tuberculosis is the major cause of skeletal infection in the developing countries . skeletal tuberculosis accounts for 10  35 % of extra pulmonary tuberculosis and only 2 % of all cases of tuberculosis . less than one percent of skeletal tuberculosis occurs in the shoulder .
we reviewed all the previous reports of scapular tuberculosis in english literature to analyse the common clinical presentation , the site of occurrence in scapula and radiographic appearance .
a 17-year - old male presented with dull aching pain and gradually progressive swelling over the left scapular region since five months .
physical examination revealed a swelling of 3 x 3 cm which was located in the left supraspinous region .
terminal range of motion was restricted with pain especially during the last 15 of abduction .
his blood investigations were unremarkable with esr of 15 mm / hr . anteroposterior radiograph of left shoulder revealed a well defined , 4 x 3 cm osteolytic lesion at the superomedial aspect of body of scapula , with surrounding sclerosis [ fig.1 ] .
his chest radiograph was normal . since appearance was similar to a bone tumor , differentiation was important and work up on same lines was planned .
whole body bone scan showed abnormal increase in tracer uptake in the body of scapula with the rest of the skeleton being normal .
computer tomography ( ct ) showed erosions involving the supero - medial aspect of the body of scapula and along the base of the spinous process of scapula [ fig . 2 and fig.3 ] .
magnetic resonance imaging ( mri ) scan revealed a well- defined lobulated lesion [ fig.4 ] .
a ct guided biopsy was done tissue and fluid were sent for cultures and histopathology .
biopsy revealed granulomas composed of epithelioid cells , lymphocytes and a few multinucleate giant cells suggestive of tuberculosis .
preoperative anteroposterior radiograph of the left shoulder showing osteolytic lesion in the superomedial aspect of scapula with surrounding sclerosis computer tomograph 3d reconstruction images showing erosive lesions on the body of scapula around the spinous process .
computer tomograph showing erosion of the left scapula magnetic resonance imaging showing the extent of cold abcess he was started on antitubercular therapy for a period of nine months .
at one year follow up , he had painfree full range of movements of shoulder . a 17- year old girl presented with swelling over her right upper back since three months .
physical examination revealed a 6 x7 cm soft , cystic and fluctuant swelling over the right scapular region [ fig.5 ] .
clinical photograph of the patient demonstrating cold abscess on the right scapular region there were no discharging sinuses .
blood investigations revealed hemoglobin of 10.3 gm % , total count of 11,300 and the erythrocyte sedimentation rate was 97mm / hr . radiograph showed an osteolytic lesion in the inferior angle of scapula with surrounding sclerosis [ fig . 6 ] .
computer tomography of thorax showed a large well defined homogenously hypoechoic mass measuring about 63  69 mm in the posterior chest wall , abutting and infiltrating right trapezius , supraspinatus , infraspinatus and lattissimus dorsi , with extension into the right axilla .
there were erosions and destruction of inferior angle of the right scapula with suspected sequetra [ fig .
all these features were suggestive of abscess in the posterior chest wall with osteomyelitis of right scapula . ultrasonography of the abdomen was normal .
she underwent incision and drainage of the abscess along with debridement , sequestrectomy and curettage of right scapula [ fig.8 ] .
mycobacterial culture ( lowenstein jensen medium ) demonstrated acid fast bacilli typical of mycobacterium tuberculosis after six weeks which was sensitive to all the first line antituberculous drugs .
biopsy showed inflammatory granulation tissue and fibroadipose tissue containing discrete confluent granulomas composed of epithelioid histiocytes and langhans type multinucleate giant cells surrounded by a dense infiltrate of lymphocytes , plasma cells , and aggregates of neutrophils .
she had complete resolution of symptoms and no recurrence at the end of three year follow up .
anteroposterior preoperative radiograph of the right shoulder showing an osteolytic lesion in the inferior angle of scapula computer tomograph axial images showing involvement of scapula and multiple sequestra .
a 17-year - old male presented with dull aching pain and gradually progressive swelling over the left scapular region since five months .
physical examination revealed a swelling of 3 x 3 cm which was located in the left supraspinous region .
terminal range of motion was restricted with pain especially during the last 15 of abduction .
his blood investigations were unremarkable with esr of 15 mm / hr . anteroposterior radiograph of left shoulder revealed a well defined , 4 x 3 cm osteolytic lesion at the superomedial aspect of body of scapula , with surrounding sclerosis [ fig.1 ] .
his chest radiograph was normal . since appearance was similar to a bone tumor , differentiation was important and work up on same lines was planned .
whole body bone scan showed abnormal increase in tracer uptake in the body of scapula with the rest of the skeleton being normal .
computer tomography ( ct ) showed erosions involving the supero - medial aspect of the body of scapula and along the base of the spinous process of scapula [ fig . 2 and fig.3 ] .
magnetic resonance imaging ( mri ) scan revealed a well- defined lobulated lesion [ fig.4 ] .
a ct guided biopsy was done tissue and fluid were sent for cultures and histopathology .
biopsy revealed granulomas composed of epithelioid cells , lymphocytes and a few multinucleate giant cells suggestive of tuberculosis .
preoperative anteroposterior radiograph of the left shoulder showing osteolytic lesion in the superomedial aspect of scapula with surrounding sclerosis computer tomograph 3d reconstruction images showing erosive lesions on the body of scapula around the spinous process .
computer tomograph showing erosion of the left scapula magnetic resonance imaging showing the extent of cold abcess he was started on antitubercular therapy for a period of nine months .
at one year follow up , he had painfree full range of movements of shoulder .
a 17- year old girl presented with swelling over her right upper back since three months .
physical examination revealed a 6 x7 cm soft , cystic and fluctuant swelling over the right scapular region [ fig.5 ] .
clinical photograph of the patient demonstrating cold abscess on the right scapular region there were no discharging sinuses .
blood investigations revealed hemoglobin of 10.3 gm % , total count of 11,300 and the erythrocyte sedimentation rate was 97mm / hr . radiograph showed an osteolytic lesion in the inferior angle of scapula with surrounding sclerosis [ fig .
computer tomography of thorax showed a large well defined homogenously hypoechoic mass measuring about 63  69 mm in the posterior chest wall , abutting and infiltrating right trapezius , supraspinatus , infraspinatus and lattissimus dorsi , with extension into the right axilla .
there were erosions and destruction of inferior angle of the right scapula with suspected sequetra [ fig .
all these features were suggestive of abscess in the posterior chest wall with osteomyelitis of right scapula .
she underwent incision and drainage of the abscess along with debridement , sequestrectomy and curettage of right scapula [ fig.8 ] .
mycobacterial culture ( lowenstein jensen medium ) demonstrated acid fast bacilli typical of mycobacterium tuberculosis after six weeks which was sensitive to all the first line antituberculous drugs .
biopsy showed inflammatory granulation tissue and fibroadipose tissue containing discrete confluent granulomas composed of epithelioid histiocytes and langhans type multinucleate giant cells surrounded by a dense infiltrate of lymphocytes , plasma cells , and aggregates of neutrophils .
she had complete resolution of symptoms and no recurrence at the end of three year follow up .
anteroposterior preoperative radiograph of the right shoulder showing an osteolytic lesion in the inferior angle of scapula computer tomograph axial images showing involvement of scapula and multiple sequestra .
tuberculosis is a major health problem in the developing countries . despite recent advances in its diagnosis and treatment ,
it has become a global epidemic with the emergence of hiv infection and multidrug resistance .
skeletal tuberculosis occurs secondary to hematogenous spread from primary focus which are usually pulmonary or lymph nodes .. less than 1% of all skeletal tuberculosis affects the shoulder , a fraction of it involves the scapula .
clinically , the findings with restricted shoulder movements may mimic frozen shoulder and the diagnosis is delayed or missed .
radiographs usually show osteopenia , osteolytic lesion with poorly defined edges and varying amounts of sclerosis and periostitis . ct and mri are useful to delineate the extent of the lesion .
the differential diagnosis for a lytic lesion on radiograph are pyogenic infections both bacterial and fungal , tumours like bone cysts , telangiectatic osteosarcoma , sarcoidosis or eosinophilic granuloma .
hence tissue biopsy is important in the diagnosis of the condition . though afb smear is not very sensitive , mycobacterial cultures are specific .
biopsy showing epitheloid granulomas and caseous necrosis is gold standard in the diagnosis of tuberculosis .
we did a literature review on isolated scapular tuberculosis and found ten reported cases [ table 1 ] .
the most common presentation was pain and swelling and only two patients had discharging sinus .
cold abscess was present in 70 % of the cases and only 30 % of all patients had systemic features like fever , loss of weight and appetite .
out of the twelve cases , six occurred in the body , three in the spine of scapula , two in the inferior angle and one in acromion .
seventy percentage of the cases were under 30 years of age while 90% of cases presented before six months from the onset of symptoms .
all patients had osteolytic lesions on radiographs , with 60 % of them had marginal sclerosis .
review of literature of previously reported cases of isolated scapular tuberculosis analysis of all twelve patients with isolated scapula tuberculosis the main step in the diagnosis of skeletal tuberculosis is thorough clinical and radiological examination . from our analysis ,
tuberculosis of the scapula must be suspected if a patient presents with age less than 30 years , with pain and swelling in the scapular region less than six months duration and radiographs showing osteolytic lesion with surrounding marginal sclerosis .
though rare , tuberculosis should always be suspected in isolated scapular swelling in developing countries .
surgery is advised only if there is giant sequestra or when there are no signs of improvement 3 to 4 weeks after initiating antitubercular therapy .
both patients showed dramatic improvement with nine months of therapy and showed complete resolution of the disease .
since all the patients reported so far with isolated involvement of scapula are immunocompetent , may be there was less chance of dissemination and none of them were multidrug resistant .
high index of suspicion is necessary to identify scapular involvement in all patients with shoulder pain .
thorough clinical and radiological examination is necessary to avoid misdiagnosis , as most shoulder problems are treated as periarthritis or frozen shoulder .
radiographs should be overlooked to identify any lesion in acromian , clavicle , scapula , coracoid process other than head of humerus .
to conclude , high index of suspicion is necessary for diagnosing this condition in endemic areas .
 introduction : isolated tuberculosis of the scapula is rare . the presentation mimics the tumors of scapula . 
 hence it is important to know the clinical presentation and when to suspect tubercular osteomyelitis of scapula . 
 few cases have been described before . 
 we have analyzed all reports with isolated scapular tuberculosis so far and described the varied presentations.case report : we report two cases of isolated scapular tuberculosis . 
 one patient underwent aspiration and was started on antituberculous drugs ( att ) and the other underwent debridement , drainage of abscess and then was started on att . 
 both had excellent outcomes at the end of one year follow up . 
 we reviewed previous published literature of isolated scapular tuberculosis . 
 the most common presentation of scapular tuberculosis is as follows : age less than 30 years and there is no difference with respect to gender . 
 swelling and pain are the commonest symptoms . 
 lytic areas with surrounding sclerosis is the commonest radiological finding . 
 body of the scapula is affected most commonly . 
 prognosis is excellent with adequate treatment.conclusion:to conclude , clinicians should have high index of suspicion for diagnosing this condition as it mimics tumors . 
 pain and swelling is the most common presentation of scapular tuberculosis . 
 radiography shows lytic lesion with marginal sclerosis . 
 the prognosis is excellent with appropriate treatment . 
Introduction
Case Report
Patient 1
Patient 2
Discussion
Conclusion