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A case of acute swelling of the left shoulder
  1. S Parekh1,
  2. M Pisaneschi2,
  3. W Sequeira1
  1. 1Department of Medicine, Cook County Hospital and Rush Medical College, Chicago, Illinois, USA
  2. 2Department of Radiology
  1. Correspondence to:
 Dr Winston Sequeira, Division of Rheumatology, Cook County Hospital and Rush Medical College, 1900 W Polk #650, Chicago, IL 60612, USA;
 Wsequeir{at}rush.edu

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Answers on p 378.

A 59 year old African American woman presented to her primary care physician with acute pain and swelling of her left arm. The initial examination revealed oedema of her left upper extremity extending to her left breast and chest wall. An ultrasound done to exclude a deep venous thrombosis of her left upper extremity was normal. An incidental finding of a subluxed left shoulder on chest radiography prompted a consultation by a specialist.

The rheumatologist noticed the patient supporting her left arm at the elbow with her right hand. The left shoulder had a large effusion with diffuse swelling of the arm but no overlying redness or tenderness. Movement of the joint was uncomfortable and reduced. All other joints in the arm were normal. Cytology of the 150 ml of bloody fluid aspirated from her shoulder identified fragments of bone and cartilage. There were no crystals and routine bacterial and mycobacterial cultures were negative. She had a positive PPD (purified protein derivative).

A repeat radiograph of the left shoulder done six weeks later (see fig 1) prompted a more detailed neurological examination. This revealed reduced pain and temperature over the left shoulder and upper arm extending towards the midline with reduced deep tendon reflexes compared to the opposite limb.

Figure 1

Radiograph of the left shoulder done six weeks after presentation; this demonstrates sharp margins almost as if part of the head of the humerus was surgically excised.

A magnetic resonance image (MRI) of the cervical spine was done to confirm the diagnosis (see fig 2).

Figure 2

MRI of the cervical spine demonstrating the large syrinx between the arrows.

QUESTIONS

  1. What disease process are the x ray and MRI findings diagnostic of?

  2. What are the other causes of osteolysis?

  3. What are the other clinical features of this disease?

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