Keywords
Bone scan - multifocal osteomyelitis - tuberculous osteomyelitis
Introduction
Clavicular tuberculosis is one of the rare forms of tuberculous osteomyelitis, and
has sometimes misleading radio-clinical aspects. Through this observation, authors
highlight the diagnostic difficulties and the important role of radiobiphosphonates
bone scan in the orientation diagnostic of this pathology.
Case Report
We report the case of a 86-year-old male patient, followed up for recent left hip
pain limiting flexion and extension movements, suggestive of hip osteoarthritis or
osteonecrosis of the left femoral head. Interrogation revealed a fever, nocturnal
shivering, and bone pains. Standard radiographics [Figure 1] and computed tomography [Figure 2] centered on both shoulders and pelvis showed osteoarthritis of the left hip and
multiple lytic lesions in both humeral heads and both clavicles, suggestive of chronic
infectious, metabolic, or secondary disease.
Figure 1 Standard radiographs of the two shoulders showing lacunar lesions in both humeral
heads and both clavicles, suggestive of chronic infectious, metabolic, or secondary
disease
Figure 2 Computed tomography in the coronal section centered on the left shoulder showing
multiple lytic lesions in the left humeral head
Bone scintigraphy showed, 2 h after intravenous injection of 740 MBq of methyl diphosphonates,
an intense and diffuse uptake in the clavicles, the two humeral heads, and at the
cervical and dorsal spine [Figure 3].
Figure 3 Whole-body bone scan with radiobiphosphonates showing intense and diffuse uptake
in the clavicles, the two humeral heads, and the cervical and dorsal spine
Spinal magnetic resonance imaging showed spondylodiscitis suggestive of Pott's disease.
Biopsy of the left humeral head confirmed the diagnosis, showing an aspect of caseo-follicular
tuberculosis [Figure 4]. Our patient was put under antituberculous treatment according to the 2 RHZ/4 RH
protocol with good clinical and radiological evolution.
Figure 4 Tuberculous osteomyelitis confirmed after biopsy of the left humeral head, showing
caseo-follicular tuberculosis aspect
Discussion
Clavicular tuberculosis is a very rare form of osteoarticular tuberculosis, representing
<5% of its localizations. Young adults are most often affected with a slight male
predominance.[1]
The involvement is often linked to a hematogenous dissemination of tubercle bacilli
from a primitive visceral focus, most often with pulmonary origin.[2]
Bone scan with radiobiphosphonates can be used to search other localizations falling
within the framework of a polystotic form. However, it does not distinguish between
an infectious and tumoral origin, and 35% of evolutionary lesions do not have an uptake
of the radioactive tracer because of their avascular or purely osteolytic nature.[3] However, bone scintigraphy can guide nonrisk biopsy in such group of patients with
multifocal disease.[2],[3]
In front of nonspecific bone lesion in radiological exploration, the surgical approach
may be necessary, especially because the differential diagnosis of benign (eosinophilic
granuloma), primary malignancy (Ewing's sarcoma, osteosarcoma), secondary, myelomatous,
or infectious origin, is still not established.
The diagnosis of tuberculous osteomyelitis is based especially on the bacteriological
samples at the level of an abscess or fistulas, or on a histological examination following
a percutaneous bone biopsy.[1]
Antituberculous treatment according to the 2RHZ/4RH protocol must be considered in
our context, with the objective of the possibility of surgical resection in the case
of failed medical treatment.[4],[5]
Conclusion
Clavicular tuberculosis is considered a rare form of tuberculous osteomyelitis. Radiobiphosphonate
bone scintigraphy is very sensitive for the diagnosis of multifocality, but the diagnosis
in these rare forms with tuberculous origin is especially based on bacteriological
samples or on a histological examination following a percutaneous bone biopsy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form, the patient has given his consent for his images and other clinical information
to be reported in the journal. The patient understands that his name and initial will
not be published, and due efforts will be made to conceal identity, but anonymity
cannot be guaranteed.
