Abstract
Septic arthritis of sternoclavicular joint (SCJ) is a rare disease, however, not uncommon in patients who abuse intravenous drugs. It can present with a wide range of manifestations that can pose diagnostic challenges, which can result in a delay in diagnosis and treatment. Over the last few decades, there is a surge in the use of nonprescription recombinant human growth hormone (rhGH) by the young healthy population and athletes for its purported ergogenic effects. Furthermore, we lack quantitative information about the adverse effects of the chronic use of rhGH in a healthy population due to the scarcity of epidemiological data. We are reporting a case of a young male athlete who was chronically using the subcutaneous rhGH formulation to build lean body mass, and presented with septic arthritis of right SCJ due to methicillin-sensitive Staphylococcus aureus (MSSA) complicated by a necrotic inflammatory response involving the mediastinum which infiltrated the apical lung parenchyma. The clinical presentation masqueraded as the mediastinal mass raising the suspicion of mediastinal malignancy. Histological analysis of the tissue of SCJ and mediastinal area revealed no malignant cells but a lymphocyte-predominant inflammatory response with germinal centers was observed, which was an atypical response to MSSA bacterial infection. We have reviewed the literature to elucidate the immune-modulatory effect of rhGH, as the chronic use of rhGH by our patient probably has contributed to an atypical immune response to MSSA. The patient was treated with an extended duration of parenteral antibiotics and multiple incision and debridements to achieve complete resolution of infection over the next six months. This is a unique case of septic arthritis of right SCJ in a patient on chronic subcutaneous rhGH which masqueraded as a mediastinal mass raising concern of malignancy; moreover, it highlights the probable immune-modulatory role of rhGH which instigated an atypical immune response to MSSA infection.
Highlights
According to a survey conducted to estimate the prevalence of use of ergonomic aids among the athletes, 5% of recreational athletes reported the use of growth hormone (GH) intending to increase the lean body mass and strength [1]
We report a case of septic arthritis of the sternoclavicular joint (SCJ) in a patient using nonprescription recombinant human growth hormone (rhGH) supplement, who presented with an anterior mediastinal mass mimicking a mediastinal neoplastic process
We have reported a case of young athletic male abusing subcutaneous rhGH who presented with complicated SCJ septic arthritis secondary to methicillin-sensitive Staphylococcus aureus (MSSA) infection with an insidious clinical course
Summary
According to a survey conducted to estimate the prevalence of use of ergonomic aids among the athletes, 5% of recreational athletes reported the use of growth hormone (GH) intending to increase the lean body mass and strength [1]. A growing mass on the right side of the chest wall with focal neurological deficit i.e., weakness of right arm abduction and weak right hand-grip, associated with X-ray findings suspicious of a malignant lesion in the paratracheal area, prompted a CT scan of the chest with contrast that revealed a 2.2 cm x 2.6 cm x 2.9 cm anterior mediastinal mass in the superior-medial aspect of mediastinum invading the lung and the pleural cavity, and it involved the right SCJ and manubrium sterni (see Figure 2). MRI of the right neck and SCJ with (see Figure 3) and without contrast were performed that revealed inflammation of the right SCJ extending from the soft tissue at the base of the neck to the anterior superior mediastinum. Follow-up MRI of the right SCJ with contrast demonstrated old postsurgical changes in the SCJ and surrounding tissues but no significant contrast enhancement is visualized which endorsed the resolution of the infectious process
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