Swelling Of Sternoclavicular Joint Research Articles

An unusual site of articular tuberculosis–A series of three conservatively managed cases

Tuberculosis (TB) infection of the Sternoclavicular joint (SCJ) is a rare entity, with 1–2% of all osteo-articular cases reported. We report a series of three cases of TB of the SCJ, in the patients presented with swelling of SCJ. Cytology showed chronic granulomatous pathology in all three cases, with one patient having Cartridge base nucleic acid amplification test positive for TB and another one having acid fast bacilli positive on Ziehl Neelsen staining. All three were put on antitubercular treatment (ATT) that resulted in significant improvement. A high index of suspicion of TB to be maintained in cases with swellings at unusual sites especially in high burden countries like India. Similarly, gradually progressive osteoarticular swellings without systemic features should also raise suspicion of tubercular etiology, as diagnosis was delayed for about 4 months in two of our cases and about 1 year in the third case. The application of newer technologies such as CBNAAT can help in early microbiological confirmation of paucibacillary disease leading to early diagnosis and prevention of possible complications.

DLBCL of Clavicle: Role of FNA in diagnosis of Rare Lesion

Primary bone lymphoma is rare, among which commonly involved site at time of presentation are femur, pelvic bones, tibia and most common type is Large B cell lymphoma which usually occurs in adults. Cases of large B cell lymphoma in clavicle as primary bone lymphoma is extremely rare finding. According to our knowledge this case may be first reported case of world. We are here reporting a case of 62-year female presented as sternoclavicular joint swelling, without fever or pain in local area. Patient was diagnosed on X ray by radiologist, as well as by clinician as, osteosarcoma of right clavicle. Patient came to Department of Cytopathology for FNA for confirmation of X ray finding. On FNA diagnosis of Non-Hodgkin lymphoma was given, and advise for biopsy and immunohistochemistry (IHC) was given for confirmation of diagnosis and to subtype NHL. On IHC Ki67 index was 85%, with diffuse positivity noted for MUM1, CD79a, and CD138 along with cytoplasmic positivity for ALK 1 and patchy positivity for PAX 5. Tumor was negative for BCL6, BCL2, CD20, CD5, CD23, CD10, CD19, CD4, CD8, CD7, CD3. Diagnosis of ALK positive DLBCL was given on biopsy after IHC. Patients with PBL treated with combined modality were found to have a superior outcome, with a significantly better survival (5-year cause-specific survival 95%). So correct and timely pathological diagnosis of DLBCL as PBL is significantly important for prognosis.

Sternoclavicular Arthritis as a Clinical Presentation for Lyme Disease

Lyme disease is caused by Borrelia burgdorferi and can lead to dermatologic, neurologic, cardiac, and musculoskeletal manifestations. The arthritis of Lyme disease is typically monoarticular, with the knee being most commonly involved. Lyme arthritis of small joints has not previously been well described. We report 3 children who presented with sternoclavicular joint swelling and who were found to have Lyme disease based on enzyme-linked immunosorbent assay and Western blot. This description of sternoclavicular Lyme arthritis highlights the importance of considering Lyme disease in the differential and diagnostic workup of new onset, small joint arthritis in patients presenting from or with travel to Lyme endemic regions.

Unilateral sternocostoclavicular hyperostosis in a patient with ankylosing spondylitis: A case report with color Doppler ultrasonogram findings

Sternocostoclavicular hyperostosis is a chronic inflammatory disorder affecting the sternoclavicular joint and upper ribs. There is a strong association with seronegative spondyloarthropathy in which bilateral involvement is common. Ultrasonography and Color Doppler findings of this entity have not been described previously, to the best of our knowledge. We describe the findings in a patient of ankylosing spondylitis who was referred for unilateral sternoclavicular joint swelling.

Quiz: Sternoclavicular Joint Swelling in a Previously Healthy Adult

A 77-year-old woman was admitted to our department because of 30-day history of low grade fever (up to 38.5°C) and pain in the left sternoclavicular joint. Twenty days before admission a progressively worsening swelling of the area occurred. She did not report any trauma and apart from low grade fever, the patient had also general symptoms such as loss of appetite, weakness and malaise. Her past medical history revealed only mild arterial hypertension. The patient had never received any kind of immunosuppression in the past whereas, there was no history of tuberculosis, diabetes mellitus, iv drug abuse, immune dysfunction or other known risk factors which have been associated with the presence of sternoclavicular joint infection (SCJI) [1]. She had been treated previously by her own general practitioner for 10 days before admission with oral beta-lactam antibiotic and cephalosporin without any improvement. On admission, physical examination revealed a dolorous, inflammatory lesion of the left sternoclavicular joint (Figure 1) and movement limitation of the left arm, whereas there was no ascites or peripheral lymphadenopathy. Laboratory work-up showed only moderate elevation of CRP (5.7 mg/dL; upper normal limit < 1 mg/dL), increased erythrocyte sedimentation rate (ESR; 66 mm/1h), positive tuberculin test (20 mm) while chest x-ray was normal. MRI of the area showed mild osteomyelitis of the clavicle and cellulitis of the surrounding tissues with no effusion at SCJ. The CT scans of the thorax, upper and lower abdomen and retroperitoneal space revealed no lymphadenopathy or pulmonary lesions. After drawing several sets of blood cultures, treatment with daptomycin was started at a dose of 8 mg/kg/day. We chose daptomycin as unfortunately in our area the rates of communityand hospital-associated methicillin resistant Staphylococcus aureus (MRSA) infections have been increased from 14.5% in 2000 up to 40-50% in 2006 and 65% in 2007-2009 [2,3]. Therefore, in our practice we usually manage severe infections of soft tissues, bone or spine initially with vancomycin, teicoplanin or daptomycin until a positive culture with sensitivity tests was obtained [4].

Tuberculosis of the sternoclavicular joint

Tuberculosis is seen in every part of the body, but sternoclavicular joint tuberculosis is rare. We report a case of tuberculosis of the sternoclavicular joint in 70-year-old woman having complained of the right sternoclavicular joint swelling. She had a previous history of pulmonary tuberculosis, and visited her doctor for right sternoclavicular joint swelling on February 2006. A chest CT scan showed a low density area with destructive osseous changes in the right sternoclavicular joint. Definite diagnosis could not be done by twice needle biopsy, but we diagnosed her as tuberculosis of the sternoclavicular joint based on the clinical course and the findings of the examination. As her condition did not improve after 3 months treatment with anti-tuberculous drugs, we conducted therapeutic surgical procedure. Definite diagnosis of sternoclavicular joint tuberculosis was made on the basis of the presence of mycobacteria in the histological specimen and PCR-TB positive result. We kept the wound opened and continued administration of anti-tuberculous drugs, and her condition does not deteriorate. Tuberculosis should be considered in case of a patient with arthritis and previous history of tuberculosis, even if it is seen in rare location. Diagnostic and therapeutic surgical procedure should be taken into consideration, if there is no improvement of the condition after a diagnosis of bone and joint tuberculosis, and the administration of chemotherapy for tuberculosis.

A Case ofEscherichia ColiSternoclavicular Septic Arthritis

Septic arthritis of the sternoclavicular joint is a rare condition. The predisposing risk factors include intravenous drug abuse, subclavian vein catheter placement, diabetes mellitus and trauma. Delayed or inadequate management can lead to irreversible joint damage with subsequent disability, even death. We report a 48-year-old female patient who presented with right sternoclavicular joint swelling and right shoulder pain. Magnetic resonance imaging of the sternum showed swelling of the right sternoclavicular joint with gadolinium enhancement. Synovial fluid and bone tissue culture revealed Escherichia coli (E.coli), and confirmed the diagnosis of sternoclavicular septic arthritis. She was successfully treated with surgical debridement and ciprofloxacin without recurrence. This is the first case report of E.coli sternoclavicular septic arthritis in Korea.