Journal of the Louisiana State Medical Society
C linical C ase of the M onth
A 44-Year-Old HIV-Infected Man With Right- Shoulder Swelling
Carl Mickman, MS; Carrie Caruthers, MD; Jaclyn Spiegel, MD; Ron Schiro, BS; Joanne Maffei, MD; Charles V. Sanders, MD; Fred A. Lopez, MD
Immunocompromised patients are susceptible to various joint infections with less-common pathogens, such as mycobacterium. Physicians should have a low threshold to investigate the cause of an arthropathy further. An aspiration of the effusion is usually warranted to identify the possible pathogen and target treatment. We report an unusual presentation of a human immunodeficiency virus-infected patient with a chronic effusion arthropathy of his right shoulder due to Mycobacterium kansasii . We review the risk factors, transmission, clinical manifestations, and management of Mycobacterium kansasii .
CASE PRESENTATION A 44-year-old man with a past medical history of hu- man immunodeficiency virus (HIV) and hepatitis C infec- tions presented for a therapeutic paracentesis secondary to acute liver failure. His past medical history also included non-adherence to combination antiretroviral therapy, a his- tory of Pneumocystis jirovecii pneumonia, and a resection of a squamous cell cancer of the tongue. At this presentation, the patient was also evaluated for a longstanding effusion arthropathy of the right shoulder. He had first noticed swell- ing in the area two years earlier and denied any trauma, associated pain, or limitation of his daily activities. Three weeks prior to presentation, his CD4 count was 40/mm 3 with a CD4 percentage of 8.3% and a viral load of 49,504 copies/mL. His tuberculous interferon-gamma release as- say test was negative, he denied any respiratory symptoms, and his chest X-ray was within normal limits. He admitted to prior intravenous drug use, and his last use was more than one year prior to presentation. He had been monoga- mous for the past two years with one partner who was also HIV-infected. At the time of presentation, the patient had recently been prescribed a new regimen of combination antiretroviral therapy; however, he had been non-adherent due to medication side effects. On examination, the patient’s right shoulder mani- fested a marked effusion anterior to the deltoid muscle that extended to the subdeltoid region (see Figures A, B). The area was non-tender, non-erythematous, and cool to the touch; and a transillumination test was positive. There
were no associated skin lesions. He had nearly full active range of motion, and his strengthwas onlymildly decreased compared to the contralateral side. The patient developed minimal discomfort withmedial humeral rotation; however, he had no point tenderness or pain with use of rotator-cuff muscles. An X-ray revealed degenerative changes of the humeral head, including subchondral cysts and narrowing of the joint space. Swelling caused displacement of the deltoid muscle laterally. Magnetic resonance imaging (MRI), with and without gadolinium contrast, revealed a large simple subacromial-subdeltoid bursa fluid collection with no septations or irregularity of the wall (see Figure C). The fluid collection involved the majority of the entire under- surface of the deltoid muscle. It measured approximately 11 cm anteroposteriorly, 8 cm craniocaudally, and 2 cm in thickness. There was no communication between the subacromial-subdeltoid bursa and the glenohumeral joint space. Extensive diffuse synovial thickening with pannus formation and periarticular erosions was present in the glenohumeral joint. The patient underwent a diagnostic arthrocentesis of the bursa. Approximately 10ml of a thick, reddish, myxoid fluid with fatty material were aspirated. Drainage was limited in quantity by the viscosity of the fluid. A Gram stain noted moderate white blood cells (WBC) and no organisms. No crystals were noted, and the cytology for malignant cells was negative. Smears for fungal and mycobacterial organisms were also negative (including acid-fast bacilli smears), and cultures for aerobic and anaerobic organisms were negative
182 J La State Med Soc VOL 166 July/August 2014
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