Case Presentation
A 42-year-old Middle Eastern female patient from Iran was admitted to Sina Medical Research & Training Hospital because of the acute arthritis of the left sternoclavicular joint on September 24, 2019. She was a married woman with 2 children and was a hairdresser and tattoo artist. She had no history of specific disease except a history of penicillin allergy and uterine myoma surgery seven months before admission.
She developed pain in the left sternoclavicular joint with spread to the left neck, shoulder and submental area two weeks before hospitalization, which gradually intensified and led to neck pain and limited movement of the left upper limb due to pain and then erythema and heat and swelling were added to the sternoclavicular joint. The shoulder pain was reduced by using a slightly warm compress on it. She was hospitalized with a diagnosis of acute sternoclavicular joint arthritis owing to a lack of response to outpatient treatments and topical compounds.
One and a half months ago, because of discharge from the left breast ultrasound was done. The results revealed a fibrocystic change in both breasts, reactive axillary lymph nodes on both sides and a complicated cyst in the left breast which was completely aspirated under an ultrasound guide. Then, 5 ccs of concentrated pus were drained and sent to the culture, and the result was negative.
According to the abovementioned history and examination, the patient was admitted with the diagnosis of acute left sternoclavicular arthritis.
Over one and a half months, she had been taking co-amoxiclav, dexamethasone, celecoxib, piroxicam, Gabapentin, NEUROBION, cephalexin, and vitamin E. She had no fever, chills, headache, nausea and vomiting but she occasionally complained of scant purulent discharge from the left breast and a sense of heaviness in it. Examination of the heart, lungs and abdomen were normal and she had no skin rash. Limited movement of the left upper limb was due to pain in the left sternoclavicular region and this region had slight erythema and tenderness in the palm. The right breast was normal and the left was tense.
Her vital signs at admission were: Blood pressure: 110/70, Body temperature: 36.8 axillary, Pulse rate: 82, and Respiratory rate: 18. Cardiac echocardiography, chest and neck CT scan as well as liver and spleen ultrasound were normal.
We started to study the cause of acute sternoclavicular arthritis. MRI of the left sternoclavicular joint was performed, there was subarticular bone marrow edema at both the clavicular and sternal sides of the left sternoclavicular joint as well as some surrounding deep soft tissue edema, in favor of osteoarthritis. No obvious bony erosion was detected.
Because of the left breast discharge ultrasound was conducted and the result showed a fibrocystic change of both breasts and a hypoechoic mass in the left breast of 6.3×4.7 cm. A core needle biopsy of a left breast abscess was performed and the reported biopsy by the pathologist was as follows: Breast tissue with moderate mixed inflammation, fibrocystic change, and foci of adenosis with florid hyperplasia. For definite diagnosis and ruling out of atypical florid hyperplasia Immunohistochemistry (IHC) staining for P63, SMA, CK5/6, and ER were recommended. IHC findings did not confirm atypical changes.
Breast abscess culture revealed few colonies of coagulase-negative staphylococcus.
Despite treatment with naproxen, pain and tenderness of the left sternoclavicular joint and limited movement persisted until getting serology of brucellosis (Wright: 1/160) and positive blood culture for Brucella. Consequently, the patient was treated with Streptomycin and doxycycline. Four days later she felt improvement in the left sternoclavicular joint. Pain and tenderness in the joint significantly decreased and the patient was able to move the left upper limb and the discharge from the patient’s left breast was stopped. After the diagnosis of brucellosis and good response to treatment, on the 14th day of hospitalization, the patient was discharged and requested for continuing treatment order with doxycycline and Streptomycin for one week followed by doxycycline and rifampin and following-up on outpatient basis.
The laboratory workup was summarized in Table 1.
30 days after discharge, she had been in good clinical condition with normal sternoclavicular joint, and normal examination of the left breast without any discharge. Also, additional ultrasound of the breasts showed a fibrocystic change in both breasts without either evidence of collection or axillary lymph nodes.