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Weekly Chest CasesArchive of Old Cases

Case No : 969 Date 2016-05-23

  • Courtesy of H Kang, SK Park / Kosin University Gospel Hospital
  • Age/Sex 31 / M
  • Chief ComplaintLeft anterior chest pain with palpable mass
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Tuberculous osteomyelitis in left clavicle
Radiologic Findings
Chest CT images show a well-defined osteolytic lesion with cortical destruction and soft tissue mass formation in the medial end of the left clavicle, which shows soft tissue mass formation extending to the anterior chest wall (Fig 2a-b). MR images show a well- defined irregular shaped abscess lesion with extension to the subcutaneous area. The lesion is which shows relatively low signal intensity (SI) in the central portion on both T1- and T2-weighted images (WI), with a smooth, thin rim showingand rim of high SI on T2-WI (Fig 3a), slightly high SI on T1-WI (Fig 3b), and diffuse enhancementweighted image (WI) (Fig 3a) and rim of mildly increased SI on T1WI (Fig3b). This lesion has thin and smooth wall with increased enhancement on contrast enhancement T1-WIGd-T1WI (Fig 3c).
The Eexcisional biopsy in theof the lesion was performed, and the pathological analysis left clavicle revealed chronic granulomatous inflammation with necrosis and positive for tuberculosis in nested PCR.
Brief Review
Extrapulmonary tuberculosis presenting with skeletal involvement accounts for 1 to 4% of all patients with tuberculosis. Osteoarticular tuberculosis is almost always secondary to a primary focus elsewhere in the body, and an definite attempt should be made to examinescreening the pulmonary, GI tract, and renal systems for evidence of disease. Most of the cases with skeletal involvement are in the spine, and involvement of the appendicular skeleton is unusual. Tubercular involvement of the clavicle is extremely rare. The lesions may be destructive or proliferative (spina ventosa). In tuberculosis of the clavicle, plain radiographs may show diffuse thickening and honeycombing, or multiple cystic cavities, or sequestration, similar to pyogenic osteomyelitis. It can resemble a neoplastic process with expansile or destructive features radiological picture on radiographs, often requiringhence a biopsy may be necessary to confirm the diagnosis. On CT, destructive changes are better appreciated, particularly in the bone window setting. MR imaging can help in the early detection and better delineation of the extent of tuberculous ostomyelitis. Tubercular granulomas show low to intermediate signal intensity on T2-weighted images, due to the presence of central caseating necrosis. Lesions with a rim of mildly high signal intensity on T1-weighted images, a non-specific indicator of an infective process, may also be seen.
References
1. AN Aggarwal, IK Dhammi, AP Singh, Skumar, MK Goyal Tubercular osteomyelitis of the clavicle: a report of four cases Journal of orthopaedic surgery 20016;17(1):123
2. PL Basanagoudar, PN Gupta, R Bahadur, MS Dhillon Tuberculosis of the clavicle presenting as an extpansile lytic lesion: a case report Acta Orthopaedica Belgica 2001;67(5):505
3. P Sharma MR features of tuberculous osteomyelitis Skeletal Rariol 2013;32:279

Keywords
Chest wall, Infection, Bacterial infection, Tuberculosis,

No. of Applicants : 87

▶ Correct Answer : 40/87,  46.0%
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
  • - Saitama-Sekishinkai Hosptal , Japan Mihoko Yamazaki
  • - Otsu Municipal Hospital , Japan Noriatsu Ichiba
  • - Osaka Rosai Hospital , Japan Hiromitsu Sumikawa
  • - Kinki University Faculty of Medicine, , Japan Mitsuru Matsuki
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Niigata University , Japan Atsushi Uehara
  • - The University of Tokyo Hospital , Japan Akifumi Hagiwara
  • - University of Tsukuba Hospital , Japan Shioto Oda
  • - Nihon University Itabashi Hospital , Japan Yusuke Watanabe
  • - Policlinico Umberto I , Italy Paolo Baldassari
  • - DRRPGMC KANGRA AT TANDA , India Dinesh Sood
  • - Asan Medical Center , Korea (South) Hyung Jung Koo
  • - The first affiliated Hospital of Xiamen University , China Qing Qiang Guo
  • - The University of Tokyo Hospital , Japan Toshihiro Furuta
  • - Dong-A University Hospital , Korea (South) Ji-yeon Han
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Chonnam National University Hospital , Korea (South) So yeon Ki
  • - Chungbuk national university , Korea (South) Yong Kim
  • - Medicheck health care , Korea (South) Chae Lim
  • - Kyung Hee University Hospital at Gangdong , Korea (South) Han Na Lee
  • - kangbuk samsung , Korea (South) jihyun kim
  • - Okayama University Hospital , Japan Toshiyuki Komaki
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - University of Tsukuba, Dept of Radiology , Japan Manabu Minami
  • - Himeji Red Cross Hospital , Japan Mayu Uka
  • - Kyungpook national university hospital, Korea , Korea (South) Sung Jun Moon
  • - Samsung Medical Center , Korea (South) Boda Nam
  • - Chungbuk national university hospital , Korea (South) Miran Yeon
  • - Seoul national university hospital , Korea (South) Kumju Chae
  • - Kanto Rosai Hospital , Japan Taku Tajima
  • - DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
  • - Daejin Medical Center Bundang Jesaeng General Hospital , Korea (South) Donghwan Kim
  • - Fortis hospital , Mohali , India Shaleen Rana
  • - The University of Tokyo Hospital , Japan Kaoru Sumida
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - University of Tsukuba , Japan Toshitaka Ishiguro
  • - Kyoto University , Japan Akihiko Sakata
  • - the first affiliatited hospital of nanjing medical univercity , China Hai Xu
  • - chungbuk university hospital , Korea (South) Hyeonmi Ryu
▶ Correct Answer as Differential Diagnosis : 13/87,  14.9%
  • - Northern Yokohama Showa university , Japan Kota Watanabe
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Shiga University of Medical Science , Japan Akitoshi Inoue
  • - Eren Hastanesi Istanbul , Turkey Armagan Sarac
  • - NIMS, HYDERABAD , India bhaskar kakarla
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Avrasya Hospital , Turkey Murat Ulusoy
  • - GHICL , France manuel toledano
  • - ICD,MCH CALICUT , India rikhy krishnan
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
  • - Private sector , Greece Vasilios Tzilas
▶ Semi-Correct Answer : 8/87,  9.2%
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - PRINCE ALI KHAN HOSPITAL , India FAHAD LODHIA
  • - �stanbul , Turkey Ayhan Yilmaz
  • - Department of Radiology, Seoul National University Bundang Hospital , Korea (South) Sung Hyun Yoon
  • - Narayana Multispeciality Hospital Jaipur Raj , India JAINENDRA JAIN
  • - Centre Imagerie de Fribourg , Switzerland Benoit RIZK
  • - Maternity & child hospital , Saudi Arabia Sania ALBlushi
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia Yuranga Weerakkody
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