Painful chest wall swelling.

A 70 year old man, a non-smoker, presented with a painful swelling over the right sternoclavicular joint and low grade continuous fever for a period of two months. The patient had been empirically started on antituberculous therapy on the suspicion of tuberculous osteomyelitis, but his fever and swelling persisted. On clinical examination, a hard and tender swelling was present over the right sternoclavicular joint. The swelling was fixed to the underlying bone, but not to the overlying skin. The patient did not have any skin lesions. Examination of his respiratory system revealed no abnormality. Examination of other systems was unremarkable. Blood investigations showed a haemoglobin concentration of 160 g/l. The total white blood cell count was 10.5 × 10/l with 72% polymorphonuclear cells, 26% lymphocytes, and 2% eosinophils. ELISA testing for HIV infection was negative. Other haematological and biochemical parameters were within normal limits. Fine needle aspiration cytology of the swelling showed a few red blood cells, polymorphonuclear cells, lymphocytes, and a few epithelioid cells in a necrotic background. No granulomas or giant cells were seen. Computed tomography (plain and contrast) of the thorax revealed a right sternoclavicular and first costoclavicular joints arthropathy with subchondral sclerosis and abnormal periarticular soft tissue mass. A technetium-99 bone scan was done (shown in fig 1) which revealed the diagnosis.