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J Thorac Cardiovasc Surg 2007;133:586-587
© 2007 The American Association for Thoracic Surgery

Brief Communication

Mediastinal mass: A diagnostic conundrum

Vamsidhar Rachapalli, MRCS*, Anil John, FRCS, Michael J. Unsworth-White, FRCS (CTh)

Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth, United Kingdom.

Received for publication July 25, 2006; accepted for publication September 5, 2006.

* Address for reprints: V. Rachapalli, MRCS, 8, Ffordd Ty Unnos, Cardiff CF14 4NJ, United Kingdom. (Email: r_vamsidhar{at}yahoo.com).

Clinical Summary

Septic arthritis of the sternoclavicular joint (SCJ) is a rare condition that can present as anterior mediastinal disease with venous obstruction and can be a clinical conundrum.1Go We present one such case, which was resolved only after incision and drainage.

A 74-year-old man had a 2-week history of a tender mass situated at the suprasternal notch and extending over the right clavicle. It was associated with swelling of the right upper limb of similar duration. He also reported recent onset of shortness of breath. He had a history of ischemic heart disease for which he underwent coronary artery bypass grafting 8 years earlier. Other comorbidities included hypertension and atrial fibrillation.

On examination, he was apyrexic and had rate-controlled atrial fibrillation. He had a 3 by 4 cm fluctuant nonpulsatile right suprasternal swelling extending retrosternally. His right arm was swollen with pitting edema but with intact sensorimotor function.

Thoracic computed tomographic scan demonstrated a 7 by 6 cm soft tissue density in the right superoanterior aspect of the chest extending retrosternally to the confluence of the right jugular and subclavian arteries and right SCJ (Figure 1).


Figure 1
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  		Figure 1. Computed tomographic scan. Retrosternal extension of the abscess (arrow) arising from the right supraclavicular joint.

 
The mass was incised and pus drained the following day. The cavity extended into the right SCJ. Beta-hemolytic streptococcus was cultured from the pus and the patient was commenced on the appropriate antibiotics. The patient’s condition gradually improved and the swelling of the right arm subsided.

Discussion

Septic arthritis of the SCJ is a rare condition, which was first reported in 1896 by Vogelieus, as recounted by Mohyuddin.1Go The SCJ is said to be involved in 2% of cases of septic arthritis.2Go Some authors have reported that it may account for as many as 9% of cases.3Go

The SCJ involvement is associated with diabetes, systemic steroid therapy, alcoholism, intravenous heroin abuse, immunoparesis, rheumatoid arthritis, and local infection and can occur as a rare complication of subclavian vein thrombosis.2,4Go It has also been reported in healthy or apparently healthy individuals.4Go

Septic involvement of the SCJ presents with minimal symptoms, as it usually does not manifest as a swollen and painful joint.1Go Most often, it presents as a complication, resembling other causes of anterior chest wall pain, such as tumors of the clavicle and sternum and even pneumonia.4Go Complications include retrosternal abscess, fistula formation, mediastinitis, superior vena cava syndrome, and osteomyelitis.1Go Mediastinal involvement can be life-threatening, especially in immunocompromised patients.2Go Suspicion should be entertained when patients have a swelling over the joint.1Go We are reporting the first case in which it has presented as subclavian compression syndrome. Early recognition is of paramount importance to prevent more serious complications such as mediastinitis or superior vena cava syndrome.1Go

The organism most usually implicated is Staphylococcus aureus. 4Go Other organisms isolated include Brucella spp, Serratia marcescens, Candida albicans, and Streptococcus. Pseudomonal arthritis has been reported in subjects addicted to heroin and intravenous drugs.4Go

Computed tomography is the imaging modality of choice. It not only helps in demonstrating the anatomy of the joint and surrounding soft tissues, but it also aids aspiration of joint fluid in septic arthritis.2Go Magnetic resonance imaging is used as an adjunct to further demonstrate joint involvement.2,4Go

SCJ septic arthritis can be managed conservatively and surgically. Carlos and associates5Go recommend conservative management for early cases, but in the presence of extra-articular involvement, aggressive surgery with en bloc resection would result in eradication of infection with minimal disability.

Although rare, SCJ septic arthritis is associated with significant morbidity. Its diverse presentations can be a diagnostic challenge.

References

  1. Mohyuddin A. Sternoclavicular joint septic arthritis manifesting as a neck abscess: a case report. Ear Nose Throat J 2003;82:618-621.[Medline]
  2. LeLoet X, Vittecoq O. The sternocostoclavicular joint: normal and abnormal feature. Joint Bone Spine 2002;69:161-169.[Medline]
  3. Yood RA, Goldenberg DL. Sternoclavicular joint arthritis. Arthritis Rheum 1980;23:232-239.[Medline]
  4. Gillis A, Friedman B, Caraco Y, Blankstein A, Yellin A, Friedman G. Septic arthritis of the sternoclavicular joint in healthy adults. J Intern Med 1990;228:275-278.[Medline]
  5. Carlos GN, Kesler KA, Coleman JJ, Broderick L, Turrentine MW, Brown JW. Aggressive surgical management of sternoclavicular joint infections. J Thorac Cardiovasc Surg 1997;113:242-247.[Abstract/Free Full Text]




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