Clinical microbiological case: a firm, right infraclavicular mass in an adult woman with connective tissue disease

Abstract

A 34-year-old non-pregnant female was admitted to our hospital for evaluation of fever, malaise, and a painful mass on the right chest wall, which had first appeared 10 days previously. She denied any local injury, trauma, injection, skin abrasion or infection in her right arm. Her symptoms did not respond to treatment with oral cloxacillin (500mg four times daily for 3 days). She had been diagnosed a year previously with undifferentiated connective tissue disease (UCTD), and did not currently require therapy. Physical examination showed a febrile female in no apparent distress. A firm, tender, non-fluctuant mass was observed under the pectoralis muscle in the right anterior infraclavicular area. The overlying skin was warm but without signs of cellulitis (Figure 1). A chest X-ray revealed a minimal right pleural effusion, not present a year earlier, which was thought to be a reaction to the chest wall process. The evaluation of the mass included a contrastenhanced CT scan (Figure 2). An ultrasonographyguided fine-needle aspiration of the soft tissue tumor yielded blood-stained fluid, and microscopy showed an acute inflammatory infiltrate with some lymphocytes but no malignant cells. A Gram stain of the material did not reveal microorganisms, but b-hemolytic grayish colonies (2–3mm in diameter) grew on sheep’s blood agar culture 24 h later (Figure 3). Three blood cultures, one urine culture and one vaginal culture were all unrevealing.