Tuberculosis of the sternoclavicular joints

From May 1991 to December 1997, we treated 9 patients with tubercular arthritis in 10 sternoclavicular joints. The patients presented with a painful swelling (7 joints), painless swelling (2 joints) and a painless (?) discharging sinus (1 joint) having a mean duration of symptoms of 13 (6-32) months. The diagnosis was made with fine-needle aspiration or open biopsy. In 1 patient debridement of the joint was combined with open biopsy. All patients were initially put on a 4-drug regimen of antitubercular therapy (ATT). 2 joints not responding to closed treatment were surgically debrided after 2-3 months of ATT. Total duration of ATT was 14-18 months. At final follow-up after average 4.5 (1.5-7.5) years, all lesions had healed. 3 patients had mild limitation of shoulder motion, with no pain, and 2 patients had a cosmetically ugly scar at the site of the sinus or biopsy.

Radiation induced sarcoma following treatment of breast cancer

The occurrence of radiation induced sarcoma following treatment of breast cancer is rare. It has an average latency of ten years and it correlates with the dose and technique of radiation. The prognosis is poor due to delay in diagnosis. We present a case where a female patient developed a chondrosarcoma of sternoclavicular joint 19 years after radiotherapy for breast cancer.

Focal myositis of the sternocleidomastoid muscle

Focal myositis is an unusual inflammatory lesion of skeletal muscle. It usually affects the extremities, but can present rarely in the head and neck region. We present a case of an elderly woman with focal myositis of the sternocleidomastoid muscle and review of the previous literature on this subject.

Thoraco-cervical fibromatosis: treatment of surgical excision

We present a case of massive thoraco-cervical fibromatosis treated by sternotomy and simple excision. The patient remains disease-free after careful follow-up of three years. We suggest that if the lesion is encapsulated and position or size prevents en bloc removal, simple excision may be curative.

Sternoclavicular septic arthritis in a patient with end-stage liver disease

Sternoclavicular septic arthritis is an uncommon clinical entity that is often misdiagnosed on initial presentation. It has generally been described in IV heroin users and immunocompromised hosts. We report the case of a 43-year-old woman with endstage liver disease who presented with a fever, a painful sternoclavicular joint, and gastrointestinal bleeding. The clinical presentation, diagnosis, and treatment of sternoclavicular septic arthritis are reviewed.

[Osteoarticular infections caused by Streptococcus agalactiae. Report of 4 cases]

BACKGROUND

Streptococcus agalactiae (group B streptococcus) is a rare etiology of osteoarticular infection in adults. In a literature review (Medline-Embase plus) up until may 1994, we have found only 51 cases. In most patients, diabetes mellitus, liver disease or long-term steroid therapy were documented.

METHODS

Four adult patients with osteoarticular infection due to S. agalactiae from two Galician hospitals were studied from January 1988 to October 1994: prepatellar bursitis (one case), septic monoarthritis (2 cases) and psoas abscess associated to cervical spondylodiscitis and oligoarthritis (left sternoclavicular and left hip joints).

RESULTS

In the first patient, a young woman with prepatellar bursitis, a previous local trauma was recorded. The second case, a man with septic arthritis of right knee, had degenerative disease of the knees and a prostatic adenocarcinoma. In the third patient, a diabetic woman with septic arthritis of the left shoulder, vulvovaginitis due to Candida albicans was found. The last patient suffered vertebral osteomyelitis of the cervical spine (C3-C4), arthritis of the left sternoclavicular and hip joints and abscess of the ipsilateral psoas. The evolution was favourable in the four cases.

CONCLUSIONS

Although uncommon, osteomyelitis and arthritis caused by group B streptococcus should be considered as opportunistic pathogen in adults with debilitating conditions. Early recognition and prompt institution of adequate therapy can help avoid joint destruction and severe complications.

Bilateral sternoclavicular joint septic arthritis presenting as cutaneous abscesses

The sternoclavicular joint can be involved in ankylosing spondylitis as well as in rheumatoid and degenerative arthritis. Septic arthritis of this joint is infrequently seen, and the diagnosis of this infection can be missed until it presents with a complication. We describe a patient with bacteremia whose presentation of bilateral sternoclavicular joint septic arthritis was multiple cutaneous abscesses on her chest wall.

[S. pneumoniae sternoclavicular arthritis in a patient with HIV infection]

HIV infection is a predisposing factor for pneumococcic infection. While pneumonia is the most frequent location, other locations (articular, meningeal, endocardiac, etc) have been less frequently described. Among the articular infections described in patients with HIV infection, the sternoclavicular affection is extremely rare and it usually develops in association with parenterally drug addiction, being Staphylococcus aureus and Pseudomonas aeruginosa the most frequently germs involved. We describe the first case of sternoclavicular arthritis by Streptococcus pneumoniae in a patient with HIV infection. In our case, the chronic hepatopathy associated to alcohol consumption is a predisposing factor related to the pneumococcic infection. Our case suggests the need to formally investigate the HIV infection in young patients with invasive pneumococcic infection.

Compression brachial plexopathy caused by chronic posterior dislocation of the sternoclavicular joint

Thoracic outlet syndrome developed in a patient due to chronic posterior dislocation of the sternoclavicular joint, following an all-terrain vehicle accident. Decompression of the thoracic outlet was accomplished by surgical reduction of the clavicle, excision of the medial clavicle and reconstruction of the costoclavicular ligament. The patient's symptomatology was relieved by the surgical procedure performed.

Sternoclavicular brucellar arthritis: a report of 7 cases and a review of the literature

OBJECTIVE

To describe the clinical features of sternoclavicular arthritis.

METHODS

Medical records review of patients with sternoclavicular brucellar arthritis diagnosed and treated in a University Hospital in Lima, Peru.

RESULTS

Over a 21-year period, 1,729 cases of brucellosis were diagnosed and treated. Seven patients with sternoclavicular arthritis were identified; 5 had an acute course with current or past evidence of systemic infection. Four patients had involvement of another joint and one of the 7 developed a chest wall abscess. All patients recovered without sequelae.

CONCLUSION

Recovery without sequelae is expected if patients with sternoclavicular brucellar arthritis are promptly diagnosed and treated.

Anatomical mechanisms explaining damage to pacemaker leads, defibrillator leads, and failure of central venous catheters adjacent to the sternoclavicular joint

The literature suggests that approximately 93% of all pacemaker lead fractures occur in the segment of the lead lateral to the venous entry, and costoclavicular compression has been implicated. While blood vessels can be compressed by movements of the clavicle, our research suggests that lead and catheter damage in that region is caused by soft tissue entrapment rather than bony contact. Dissection of eight cadavers with ten leads revealed that two entered the cephalic vein, and were not included in the study. Of the other eight leads, four passed through the subclavius muscle, two through the costoclavicular ligament, and two through both these structures before entering the subclavian, internal jugular, or brachiocephalic vein. Anatomical studies demonstrated that entrapment by the subclavius muscle or the costoclavicular ligament could cause repeated flexing of leads during movements of the pectoral girdle. Cineradiology of patients with position dependent catheter occlusion confirmed entrapment by the subclavius muscle. Soft tissue entrapment imposes a static load upon leads and catheters, and repeated flexure about the point of entrapment may be responsible for damage previously attributed to cyclic costoclavicular compression.

Efficacy of the supraclavicular route for temporary hemodialysis access

The percutaneous supraclavicular approach for temporary central venous hemodialysis access was successfully used in 27 of 34 cases (79%) without significant complications and was found to be a durable technique acceptable to every patient. The supraclavicular site was used from 3 to 156 days (mean, 40 days). The average catheter life was 25 days, and 13 guidewire catheter changes among eight patients were required for catheter limb thrombosis or suspected infection. Preventable kinks resulting from technical error occurred in two catheters (5%), necessitating guidewire replacement in one. A total of 41 catheters were used, and infection was documented in one (2%). Catheters were intentionally removed in 21 patients and were removed for proved infection (1) or suspected infection (5) in the remaining six patients. No new clinical evidence of central venous stenosis or thrombosis, such as arm swelling, prominent cutaneous collateral veins, or increased venous pressure at dialysis, was observed. We suggest the supraclavicular approach as the primary route for temporary central venous hemodialysis access. Continued follow-up is necessary to substantiate the initial favorable experience with the supraclavicular technique.

Sternoclavicular joint disease in psoriatic arthritis

The radiological and tomographic aspects of the sternoclavicular joint were examined in 10 patients with psoriatic arthritis to evaluate better how this joint was affected using different radiological techniques. Imaging of the sternoclavicular joint showed that computed tomography provides a better visualisation of erosions, subchondral cysts, and sclerosis than standard radiography and conventional linear tomography.