Teaching Case

A 60-year-old woman presented with a history of severe pain in the left shoulder joint.

The patient was diabetic and presented with two months history of severe and rapidly progressive pain in left shoulder joint. There was no history of previous trauma. On examination, the left shoulder joint had a diffuse swelling with ill defined margins. The overlying skin was tense and shiny. Movements of shoulder were painful and restricted in all directions. There was no distal neurovascular deficit. The tuberculin test was strongly positive. Chest X-Ray was normal. An anteroposterior roentegenogram of the left shoulder revealed a soft tissue swelling and a lytic lesion of the head of the humerus (fig 1). An enhanced computed tomography scan showed bony destruction of the head of humerus (fig 2-3). There was calcifications in and around the joint. Ponction and synovial biopsy of joint was removed. A cytological examination showed caseation and a granulomatous lesion strongly suggestive of tuberculosis. The patient was started on four drug antiubercular therapy initially (INH, RFP, EB, PZA) and was put on two drugs after two months. There was continued for sixteen months. The shoulder was immobilized. At final follow up she had gained weight, had no pain or swilling, but the movements were restricted.

The incidence of tuberculosis of the shoulder joint is 1- 2,8% of the skeletal tuberculosis. This is may differ clinically and pathologically from tuberculosis of other joints and can be difficult to diagnose in early stages. The dry type of lesion is commonly reported in adults, commonly known as “caries sicca” (1-2). There is usually concomittent involvement of the synovial membrane and the subchondral bone. Radiologically such a lesion may show osteoporosis, subchondral erosions, diminished joint space, relative sclerosis and progressive joint destruction (1). The acute fulminating variety of shoulder tuberculosis, as seen in our patient, is common in children but very rare in adults and may simulate acute osteomyelitis, septic arthritis or ostegenic sarcoma. Computed tomography was more helpful than plain X-rays in diagnosis as it clearly demonstrated bony destruction of the glenoid cavity and the humerus, and showed pathological fracture dislocation of the shoulder (1, 3). In MRI, T2-weighted images showed extension of abscess clearly (2, 3). The diagnosis was confirmed by synovial biopsy or fine needle aspiration cytology (1, 2). The patient responded very well to anti-tubercular therapy with rest in an immobilizer.