PMC5768246_01
First admission to our institution, 4 years ago. Lumps fixed on the subcutaneous tissue of the left arm.
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Before 4 years, he was admitted to our hospital due to painless lumps fixed on the subcutaneous tissue of the left arm (Figure 1).
First X-rays showing (AP and lateral view) distal diaphyseal involvement. The arrows show the thickening and cortical irregularity.
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Radiographs of the left humerus revealed an alteration of the bone structure with distal diaphyseal involvement and thickening and cortical irregularity, which extended up to the metaphysis (Figure 2).
CT scan, arrows showing osteolysis and periosteal reaction. Diffuse involvement of adjacent soft tissues.
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A computed tomography (CT) scan disclosed an alteration in the osseous morphology of the metaphysis-diaphysis in the distal third of the humerus at an intramedullary and cortical level, with osteolysis, periosteal reaction, diffuse involvement of adjacent soft tissues and several lower density, superficial, poorly defined liquid areas (Figure 3).
MRI showing multiple liquid deposits and muscular oedema related to joint effusion.
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A magnetic resonance imaging (MRI) scan confirmed the multiple liquid deposits on the thick walls of the soft tissues and muscular oedema related to joint effusion (Figure 4).
Digital anatomic pathology images (haematoxylin-eosin). The arrows indicate colonies of Actinomyces.
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Aspiration was performed, and the extended coloured (Diff-Quick) haematoxylin-eosin, pap-test showed lymphocytes, leukocytes, macrophages, multinucleated giant cells and accumulations of bacillary structures (Actinomyces), consistent with a granulomatous inflammatory process (Figure 5).
Immediate postoperative X-rays (AP and lateral view) after introducing first cement spacer with antibiotics.
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MRI at 3-year follow-up after first index procedure. Disease progression and spreading to the metaphysis of the proximal humerus (arrows).
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Radiology studies and an MRI scan evidenced that the disease had spread to the metaphysis of the proximal humerus (Figure 7).
Wide surgical resection of the humerus. Proximal metaphysis was preserved.
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An antibiotic cemented rod with vancomycin was inserted (Figures 8 and 9).
X-ray showing first antibiotic-coated rod.
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An antibiotic cemented rod with vancomycin was inserted (Figures 8 and 9).
X-rays showing last cemented rod with antibiotic beads.
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After 6 months, symptoms continued, the rod was replaced with a new one and antibiotic beads were inserted in the fistular areas (Figure 10).