Appearances are Deceptive: Staphylococcus Superinfection of Clavicular Tuberculous Osteomyelitis.

A man, aged 25 years, presented with pain, swelling, and drainage from the right clavicular area. He had a past history of abscess at the sternoclavicular joint. The cultures from the drainage site grew methicillin-sensitive Staphylococcus aureus, and he was placed on appropriate antibiotics. As S. aureus infection of the clavicle is often secondary in nature, particularly in adults, a thorough workup was done to identify the underlying cause. Quantiferon gold, done as a part of the workup, came back positive, while the bone cultures grew S. aureus and Mycobacterium tuberculosis. He was placed on 9 months of combination therapy for tuberculosis osteomyelitis with a good clinical outcome.

Delayed Diagnosis of Pediatric Sternoclavicular Joint Infections and Clavicular Osteomyelitis During the COVID-19 Pandemic: A Report of 3 Cases.

Sternoclavicular joint infections and osteomyelitis of the clavicle are extremely rare infections, especially in the pediatric population. Early signs of these infections are nonspecific and can be mistaken for common upper respiratory infections such as COVID-19 and influenza. Rapid diagnosis and treatment are critical for preventing potentially fatal complications such as mediastinitis. We present three cases of sternoclavicular joint infections in the past year during the COVID-19 pandemic. All three patients had delayed diagnoses likely secondary to COVID-19 workup. Each patient underwent surgical irrigation and débridement. Two of three patients required multiple surgeries and prolonged antibiotic courses. Placement of antibiotic-impregnated calcium sulfate beads into the surgical site cleared the infection in all cases where they were used. All three patients made a full recovery; however, the severity of their situations should not be overlooked. Children presenting to the hospital with chest pain, fever, and shortness of breath should not simply be discharged based on a negative COVID-19 test or other viral assays. A higher index of suspicion for bacterial infections such as clavicular osteomyelitis is important. Close attention must be placed on the physical examination to locate potential areas of concentrated pain, erythema, or swelling to prompt advanced imaging if necessary.

Anaerobic clavicular osteomyelitis following colonoscopy in a hemodialysis patient.

Patients on dialysis are immunocompromised and are therefore susceptible to both common and unusual infectious complications. These infections are often related to their dialysis access but even routine diagnostic tests unrelated to dialysis can also lead to rare adverse events. We present an unusual case of clavicular osteomyelitis from Bacteroides fragilis in a patient on maintenance hemodialysis following colonoscopy. The risk factors for this unusual site of infection, the incidence and guidelines for prophylactic antibiotic administration are discussed here.

Multifocal tuberculosis revealed by multiple cutaneous gummas in the immunocompetent.

Cutaneous tuberculosis is rare. Its occurrence in multifocal tuberculosis (MT) is uncommon and happens frequently in the context of immunosuppression. We report the case of MT with multiple cutaneous gummas and bone and lung involvement that occurred in an apparently immunocompetent patient.

Clavicular tuberculosis following trivial trauma.

Tuberculosis of the clavicular bone is a very rare clinical entity, with limited cases reported in the United States. Furthermore, sparing of the sternoclavicular joint is exceedingly unusual. A literature review of the prevalence of clavicular tuberculosis identified fewer than 80 cases reported since the discovery of the tubercular bacillus, over a century ago. To our knowledge, there have been no cases reported over the last decade in the United States. A rare case of tuberculous osteomyelitis of the clavicle in an immunocompetent patient who presented with swelling of the upper chest is reported.

Nonunion After Clavicle Osteosynthesis: High Incidence of Propionibacterium acnes.

OBJECTIVE: The objective of this study was to review the etiology of clavicle nonunions after osteosynthesis and investigate the outcomes of a treatment with a single-stage revision. DESIGN: Retrospective case series. SETTING: Orthopaedic specialty hospital. PATIENTS: Twenty cases of nonunion after osteosynthesis of the clavicle were identified. The average age was 44 years (±13 years). In 9 cases, there was catastrophic implant failure that prompted the revision surgery. In the 18 cases in which cultures were taken, 15 of the 18 (83%) were treated as infections with a course of antibiotics. In 14 cases, the cultures were positive for Propionibacterium acnes. RESULTS: Fifteen patients were treated with a prolonged course of antibiotics. Eighteen patients had follow-up, and the average time to radiographic union was 22 weeks. There were no cases of nonunion after revision surgery. CONCLUSIONS: There is a high rate of positive cultures in cases of nonunion after osteosynthesis of the clavicle. This suggests the etiology of midshaft clavicle nonunions may result from a combination of suboptimal mechanical fixation and latent infection. Our treatment protocol of superior and anterior plating, interfragmentary fixation, bone grafting, and appropriate antimicrobial treatment of latent infections has resulted in 100% union rate. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Primitive sternoclavicular septic arthritis]. / Arthrite septique sternoclaviculaire primitive.

INTRODUCTION: Sternoclavicular infections are unusual, and it even more unusual for infection to occur here as a primary site. CASE REPORT: We report the case of a 53-year-old patient with no prior medical history or risk factor who consulted because of sternal swelling of inflammatory character. CT-scan, bacteriological and histological analysis of samples concluded the diagnosis of primary sternoclavicular staphylococcal septic arthritis. Management consisted of antibiotics and was associated with a flattening of the lesion. The outcome at 6 months was favorable. CONCLUSION: Sternoclavicular infections should be evoked early in the course of sternoclavicular pain in order to avoid any locoregional complications and mostly mediastinitis.

The role of surgery in primary osteomyelitis of the chest wall.

Seven patients with primary osteomyelitis of the chest wall are described. All patients presented with pain at the site of infection, and four patients had a tumor-like mass that could easily be confused with a neoplastic process. All were heroin addicted and pseudomonas was the most common organism cultured. Conservative management with antibiotics for a minimum of 4 weeks is recommended with operation assuming a secondary role, namely, to assist in the initial diagnosis or in the form of limited resection of residual sinuses. Primary wide resection is discouraged.

False positive indium-111 white blood cell scan in a closed clavicle fracture.

Aggressive treatment of the multiply injured patient often requires early fixation of many fractures, some of which may be open. Often, patients develop postoperative fevers requiring a thorough workup to rule out infection. Recently, indium-111 white blood cell (WBC) imaging has become a valuable adjunct in the diagnosis of acute infection. The patient described had a simple, closed clavicle fracture with markedly increased activity on an indium-111 WBC scan obtained for fever workup. This subsequently proved to be a normal, healing, noninfected fracture by other diagnostic techniques. Noninfected, simple closed fractures should be added to the list of causes for a false-positive indium-111 WBC scan.

Salmonella sternoclavicular osteomyelitis in a patient with Crohn's disease.

We describe a 73-year-old man with Crohn's disease and previous sternotomies, who developed Salmonella sternoclavicular osteomyelitis subsequent to a Salmonella enteritidis sepsis and closed fracture of his clavicle. We include evidence from several cases related to sternoclavicular osteomyelitis, and Salmonella osteomyelitis. We continue by summarising the aetologies of these diseases, and risk factors that predispose to them.

Coccidioidomycosis masquerading as malignancy.

Skeletal coccidioidomycosis is extremely rare and in the non-endemic areas, diagnosis is often delayed or missed resulting in extensive and unnecessary medical investigation for other diseases. The authors report a case of disseminated skeletal coccidioidomycosis in a previously healthy person living in a non-endemic area, who was initially thought to have a malignancy. Due to the presence of multiple expansile lytic bone lesions on x-rays and CT scan, an extensive investigation for malignancy was done. Diagnosis of coccidioidomycosis was made when H&E and Gomori's methenamine silver staining of a bone biopsy sample revealed multiple fungal spherules, which were confirmed to be Coccidioides immitis by culture and PCR. On questioning, the patient admitted to have spent 2 weeks in Arizona (an endemic area) few months ago. He was discharged home on long-term fluconazole. At 1 month clinical follow-up, a significant improvement in his lesions was noticed.

Clavicular osteomyelitis: a rare complication of head and neck cancer surgery.

BACKGROUND: We report the 10th case in the English-language literature describing clavicular osteomyelitis that presented after radical treatment for laryngeal carcinoma and discuss the pertinent diagnostic and therapeutic measures. It presented a diagnostic dilemma. The differential diagnosis included tumor recurrence, metastatic bone disease, and postradiotherapy complications. METHODS AND RESULTS: A 45-year-old man who was a heavy smoker and known drug abuser presented with acute airway compromise and was diagnosed with squamous cell carcinoma involving the glottis and subglottis. Total laryngectomy, total thyroidectomy, and bilateral neck dissection were performed, and the patient underwent chemoradiotherapy. On follow-up 1 year later, the patient was seen with left stomal dehiscence and a large area of cellulitis extending across the left clavicle and down to the axilla. At surgery, a large anterior chest wall abscess was found. Biopsy showed no evidence of tumor. After aggressive treatment, the patient remains disease free. CONCLUSIONS: This condition is rarely encountered after major head and neck surgery. Aggressive surgical debridement and antibiotic therapy remains the mainstay of treatment. Prompt diagnosis and treatment are mandatory due to the potential life-threatening complications associated with the condition. Bony resection will aid in adequate flap placement.

Osteomyelitis of the clavicle: clinical, radiologic, and bacteriologic findings in ten patients.

Most lesions of the clavicle are traumatic and pose few diagnostic difficulties. Nontraumatic clavicular lesions, on the other hand, are rare and frequently present problems in diagnosis. This report reviews the clinical, radiologic, and bacteriologic findings in ten patients, six of whom were diagnosed as having acute osteomyelitis and four chronic osteomyelitis. The differential diagnosis of clavicular osteomyelitis is also discussed. The clinical duration of the infectious process in these patients ranged from 2 weeks to 1.5 years. All patients presented with pain; six had fever, three had localized swelling or a mass, and three had soft tissue abscesses. The radiographic findings also varied: the lesion was predominantly sclerotic in four patients, lytic in three, and mixed in two patients; in the one patient in whom magnetic resonance imaging was the only imaging study performed, these features could not be properly evaluated. Periosteal reaction was detected in three patients. Staphylococcus aureus was the causal organism in four patients, while in the remaining six patients different microorganisms were cultured, including Coccidiodes immitis and Mycobacterium tuberculosis. Six patients required biopsy for final diagnosis. Although clavicular osteomyelitis is rare, particularly in adults, it should be considered in the differential diagnosis of a clavicular lesion. The final diagnosis often depends on the results of biopsy and cultures.

Multiple cystic tuberculous lesions in the skeleton (Jüngling disease): a case report.

STUDY DESIGN: A case is reported. OBJECTIVES: To report and discuss a case of multiple cystic tuberculous skeletal lesions. SUMMARY OF BACKGROUND DATA: Multiple cystic tuberculosis lesions of the skeleton, or Jüngling disease, is a rare variety of tuberculosis reported extensively 30 to 40 years ago. No such severe type of tuberculosis has been reported in recent years. The patient was a 43-year-old woman with a history of steroid treatment, whose cervical lesions caused C2 and C3 destruction and spinal cord impingement. METHODS: Medical history, laboratory data, radiographs, bone scan, and MRI were studied. The bone scan showed lesions in both the axial and peripheral skeletons. As shown on the radiographs and MRI, the C2-C3 vertebral bodies were extensively destroyed. RESULTS: An open biopsy of the right clavicle confirmed the diagnosis of tuberculosis. Because of the neurologic involvement, the patient was treated with C2-C3 anterior radical resection and fusion combined with standard antituberculosis chemotherapy. During a follow-up period of 12 months, no progression in other skeletal lesions was observed. Follow-up radiographs showed fusion in the C2-C3 lesions. CONCLUSIONS: Although the prognosis of Jüngling disease is good, radical surgical treatment should be chosen when there is neurologic involvement. To prevent such a severe type of tuberculosis, it is recommended that steroid therapy should be withheld until tuberculosis is excluded in the diagnosis.