A 65-year-old male presented to us in the outpatient department on March 2019 with complaints of pain in the right shoulder for the past 6 months and dumbbell-shaped swelling progressively increasing in size around the same region for the past 4 months. He had severe pain and global restriction of movements in the right shoulder which urged him for medical attention. There was no history of trauma, manipulation, fever, or night sweats. The patient had a history of pulmonary TB 2 years back, for which he was treated with anti-tubercular drugs according to the Revised National Tuberculosis Control Program (India) guidelines for 6 months and declared sputum negative. There is no history of any other systemic disorders.
Reveals massive dumbbell-shaped swelling over the right shoulder which is soft in consistency with ill-defined margins showing cross-fluctuation (Fig. 1-3). The overlying skin was tense and shiny, with no venous engorgement. There was no discharging sinus or pointing abscess. Local temperature was normal. Tenderness was present on palpation of anterior and posterior capsule region, deep axilla, and lateral aspect of the scapula. Movements of the shoulder were painful and restricted in all directions. There was no distal neurovascular deficit. Axillary lymph nodes were enlarged.
Revealed hemoglobin (Hb) of 11 gm%, a total leucocyte count of 11,000 mm3, differential count of 48% lymphocytes, 50% polymorphs, 2% eosinophils, and erythrocyte sedimentation rate (ESR Westergren) was 60 mm/hr.
X-ray right shoulder anteroposterior view (Fig. 4) shows erosion of the glenoid cavity and head of the humerus with a reduction in the joint space. Obliteration of adjacent fat planes is seen with minimal erosion of lateral end of the clavicle. Soft-tissue shadow is suggestive of gross fluid collection. There is no dislocation of the glenohumeral joint.
Chest X-ray (Fig. 5) showed widespread small nodular opacities distributed throughout both the lungs suggestive of miliary TB.
Magnetic resonance imaging right shoulder joint (Fig. 6, 7) shows cortical erosions involving articular margins of the humeral head and bony glenoid. Proximal migration of humeral head at the shoulder joint is seen. There are moderate joint effusion and synovial thickening with a large loculated periarticular collection extending to supraspinatus fossa and upper arm along with the deltoid muscle. Largest collection measures approximately 14 cm x 6 cm. There are rotator cuff muscles atrophy and few enlarged lymph nodes in the axilla. This picture was suggestive of tuberculous arthropathy of the right shoulder joint.
Diagnostic aspiration of the cold abscess was done from the non-dependent region under aseptic precaution, material aspirated was sent for pus culture, acid-fast bacilli (AFB) staining, Gene-Xpert, and culture for Mycobacterium tuberculosis (Mtb). AFB staining came negative. MTb was detected with Gene-Xpert documenting no rifampicin resistance. Culture with Mycobacterium growth indicator tube (TB-MGIT) came positive in 3 weeks with the bacilli susceptible to all first-line anti-tubercular drugs. There was no superadded pyogenic infection being ruled out by final pus culture and sensitivity report.
The patient was started on first-line anti-tubercular therapy (ATT) isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months then switched to HRE for 6 months and HR for the next 4 months. Therapeutic aspiration of the cold abscess was done and 1 g of streptomycin was injected into the lesion once the diagnosis was confirmed by diagnostic aspiration. The patient was provided with shoulder immobilizer and compression bandage after the procedure. A similar procedure of injecting streptomycin was repeated thrice at monthly intervals. After 3 months, the swelling and pain were alleviated; the patient was started on physiotherapy and shoulder range of motion exercises. The total duration of multidrug anti-tubercular chemotherapy was 1 year. At 1-year follow-up, although the movements were restricted (flexion 50 , extension 20 , abduction 60 , adduction 0 , internal rotation 10 , and external rotation 10 ) and mostly scapulothoracic, the patient had gained weight, had no pain or swelling, and could carry out his day-to-day activities without much discomfort (Fig. 8). The anteroposterior radiograph (Fig. 9) showed healing with sclerosis at proximal humerus and superior migration of head of the humerus. There were no changes in the glenoid cavity.