Tuberculous arthritis of the sternoclavicular joint. A report of three cases.

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Abstract
Tuberculous arthritis and osteomyelitis are uncommon diseases, but their sequelae may be disabling. Compared with other sites of skeletal tuberculosis, the clavicle and sternoclavicular joint have received little attention in the literature. We describe the cases of three adults who had a tuberculous infection in the sternoclavicular joint and the surrounding tissues. For each patient, modern imaging techniques greatly enhanced the understanding of the extent of the disease process. CASE 1. A seventy-four-year-old man who had had a painless swelling of the right sternoclavicular joint and of the proximal part of the right clavicle for nine months was seen in our hospital in 1989. With the exception of the localized swelling, no other focal findings were noted, and the motion of the shoulder was normal. The erythrocyte sedimentation rate was elevated to fifty-eight millimeters per hour, and the test for c-reactive protein was positive (forty-nine milligrams per liter). The leukocyte count was normal. A tuberculin skin test, however, was positive. A roentgenogram showed opacification of the right upper lung field and suggested a lytic lesion in the medial part of the right clavicle (Fig. 1-A). Tomography demonstrated erosive destruction of the right clavicle and first rib (Fig. 1-B). Computerized tomographic and magnetic resonance images demonstrated a soft-tissue mass, which expanded over the sternoclavicular joint to the mediastinum and displaced the subclavian vessels (Figs. 1-C, 1-D, and 1-E). Furthermore, the computerized tomographic image revealed old inflammatory changes in the apex of the right lung, which were consistent with primary tuberculosis. An open biopsy was performed. The diagnosis of tuberculous arthritis and osteomyelitis was made on the basis of the presence of tubercles and mycobacteria in the histological material. A gallium scintiscan failed to reveal any abnormal accumulation of isotope in joints other than the right sternoclavicular joint. Isoniazid (0.3 gram per day), rifampin (0.45 gram per day), ethambutol (0.75 gram per day), and streptomycin (three grams, three times per week) were administered for three months. There was no clinical improvement, and the patient was hospitalized and operative debridement was performed. The sternoclavicular joint was found to be filled with granulomatous tissue as well as with bone and capsular debris. The articular disc was completely destroyed. The inflammatory mass expanded into the mediastinum. Two centimeters of the medial part of the clavicle, the medial end of the first rib, and the inflammatory mass were excised. The chemotherapy protocol was continued. However, after one month, the rifampin was discontinued because of hepatic dysfunction. The isoniazid, ethambutol, and streptomycin were given for an additional six months. At a follow-up examination two years after treatment, there was no evidence of clinical recurrence of the tuberculous arthritis and osteomyelitis. The patient had a full range of motion of the right shoulder joint and no pain. CASE 2. A fifty-four-year-old man was examined in 1977 because he had had a painless swelling for ten years in the right sternoclavicular joint and pain in the right shoulder with movement. There was no tenderness or local heat over the swollen sternoclavicular joint. Motion of the shoulder was only slightly affected. Hematological examination revealed elevation of both the leukocyte count and the erythrocyte sedimentation rate (12.0 x 109 per liter (12,000 per cubic millimeter) and sixty-one millimeters per hour, respectively) and a positive test for c-reactive protein. A tuberculin skin test was positive.

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