1. Dr. Jalal Mohsin Uddin DTCD, FCPS (Pulmonology)
Tuberculosis of clavicle presented as a case of disseminated tuberculosis .
Dr. Jalal Mohsin Uddin
DTCD, FCPS (Pulmonology)

2. Particulars of the patient :
Name : Md . Riazul Islam
Age : 19 yrs
Sex : Male
Occupation : Student
Marital status : Unmarried
Address : Noakhali
Date of admission : 25/ 07/2010

3. H/O present illness : Coughing out of blood for five months.
Swelling in the middle of the right collar-bone and upper part of the chest for four months.
Pain in the right shoulder for three months.
Shortness of breath for seven days.

4. H/O present illness :
According to the statement of the patient, he was completely well five months back, after that he developed coughing out of blood, initially it was scanty in amount, about 5 to 10 ml per day but in last three months it became about 30 to 50 ml/day.

5. H/O present illness…..(continue)
On the other hand, four months back he developed a small swelling near the middle point of right collar bone which was also encroaching upper part of the chest. The swelling was gradually increasing in size.

6. H/O present illness……(continue)
Riazul was complaining pain in the right shoulder, which was dull aching in nature and was radiating in the left arm.
He was also complaining about occasional low grade intermittent fever.
In last seven days he developed shortness of breath. He was breathless even at rest.
He lost his appetite and about 1/3rd of his body weight during the period of his illness.

7. Treatment history :
In this period he under went several investigations, sputum for AFB (3 samples) three times. All the times they were negative. He got an X-ray chest P-A view but the physician failed to find out any significant lesion. He received transfusion of 4 units of blood and also received various antibiotics, like azithromycin, cefixim etc.

8. He was a non smoker and there was no history of drug addiction.
H/O past illness / personal history / socioeconomic status and immunization history.
Patient neither suffered from tuberculosis nor came into contact of any patient suffering from tuberculosis. He was neither diabetic nor asthmatic.
He was a non smoker and there was no history of drug addiction.
He was from a middle class family.
He received all the vaccine as per EPI schedule .

9. General examination :
Patient was ill looking, his built was average, he was cooperative, conscious and was comfortable in propped up position, his nutritional was poor.
He was moderately anemic, not icteric, not cyanosed.
JVP was not raised and there was no lymphadenopathy in accessible site.
There was no bony tenderness, edema or dehydration.
Pulse was 92/min, BP-110/70 mm of Hg, Respiratory rate was 22 breaths/min and recorded temperature was 98°F.
Weight of the patient was 47kg.

10. Examination of respiratory system:
On inspection this young man was dyspneic as evident by respiratory rate 22 breaths/min, accessory muscles of respiration were in action and presence of intercostal recession. There was an ill defined swelling encroaching middle 2/3rd of the left clavicle, upper part of the chest and root of the neck

11. Examination of respiratory system….(continue)
Shape of the chest was normal, movement of the chest was symmetrical, there was no scar mark or dilated vessels.
On palpation trachea was centrally placed, apex beat was 9 cm away from mid sternal line at left 5th intercostal space just medial to the mid clavicular line. Vocal fremitus was normal in both side. Chest movement was bilaterally symmetrical. Chest expansion was about 3 cm.

12. Examination of respiratory system…..(continue)
The area of the swelling was 4cmx3cm
It was non tender, firm to hard in consistency, over lying skin was free with normal color and temperature but it was fixed with underlying structure. It was not pulsatile.

13. Examination of chest….(continue)
Percussion note was normal in both side, upper border of liver dullness was in right 6th inter costal space along the mid clavicular line.
On auscultation breath sound was vesicular with prolong expiration, ronchi and crepitation were present in all the parts of both sides of the chest. Crepitation altered with cough. Vocal resonance was normal in both sides of the chest.

14. Examination of other system :
Abdomen was normal in size and shape, there was no hepato-splenomegaly or any other organomegaly.
Examination of musculo-skeletal and other systems reveled normal findings.

15. Salient features :
Md. Riazul Islam, 19yrs a student from Noakhali was admitted to our institute with the complain of coughing out of blood for five months, appearance of a swelling on the left collar-bone and upper part of the chest and development of shortness of breath for seven days. The swelling was gradually increasing in size. The boy received four units of blood transfusion .He lost about 1/3rd of his body weight. He was moderately anaemic. The swelling was not tender, it was fixed with underlying structure and it was firm to hard in consistency. Breath sound was vesicular with prolong expiration, ronchi and crepitation were present in both sides of the chest.

16. Provisional diagnosis :
Malignant bone tumour (osteo-sarcoma) of clavicle with suspected metastasis in the lung.

17. Differential diagnosis :
1) Secondary metastasis in the clavicle which also involved the lungs.
2) Plasmacytoma of clavicle.

18. Routine investigations:
Total count of WBC : 6000/cu mm
Differential count : N- 65%, L-25%, M-7%, E-3%.
Hb – 9gm/dl.
ESR- 80 mm in 1st hr.
PBF- Microcytic hypochromic anemia
Sputum for AFB(3 samples)- Negative.
S bilirubin, SGPT, Blood urea, S creatinine- within normal limit.
Blood grouping- O positive.

19. Specific investigations:
X-ray chest P/A view:
Part of X-ray chest PA view showing almost absence of medial 2/3rd of the left clavicle except a thin rim of bony margin at the periphery. This site of lesion correspond with the chest wall swelling. Both lung fields and cardiac shadow were normal.
Radiological diagnosis was 1)Plasmacytoma or 2) Secondary metastasis in the clavicle.

20. CT scan of chest :
Two transverse sections of CT scan of chest in pulmonary window, near the bifurcation of trachea showing both upper and lower lobes. Multiple coarse miliary shadows are distributed evenly in all the areas of selected sections with some nodular shadows markedly distributed peripherally. Impression was,
1)Milliary tuberculosis, 2)Multiple metastatic lesions.

21. CT scan of chest ……(continue)
Here re-constructed saggital sections in pulmonary window showing same type of distribution of coarse miliary and nodular shadows as previously described.

22. CT scan of chest (continue)
Saggital re-construction in mediastinal window showing thinning of inner table of left clavicle with soap bubble appearance, suggestive of osteosarcoma.
Findings was suggestive of mitotic lesion of clavicle within medial end of left clavicle with multiple secondary deposits in both lungs.

23. CT scan of chest….(continue)
Re-constructed 3-dimensional skeletal view from CT scan of chest showing erosion of medial part of clavicle.

24. CT scan of chest (continue) :
Re-constructed view showing same type of lesion.

25. CT scan………(continue)
Re-constructed view only for clavicle, showing erosion of the bone at its medial half.

26. FNAC from clavicular swelling:
Smear shows mostly caseation necrosis, a few degraded lymphocytes, focal collection of epitheloid cells and occasional degenerated polymorphs, which is characteristics of granulomatous inflammation.
Features suggestive of tuberculosis.

27. Confirmatory diagnosis :
Disseminated tuberculosis involving clavicle and lung parenchyma in the form of miliary tuberculosis.

28. Management of the patient :
Supportive management :
Oxygen inhalation 3 to 5/L through nasal catheter when patient complain shortness of breath.
Inj Hydrocortisone was given 1 vial I/V 8 hrly for 5 days.
Nebulization with salbutamol and ipratopium solution 8 hrly and when patient complain shortness of breath. It was continued for 7 days.
Two unit of whole blood was transfused.
Cap omeprazole, Tab domperidone, Iron and folic acid supplimentation and Tab pyridoxine.

29. Management …….(continue) :
Curative / specific treatment :
Anti- tubercular drugs were prescribed, initial intensive phase was extended to three months.
Continuation phase may be extended after monitoring the response of treatment.

30. Management ………..(continue)
Counseling of the patient :
1)He is not suffering from malignancy, he is suffering from tuberculosis and it is curable.
2)He should complete anti-tubercular therapy without interruption and any interruption or incomplete therapy may be life threatening for him.
3)He may suffer from common side effect, like orange colouration of urine, which is due to taking of drug and not harmful for him. He may suffer from nausea and vomiting, skin reaction even yellowish colouration of eye, in that case he should consult with doctor.
4)He should come for follow up.

31. Management ………..(continue)
Follow up of the patient:
One month later, fever,cough and coughing out of blood have subsided. Size of the swelling has decreased about 1/3rd of the previous size. His appetite has improved and he has gained weight.
He was not anaemic and icteric and gained about 3 kg weight.
ESR-40 mm in 1st hr, Hb-11gm/dl, sputum for AFB was negative, X-ray chest was normal except left clavicular erosion.
LFT and renal function were normal.

32. Brief discussion :
Extra-pulmonary or non-respiratory tuberculosis is rising in both developed and developing countries.
In one observation
Pulmonary- 79% and
Extra-pulmonary-21%
Within extra-pulmonary:
Lymph node-41%, pleural -19%, bone and joint- 11%, Genito-urinary- 7%,

33. Brief discussion……(continue)
Abdominal tuberculosis- 5%, CNS- tuberculosis – 5%, other- 12%.
Chance of extra pulmonary or atypical presentations of tuberculosis are increasing for various causes like HIV co-infection, receiving anti cancer therapy, increase number of organ transplant and more use of immuno modulating or immuno paralytic drugs .

34. Bone tuberculosis :
This form of tuberculosis presents typically 3-5 years after the initial respiratory infection, with the haematogenous spread at that initial infection, which has a predilection for the spine and growing ends of long bones, then lying there dormant until clinical disease occur.

35. Brief discussion……..(continue)
Spinal sites account for approximately half of all bone disease, but any bone and joint can be involved.
Tuberculosis should be included in differential diagnosis of unusual bone or joint lesions, particularly of an isolated lesion or mono-arthritis, otherwise there may be substantial delays.

36. Discussion………….( continue)
There are occasional reports of cases of bone tuberculosis in various sites that mimic metastatic bone disease .
Non-spinal sites seldom require surgical treatment, but surgical intervention to obtain biopsy material for histology and culture is often required.

37. Discussion…………(continue)
A 6-month short-course regimen is also recommended for bone and joint disease at non spinal sites .

38. Jamuna bridge is a very costly structure for our country.
At the same time making bridge between patient and doctor is more precious to control tuberculosis.
Thank you all .