Unilateral shoulder swelling in a preterm neonate.

A former 27 week gestation, 1090 gram birth weight Hispanic female infant was born by caesarean section because of transverse lie and preterm labor. The mother had received no prenatal care. The infant was treated at the time of delivery with Survanta™ for hyaline membrane disease. Umbilical artery and vein catheters were placed at birth and discontinued on day of life (DOL) five and seven, respectively. On DOL six, a peripherally inserted central catheter (PICC) was placed into the right upper extremity without complications. The infant's neonatal course was complicated by bacteremia due to coagulase negative Staphylococcus (CONS) on DOL 18. The PICC line was removed on that day because of infiltration of fluid into the soft tissues at the insertion site in the antecubital fossa. Urine and CSF cultures were sterile. The infant completed a two week course of intravenous vancomycin therapy on DOL 33. The patient was clinically stable receiving minimal ventilatory support until DOL 33 when she was noted to have a lump over her right clavicle and pain upon movement of her right shoulder. With the exception of several episodes of apnea and bradycardia, there were no other changes in the infant's clinical status. There was no history of recent or remote trauma. The physical examination revealed that the temperature, blood pressure, and respiratory rate were within normal parameters. The anterior fontanelle was soft and flat, the neck was supple, and there was no adenopathy. The heart, lungs, and abdomen examinations were normal. The right shoulder was minimally swollen and erythematous, but there was full range of motion about this joint. There was a 2.5 by 3.0 centimeter nonmobile mass over the medial right clavicle that was erythematous, warm, and markedly tender to palpation. The remainder of the extremity exam