PMC6367193_01
Anteroposterior (AP) radiograph shows an essentially normal appearance of the right clavicle.
jbjiv04p0040g001.jpg
PMC6367193_01_jbjiv04p0040g001.jpg
F1
Plain radiographs of the clavicle initially demonstrated no definite abnormality (Fig. 1), and the patient was treated conservatively by her local physicians.
AP plain film demonstrates interval development of mixed lucent (long arrow) and sclerotic (short arrow) changes of the mid clavicle, with periosteal reaction that is fairly smoothly contoured.
jbjiv04p0040g002.jpg
PMC6367193_01_jbjiv04p0040g002.jpg
F2
Repeat radiographs 4 months later showed marked progression of an expansile lytic process with cortical erosion (Fig. 2).
Coronal T2-weighted MR scan image reveals aggressive mid-clavicular lesion with hyperintense signal within the medullary cavity (long arrow) and surrounding inflammation in the soft tissues (short arrows).
jbjiv04p0040g003.jpg
PMC6367193_01_jbjiv04p0040g003.jpg
F3
A clavicular magnetic resonance imaging (MR) scan showed a 4 cm bone lesion with substantial edema of the surrounding soft tissues (Fig. 3).
AP plain radiograph shows diaphyseal expansion and partial healing (arrow) in response to debridement and antibiotic treatment.
jbjiv04p0040g004.jpg
PMC6367193_01_jbjiv04p0040g004.jpg
F4
Plain radiographs showed smoothly-contoured periosteal reaction over the expanded medial to mid-clavicular osteomyelitis site (Fig. 4).
Axial CT image confirms clavicular expansion and reactive bone (long arrow) with surrounding soft tissue infiltration (short arrows), consistent with persistent osteomyelitis.
jbjiv04p0040g005.jpg
PMC6367193_01_jbjiv04p0040g005.jpg
F5
Her chest CT scan demonstrated a destructive lytic lesion of the medial clavicular region with surrounding edema, consistent with osteomyelitis (Fig. 5).
a. The excision specimen consisted of viable lamellar bone (top left) and new woven bone (middle left), entrapped in a fibrous matrix with vascular proliferation and extensive acute and chronic inflammation (20X original magnification). b. At higher magnification, the native lamellar bone shows extensive scalloping (black arrow) associated with a neutrophilic infiltrate (white arrows). The findings support acute osteomyelitis (200X original magnification).
jbjiv04p0040g007.jpg
PMC6367193_01_jbjiv04p0040g007.jpg
F6
Histologic findings included acute and chronic osteomyelitis with associated fibrosis and reactive woven bone formation (Fig. 6).
AP plain film more than two years after completion of treatment demonstrates improvement of appearance of the mid clavicular osteomyelitic lesion, but persistent expansion with thickened cortex (arrows).
jbjiv04p0040g008.jpg
PMC6367193_01_jbjiv04p0040g008.jpg
F7
At the time of her last follow-up visit 2-years and 3-months after her second debridement, she remained largely symptom-free, with radiographs showing healing of the smoothly-contoured expansile clavicular lesion (Fig. 7).
AP study reveals subtle medial clavicular sclerosis and inferior cortical erosion (arrow).
jbjiv04p0040g009.jpg
PMC6367193_01_jbjiv04p0040g009.jpg
F8
Plain films revealed erosion and osseous remodeling of the inferior aspect of the medial clavicle (Fig. 8).
Axial CT image confirms mixed blastic and erosive changes along the medial clavicle (arrow).
jbjiv04p0040g010.jpg
PMC6367193_01_jbjiv04p0040g010.jpg
F9
A CT scan demonstrated mixed lucency and sclerosis in this region (Fig. 9).
Coronal T2-weighted MR scan shows bone marrow edema, erosions and phlegmon inferior to medial clavicle (arrows).
jbjiv04p0040g011.jpg
PMC6367193_01_jbjiv04p0040g011.jpg
F10
An MR scan showed medial clavicular edema extending to the sternoclavicular joint with erosive changes of the clavicle and first rib, as well as fluid collections extending anteroinferiorly from the posteromedial clavicle (Fig. 10).
a. Synovium: At scanning magnification, the synovium showed slight villous hyperplasia and scant exudate (20X original magnification). b. Synovium: A moderately dense acute inflammatory infiltrate was present in the subsynovial connective tissue (200X original magnification). c. Bone: The bone was viable without significant inflammation or scalloping and thus there was no definite histologic support for acute osteomyelitis. A small focus of new, woven bone (arrows) was noted in the subperiosteal compartment, which, while nonspecific, suggested reaction to a soft tissue process (100X original magnification).
jbjiv04p0040g014.jpg
PMC6367193_01_jbjiv04p0040g014.jpg
F11
The final pathological diagnosis was acute and chronic synovitis with fibrinopurulent exudate (Fig. 11).