM) 감염은결핵균 (Mycobacterium tuberculosis complex) 과나병균 (Mycobacterium leprae) 을제외한항산균의감염으로정의된다. 비결핵항산균은우리주변환경 ( 흙, 물, 가축등 ) 에 널리퍼져있고이중 60% 가사람에게전파된다 1,2. 정확한감염의경로는밝혀지지않았지만상처가나기쉽고풍부한활액이존재하는수부와수근부가비결핵항산균의힘줄활액막염그리고 / 또는관절염을일으키는가장흔한부위이다 3. 만성비결핵항산균이임상적으로흔한질환은아니지만특히수부에서의만성연부조직감염은현재증가하는추세이다 3,4. 비결 Copyright c The Korean Society for Surgery of the Hand 119

2 J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 핵항산균으로인한감염은주로표준화된감염치료에잘반응하지않는만성염증으로나타나기때문에내성결핵균으로오진될수도있다 5. 또한수부나수근부의만성감염치료가지연되면기능적장해를남기기때문에임상적인추정과미생물학적진단검사법을통한정확한진단과적절한치료가중요하다. 이연구에서는수부및수근부의비결핵항산균감염으로치료받은환자를후향적으로분석함으로써임상적으로더나은결과를내기위해그진단과치료의알고리즘을제시하고자하였다. 대상및방법 Institutional Review Board 승인후 2010년 4월부터 2014년 1월까지본원에서수부및수근부의비결핵항산균감염으로치료받은 10명의환자들의의무기록및방사선영상을분석하였다. 외상, 수술, 침습적시술혹은주사치료의병력이있는환자가항생제에반응없이피부궤양을동반하거나동반하지않는종창, 통증, 발적이지속되어내원하면우선결핵이나비결핵항산균감염을의심하여대상이되는환자에게 C 반응성단백검사 (C-reactive protein, CRP), 적혈구침강속도 (erythrocyte sedimentation rate, ESR), 해당부위단순방사선촬영및흉부단순촬영, 그리고해당부위자기공명영상혹은초음파를시행하였다. 검사결과만성감염이확인되면광범위변연절제술을시행하였고수술시채취된조직을이용하여미생물학적검사및그람염색 (Gram stain) 과항산균도말검사 (AFB stain) 가포함된병리검사를시행하였다. 미생물학적으로는세균배양, 항산균배양및진균배양을시행하였고필요한경우결핵 / 비결핵항산균중합효소연쇄반응검사 tuberculosis/nontuberculous mycobacteria polymerase chain reaction, TB/NTM PCR 를시행하였다. 항산균배양은 BACTEC Mycobacteria Growth Indicator Tubes (MGIT, Becton Dickinson, Piscataway, NJ, USA) 와 3% Ogawa solid media (Korean Institute of Tuberculosis, Korean National Tuberculosis Association, Seoul, Korea) 를이용하여시행하였다. 비결핵항산균배양양성이확인되면 2011년 8월까지는 Myco-ID kit (M&D, Wonju, Korea) 을이용하여그이후에는 GenoType Mycobacterium Assay (Hain Diagnostika, Nehren, Germany) 를이용하여균종을동정하였고동정된균에대해서는 CLSI M24-A2 guideline 따라약물감수성검사가시행되었다 6. 약물감수성검사는천천히자라는비결핵항산균 (slow growing NTM) 은 Sensititre SLOMYCO를이용하여, 빨리자라는비결핵항산 균 (rapid growing NTM) 은 RAPMYCO plates (Trek Diagnostic Systems, East Grinstead UK) 를이용하여시행되었다. 항산균은대체로느리게자라기때문에조직검사상만성육아종성염증 (chronic granulomatous inflammation) 이확인되면감염내과와협진하에경험적으로 isoniazid (INH), rifampin (RFP) ethambutol (EMB), pyrazinamide 항결핵제를우선시작하였다. 비결핵항산균이배양에서양성으로확인되면 M. intracellulare, M. marinum 같은서서히자라는비결핵항산균에대해서는 RFP, EMB, clarithromycin 사용하고 M. chelonae, M. abscessus, M. fortuitum 같은빠르게자라는비결핵항산균에대해서는 clarithromycin 같은 macrolide 제제와 amikacin 정맥주사를같이사용하였다. 만일약에부작용이발생하게되면환자의상태에따라감염내과와협진하에약을바꾸었다. 치료의기간은환자의회복상태에따라결정되며환자는치료가모두끝난후최소 6개월추적관찰을하였다 (Fig. 1). 수술적치료는수지의굴곡건혹은신전건의광범위활액막절제술시행한다 (Fig. 2). 이후힘줄의유착을예방하기위해두껍게압박드레싱을한후수지관절운동을수술당일부터시작하게하였다. 그리고일주일후부터가벼운압박드레싱적용하여적극적인관절운동을시작하였다. 관절염이나골수염의광범위변연절제술후에는관절을 2주간고정한후이후 Suspicion of chronic infection such as TB or NTM infection Blood serology tests Radiologic tests Confirmation of deep chronic infection 1. Extensive debridement 2. Histology, cultures (bacterial-, AFB-, fungal-culture), AFB stain with use of biopsy tissues 1. After synovectomy of the tendon Start ROM excercise on the day of operation with compression dressing Vigrous ROM excercise after 1 week 2. After bone and joint debridement Immobilization for 2 weeks Start ROM excercise After 2 weeks Histology confirms mycobacterial infection Start empirical anti-mycobacterial treatment Culture confirms NTM infection 1. Identification of species 2. In vitro susceptibility test 1. For slow growing NTM: Rifampin, ethambutol, and clarithromycin combination 2. For rapid growing NTM: oral macrolide (e.g. clarithromycin) plus parenteral agent (e.g. amikacin) Medications can be switched depending on adverse effect Fig. 1. Algorithm of our standardized treatment of NTM infection of the hand and wrist. TB, tuberculosis; NTM, nontuberculous mycobacteria; AFB, acid fast bacillus; ROM, range of motion

Ho Youn Park, et al. Diagnosis and Treatment for Deep Nontuberculous Mycobacteria Infection of the Hand and Wrist 관절운동을시작하였다.

195 이상을 excellent, 130 이상 195 미만은 good, 65 이상 129 이하는 fair, 65 미만은 poor 로평가된다. 수근부의기능적평가는수근관절운동각도로평가하였다. 결과 총 10명의환자가연구에포함되었으며환자의평균나이는 61.1세 ( 범위, 41-77세 ) 였으며 10명중 8명이남자였다.

수술전에시행한자기공명영상혹은초음파결과 6명이수부굴곡건의건초염, 한명이수부신전건의건초염, 한명이건초염을동반하는수지의관절염및골수염, 2명이건초염과 동반된수근부의감염성관절염및골수염으로진단되었다. 증상발현기간은평균 11.8개월 ( 범위, 2-36개월 ) 이었고외상후증상이발생하기까지의평균기간은 2.3개월 ( 범위, 1-4개월 ) 이었다. C 반응성단백검사는평균 0.

3 Ho Youn Park, et al. Diagnosis and Treatment for Deep Nontuberculous Mycobacteria Infection of the Hand and Wrist 관절운동을시작하였다. 수지의기능적결과는 American Society for Surgery of the Hand에따른 total active motion (TAM) 으로평가하였다 7. TAM 은중수수지관절, 근위지간관절, 원위지간관절의능동적굴곡각도의합에서신전제한을뺀각도로정의된다. 195 이상을 excellent, 130 이상 195 미만은 good, 65 이상 129 이하는 fair, 65 미만은 poor 로평가된다. 수근부의기능적평가는수근관절운동각도로평가하였다. 결과 총 10명의환자가연구에포함되었으며환자의평균나이는 61.1세 ( 범위, 41-77세 ) 였으며 10명중 8명이남자였다. 4명의환자가이전에수근관이완술, 결절종제거수술을받은병력이있었고 2명은철사나가시에찔린외상력이있었으며한명이건염으로스테로이드주사를, 한명이수근부에염좌로침을맞은병력이있었다. 2명은특별한외상력은없었다. 2명의환자에서루푸스로장기간항생제를복용한병력이있었다 (Table 1). 수술전에시행한자기공명영상혹은초음파결과 6명이수부굴곡건의건초염, 한명이수부신전건의건초염, 한명이건초염을동반하는수지의관절염및골수염, 2명이건초염과 동반된수근부의감염성관절염및골수염으로진단되었다. 증상발현기간은평균 11.8개월 ( 범위, 2-36개월 ) 이었고외상후증상이발생하기까지의평균기간은 2.3개월 ( 범위, 1-4개월 ) 이었다. C 반응성단백검사는평균 0.86 mg/dl ( 범위, mg/dl) (normal, mg/dl), 적혈구침강속도는평균 34 mm/hr ( 범위, mm/hr) (normal, 0-9 mm/hr) 이었다. 조직학적검사결과가나오기까지는평균 4.6일 ( 범위, 2-7 일 ) 이걸렸으며그결과 5명에서괴사가없는만성육아종성염증 (chronic granulomatous inflammation without necrosis), 3명에서섬유소성괴사를동반한만성육아종성염증 (chronic granulomatous inflammation with fibrinoid necrosis), 한명에서섬유화를동반한급성염증 (acute inflammation with fibrosis), 그리고한명에서급성, 만성염증 (acute and chronic inflammation) 이었다. 7명에서 tuberculosis-polymerase chain reaction (TB- PCR), 2명에서 TB/NTM-PCR 검사를시행하였고그결과는모두음성이었다. 항산균도말검사는모두시행되었으나한명에서만양성이었다. 10명에서모두비결핵항산균이배양이양성이었고배양결과가확인되기까지는평균 48.8일 ( 범위, 14-63일 ) 이걸렸다. 신속동정검사가모두시행되었으며 4명에서 M. intracellulare가 4명에서 M. marinum이한명에서 Fig. 2. Extensive debridement was performed. (A) The medical photograph shows infective tissue around the flexor tendon of the ring finger. (B) The infective tissue was massively removed preserving the A2 pulley. (C) Biopsy material was sent for histology and culture study

4 J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 Table 1. Clinical characteristics of ten cases Case Age (yr) Underlying Precipitating /sex disease factors Duration of symptoms (mo) Affected MRI/US Pathology Culture AFB PCR Medication/ Outcomes site finding TB/NTM duration (mo) 1 46/male None None 12 Ring finger, F. TS G/N: +/- M. intracellulare - -/- RFP+EMB+clari Healed Rt / /male None Excision of 24 Wrist~palm, F. TS G/N: +/- M. marinum - -/0 INH+EMB+CIPR Healed ganglion Rt / /male None Fishbone 8 Index finger, F. TS G/N: +/+ M. marinum - -/0 RFP+EMB+clari/ Healed Rt /female SLE None 12 Middle finger, Finger joint IA, G/N: +/+ M. intracellulare + -/0 RFP+EMB+clari Wound Rt OM, F. E. T /34 Revision 5 74/male None Steroid 3 Index finger, F. TS G/N: +/- M. marinum - -/0 RFP+EMB+clari Healed injection Lt / /male None Wire 2 Little finger, F. TS Acute, chronic M. abscessus - 0/0 Clari+amik+ Healed Rt Inflammation CIPR/5 7 77/male None CTR 36 Wrist joint, Wrist joint IA, G/N: +/+ M. marinum - -/0 RFP+EMB+clari Healed Rt OM, F. E. TS /9 8 66/male SLE CTR 7 Palm: 2-5th F. TS G/N: +/- M. intracellulare - -/0 EMB+clari+levo Healed fingers, Rt / /male None Acupuncture 2 Wrist joint, Wrist joint IA, Acute M. intracellulare - -/0 RFP+EMB+clari Wound Rt OM, F. E. TS inflammation /12 revision with N 10 41/female None Excision of 12 Wrist joint, E. TS G/N: +/- M. chelonae - -/- Clari+amik+moxi Healed ganglion Lt /12 MRI/US, magnetic resonance imaging/ultrasound; AFB, acid fast bacillus; PCR TB/NTM, polymerase chain reaction tuberculosis/nontuberculous mycobacteria; Rt, right; F., flexor; TS, tenosynovitis; G/N, chronic granulommatous inflammation/necrosis; RFP, Rifampin; EMB, ethambutol; clari, clarithromycin; INH, isoniazid; Lt, left; IA, infective arthritis; OM, osteomyelitis; E., extensor; CIPR, ciprobay; amik, amikacin; levo, levofloxacin; moxi, moxifloxacin; -, negative; +, positive; 0, was not performed

5 Ho Youn Park, et al. Diagnosis and Treatment for Deep Nontuberculous Mycobacteria Infection of the Hand and Wrist M. abscessus가, 그리고한명에서 M. chelonae가동정되었다. 만성육아종성염증으로확인된 8명에서경험적으로항결핵제제가균배양이전에투여되었고이후균동정및약감수성결과가나온이후감염내과협진하에그결과맞게약물을바꿔투여하였다 (Fig. 1). 수술후평균약물복용기간은평균 13.6개월 ( 범위, 5-34개월 ) 이었고한명의환자는 5개월만에자의로약물복용을중지하였다. 2명에서는약물의부작용으로 RFP에대해서설사증상을보여감염내과협진하에한명은 INH, EMB, ciprofloxacin을 13 개월, 한명은 EMB, clarithromycin, levofloxacin을 15개월동안투약하였다 (Table 1). 10명모두추적관찰을끝냈고 2명에서추적관찰기간중피부궤양이재발하여 2차수술을시행하였다. 2차수술후지속적인궤양을보인환자는없었으며추적관찰기간이끝난후모두임상적으로완치된소견을보였다. 수지의기능적결과는 2예에서 excellent, 4예에서 good, 1예에서 fair, 1예에서 poor 결과를보였다. 수근관절에감염성관절염및골수염을가지고있는 2명의환자의관절운동은각각배측굴곡 20, 20 수장측굴곡 0, 30 요측변위 0, 0 척측변위 10, 20 였다. 고찰 비결핵항산균감염의가장흔한형태는폐질환이지만수술적절개, 스테로이드등의주사치료, 자상등의외상으로인하여건강한사람에서의건초염, 감염성관절염, 골수염이점점증가하는추세이다. 하지만아직까지비결핵항산균감염을초기에발견하는것은쉽지않다 1,5. 그이유로는첫째로균의낮은병원성 (low virulence) 으로증상발생이느려서환자들이모르고지나치는경우가많고두번째로비결핵항산균의경험이많지않아오진되는경우도있으며마지막으로정확한진단검사방법이균을동정하기위해중요하나이를인지하지못하고있는경우가많이있기때문이다. 이연구에서도증상이발생하고치료를받기까지평균 8.9개월이소요되었다. 진단이지연되거나부적절한진단으로치료가늦어지면수부혹은수근부의기능적인손실을유발할수있기때문에비결핵항산균감염의예후를결정하는것은신속한진단및치료시작이다. 그러므로환자에게유발인자를자세히물어보고통상적인치료에잘반응하지않는경우의료진이비결핵항산균감염을의심하는것이중요하다. 정확한미생물학적검사가치료에중요한데가장적절한배양방법은통상적인항산균배양 (AFB culture) 이며 Mycobacterium haemophilum, M. marinum, Mycobacterium ulcerans 같은저온 (28-30 ) 에서자라는균도연부조직감염의원인균이될수있기때문에추가로검체를 30도에서초콜렛배지에배양시키는것이권유된다 8. 일반적으로비결핵항산균이배양이확인되면균동정이시행되어야하며신속동정방법이적절한치료를위해필요하다. 연부조직감염을일으키는흔한균주는 fortuitum, M. abscessus, M. chelonae, M. marinum, M. ulcerans 이다 1,9,10. 하지만비결핵항산균의모든균주가연부조직감염의원인이될수있다 9,11. 이연구에서는 4례에서 M. intracellulare가 4례에서 M marinum이 1예에서 M. abscessus가 1예에서 M. chelonae 가동정되었다. 심부연부조직, 힘줄, 관절그리고뼈의감염은수술적치료와약물치료가모두필요하며수술적변연절제술을통상적으로시행하게되는데내고정물이나피하카테터같은이물질이있는경우이를제거하는것이중요하다 1. 균에따른약물치료방법이많이소개되어져있으며그방법을정리하여표준화된치료방침을정하였다. M. intracellulare, M. marinum 같이서서히자라는비결핵항산균에는 RFP, EMB, clarithromycin이사용되어야하며 M. chelonae, M. abscessus, M. foruitum 같이빨리자라는균주에는 clarithromycin 같은경구 macrolide 제제와 amikacin 같은정맥주사제제가같이사용되어져야한다 본연구에서도 Table 1의 M. abscessus가자란 6번환자에서 amikacin을 2012년 5월 24 일부터 2012년 8월 2일까지사용하였으며 M. chelonae가자란 10번환자에서도 amikacin을 2013년 2월 22일부터 5월 14 일까지사용하였다. 2007년발표된치료지침에서도 2-4개월사용할것을권고하고있다 1. 치료가지연될수록균의과성장을유발하고흔하게많이사용되는 macrolide 나 quinolone 제제는비결핵항산균회복에악영향을끼칠수있기때문에가능하면항생제는진단과정중에는사용하지말아야한다. 이연구에서는조직검사결과가항산균으로인한염증을강하게시사하는만성육아종성염증으로확인되면 macrolide 나 quinolone 을포함하지않는항결핵제제를경험적으로투여하였다. 비결핵항산균폐감염에서는이런경험적인치료가효과적인것으로알려져있다 1. 저자들은연부조직이나골감염에도이점이비슷하게적용될것으로가정하여조직검사결과가확인되면배양결과가나올때까지이를사용하였다. 심부감염에서의약물치료의기간은 12-19개월정도로추천되고있다 1. 하지만자의로약물치료를중단한 2예에서도완전히회복된소견을보였다. 이는약물치료기간을정하기어렵다는것을시사하며또한수술적으로광범위하게병변을제거하는것이약물치료와함께 123

J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 중요하다고생각된다.

이연구에포함된환자는모두심부감염이었으며손가락관절과수근관절에골수염및관절염으로진단된 3예

This patient had taken steroids for a long period because of lupus disease.

(B) Postoperative X-ray shows massive removal of infective bone. Fig. 4.

6 J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 중요하다고생각된다. 비결핵항산균심부감염은유발인자, 환자의면역상태그리고천부감염의지속기간과관련이있기때문에면역이저하되고진단이지연되는것은심부감염을일으키는원인이 된다 5. 이연구에포함된환자는모두심부감염이었으며손가락관절과수근관절에골수염및관절염으로진단된 3예중심한관절파괴를보인 2예는루푸스로오랫동안스테로이드를복용중인환자였다 (Figs. 3, 4). 천부감염인경우약물치 Fig. 3. A 47-year-old patient with chronic infective arthritis and osteomyelitis combined with tenosynovitis of the finger joint. This patient had taken steroids for a long period because of lupus disease. (A) Preoperative X-rays shows severely destructed finger joint of the middle finger. (B) Postoperative X-ray shows massive removal of infective bone. Fig. 4. A 73-years-old patient with chronic infective arthritis and osteomyelitis combined with tenosynovitis of the wrist joint. This patient had taken steroids for a long period because of lupus disease. (A) Preoperative X-rays shows diffuse osteopenia and bony erosion at the wrist joint. (B) Magnetic resonance imaging shows synovial proliferation wrist joint, involvement of the flexor and extensor tendons, and carpal bone erosion. (C) Extensive debridement including synovectomy and Darrach operation was performed. Postoperative X-rays at the final follow-up shows decreased swelling and consolidation of the remaining carpal bones

7 Ho Youn Park, et al. Diagnosis and Treatment for Deep Nontuberculous Mycobacteria Infection of the Hand and Wrist 료에도반응을하나심부감염은수술적치료가꼭필요하다. 심하게파괴된관절및광범위한변연절제술은상처조직및관절구축을유발하여기능적인손실을보이게된다. 수근관절의감염을보인 2례는심한관절운동저하소견을보였으며손가락관절의심한관절파괴를보인한예에서 TAM 이 65 이하로 poor 한결과를보였다. 조기관절운동이기능적결과를호전시키지만감염을악화시키고상처치유가지연되거나지속적으로농루를형성하는등의문제가생길수있다 15. 그러므로수부의수술후적극적인관절운동은 7일에서 10일후에시작하는것이상처치유에도움이되는것으로되어있다 16. 저자들도수부건초염수술후일주일후부터가벼운압박드레싱으로교체하여적극적인수지관절운동을시작하였으며수근부의감염성관절염및골수염치료후에는반기브스고정을시행하였고수술후 2주째부터손목보호대보호하게관절운동을시작하였다. 이연구의제한점은후향적인관찰연구이며증례수가부족하여이논문에서제시한방법이일반화하기어렵다는것이다. 이는비정형항산균감염이증가하는추세이기는하지만아주흔한질병이아니기때문으로생각되며추후증례를더늘려나갈계획이다. 이논문의의의는심부감염에서수술과약물치료를어떻게병행하고술후관리를어떻게하는것이좋은가를제시한점이의미가있다고생각된다. 또한만성세균성감염인경우와결핵감염, 그리고비결핵항산균의임상적양상은비슷하기때문에임상적양상으로만감별을하는것은어려울것이다. 그러므로수술적치료시에흔히생각할수있는만성세균성감염, 결핵외의요즘증가추세에있지만간과하기쉬운비결핵항산균의가능성을배제하지말고이에대한수술검체를이용한검사가필요하겠다. 결론 수부및수근부의심부비결핵항산균의치료가지연되면기능적인손실을유발하게된다. 그러므로그치료결과를향상시키기위해서는위험요인이있는환자에있어서의료진의임상적인의심이조기발견을위해중요하고정확한미생물학적진단기술이요구된다. 저자들은이연구에서제시한진단및치료지침이수부및수근부의비결핵항상균심부감염치료에도움이될것으로생각된다. REFERENCES 1. Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 2007;175: von Reyn CF, Arbeit RD, Horsburgh CR, et al. Sources of disseminated Mycobacterium avium infection in AIDS. J Infect. 2002;44: Yoon HJ, Kwon JW, Yoon YC, Choi SH. Nontuberculous mycobacterial tenosynovitis in the hand: two case reports with the MR imaging findings. Korean J Radiol. 2011;12: Mazis GA, Sakellariou VI, Kontos F, Zerva L, Spyridonos SG. Recurrent fluctuant mass of the wrist and forearm associated with chronic tenosynovitis by Mycobacterium kansasii. Orthopedics. 2011;34: Lee WJ, Kang SM, Sung H, et al. Non-tuberculous mycobacterial infections of the skin: a retrospective study of 29 cases. J Dermatol. 2010;37: Woods GL; Clinical and Laboratory Standards Institute. Susceptibility testing of mycobacteria, nocardiae and other aerobic actinomycetes tmvpdltm tkrwp: approved standard. Wayne, PA: Clinical and Laboratory Standards Institute; Strickland JW, Glogovac SV. Digital function following flexor tendon repair in Zone II: A comparison of immobilization and controlled passive motion techniques. J Hand Surg Am. 1980;5: Mazon A, Gil-Setas A, Alfaro J, Idigoras P. Diagnosis of tuberculous arthritis from the isolation of Mycobacterium tuberculosis in blood agar and chocolate agar. Enferm Infecc Microbiol Clin. 2000;18: Wolinsky E. Nontuberculous mycobacteria and associated diseases. Am Rev Respir Dis. 1979;119: Wallace RJ Jr, Swenson JM, Silcox VA, Good RC, Tschen JA, Stone MS. Spectrum of disease due to rapidly growing mycobacteria. Rev Infect Dis. 1983;5: Falkinham JO 3rd. Epidemiology of infection by nontuberculous mycobacteria. Clin Microbiol Rev. 1996;9: Wallace RJ Jr, Swenson JM, Silcox VA, Bullen MG. Treatment of nonpulmonary infections due to Mycobacterium fortuitum and Mycobacterium chelonei on the basis of in vitro susceptibilities. J Infect Dis. 1985; 152: Wolinsky E, Gomez F, Zimpfer F. Sporotrichoid Mycobacterium marinum infection treated with rifampin-ethambutol. Am Rev Respir Dis. 1972;105:

8 J Korean Soc Surg Hand Vol. 20, No. 3, September Aubry A, Chosidow O, Caumes E, Robert J, Cambau E. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates. Arch Intern Med. 2002;162: Cheung JP, Fung B, Wong SS, Ip WY. Review article: Mycobacterium marinum infection of the hand and wrist. J Orthop Surg (Hong Kong). 2010;18: Chow SP, Stroebel AB, Lau JH, Collins RJ. Mycobacterium marinum infection of the hand involving deep structures. J Hand Surg Am. 1983;8: 수부및수근부의비결핵항산균심부감염의진단및치료 박호연 1 윤준오 2 박진웅 2 윤재연 2 김진삼 2 1 가톨릭대학교의정부성모병원정형외과교실, 2 울산대학교의과대학서울아산병원정형외과교실 목적 : 더나은임상결과를위한수부및수근부의비결핵항산균심부감염의진단과치료방법을정리하여그지침을제시하고자하였다. 방법 : 수부및수근부의비결핵항산균심부감염환자 10명을대상으로광범위변연절제술을시행하였고조직검사가항산균을인한감염을시사하면경험적으로항결핵제를투여하였다. 이후균배양이확인되면신속균동정및약물감수성검사를시행하고그에맞는약물치료를시행하였다. 수지의기능적결과는 total active motion 으로평가하였고수근관절은관절운동각도로평가하였다. 결과 : 7명이수부및수근부의건초염 3명이감염성관절염및골수염으로진단되었다. 추적관찰기간중 2명의환자에서피부궤양이재발하여 2차수술을시행하였고이후재발소견보이지않아모두임상적으로치유된소견을보였다. 수지의기능적결과는 2예에서 excellent, 4예에서 good, 1예에서 fair, 1예에서 poor, 평균수근관절운동은 2명에서배측굴곡 20, 수장측굴곡 15, 요측변위0, 척측변위15 였다. 결론 : 이연구에서제시한진단및치료지침이수부및수근부의비결핵항상균심부감염치료에도움이될것으로생각된다. 색인단어 : 수부및수근부, 비결핵항산균감염, 진단및치료지침 접수일 2015 년 6 월 11 일수정일 1 차 : 2015 년 8 월 14 일, 2 차 : 2015 년 8 월 27 일게재확정일 2015 년 8 월 27 일교신저자김진삼서울송파구올림픽로 43 길 88 울산대학교의과대학서울아산병원정형외과학교실 TEL FAX micro@amc.seoul.kr 126

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical