Title : Tuberculosis mimicking as clavicular malignancy " Primary Tuberculosis of the Clavicle"
Abstract:
INTRODUCTION:
Osteoarticular Tuberculosis involves 2-5% of all tubercular lesions in the body in which 50% affect spine. Tuberculosis of sternoclavicular region accounts for 1-2%. Primary tuberculosis of clavicle without involvement of adjacent joint is <1% . osteomyelitis of clavicle is a rare form of infection occurring from hematogenous spread or trauma. Incidence of clavicle osteomyelitis accounts for <3% of all osteomyelitis Therefore,early recognization of osteomyelitis and establishing cause will reduce unnecessary and invasive investigations or therapeutic procedures. Diagnosis by clinical, radiological, pathological and microbiological confirmation of clavicular swelling should be done at a initial presentation and appropriate treatment to be started as early as possible to improve the outcome and prevent complications.
CASE REPORT:
A 55year old Asian male presented with complaints of swelling over the left clavicle for 1month gradually progressive in size associated with pain over swelling and associated with history of decreased range of movement of left shoulder. There is no history of fever,weight loss, loss of appetite. No history of any associated respiratory complaints. No history of trauma, prior tuberculosis and antitubercular therapy in past. Patient had many consultation for above complaint diagnosed as fracture clavicle and conservatively managed at a regional local health center. But symptoms progressive in nature and patient presented at our hospital for further workup. Nil comorbidities. on examination, swelling of size 5*5*2cm over medial end of clavicle , firm to hard in consistency, notwarmth, tenderness and bony crepitus present.
On evaluation , base line blood investigation within normal limits, chest xray aand xray left shoulder showed expansile cystic lytic lesion over the medial end of clavicle with fracture of medial 1/3rd clavicle, no active pleuroparenchymal lesion. CT shoulder showed cystic lytic lesion of 5*5.5cm with communited fracture over medial end of clavicle with surrounding periosteal thickening and old healed fracture of middle and lateral 1/3 clavicle. With normal adjacent joint. High frequency ultrasound of left clavicle showed hypoechoiec collection measuring 3.3*1.5cm in subcutaneous plane extending into intramuscular plane with air pockets with possibility of abscess. FNAC of swelling done 1.5ml thick pus aspirated and analysed . which showed granulomatous lesion composed of epitheloid cells, multinucleate giant cells with lymphocytic background with few neutrophils with features of caseous necrosis. CBNAAT showed Mycobacterium tuberculosis detected low with rifampicin sensitive. Diagnosis of Primary Tuberculosis of Clavicle made and patient started on Antitubercular therapy and patient tolerating antitubercular therapy and showed improvement and patient on regular followup.
DISCUSSION :
Clavicular tuberculosis Is less common than other skeletal tuberculosis. Tuberculosis of clavicle can involve any site, with most common is noted in medial 1/3rd of clavicle. Adjacent joint involvement can be seen and is associated with pain without significant bone destruction, which may later present with cold abscess, discharging sinuses and non healing ulcers. Radiologically either destructive or proliferative and pathological fractures may be seen. Diagnosis based on plain radiography is challenging due to overlapping of anatomical structure. CT and MRI provide better diagnosis and confirmed by histopathological and microbiological confirmation with bony tissue specimen obtained by FNAC(fine needle aspiration cytology),core biopsy and curettage. The mainstay of treatment is antitubercular therapy. In case of non responsive or poorly responding individual surgical treatment combined with antitubercular therapy to be given. Clavicular Tuberculosis should be considered as an important differential for chronic swelling or non traumatic lesion of clavicle.
