Image Quiz
Shoulder Pain, Fever, and Chills in a Fifty-Three-Year-Old Man1
A fifty-three-year-old, right-hand-dominant man presented to the emergency department of our institution with a two-week history of progressive pain in the right shoulder, fever, and chills. In the week before admission, he first was seen by a local chiropractor and then was seen in the emergency room of another hospital. In both instances, the patient was diagnosed with a muscle strain and was managed with pain medication and muscle relaxants. The shoulder pain gradually increased in intensity over the two-week period before admission, ultimately escalating to the point at which the patient was unable to move the shoulder girdle without severe pain. Pain and the sensation of fullness were localized to the posterior aspect of the shoulder in the scapular and axillary regions. The patient denied having sustained any blunt or penetrating trauma to the shoulder region, and he had undergone no previous operations on the right shoulder. He had had no contact with any infectious individual and had no history of skin infection or dermal compromise, systemic illnesses or immunocompromise, recent infection, intravenous drug usage, or previous aspirations or injections about the shoulder.
During the initial evaluation in our emergency department, the oral temperature was 100.9°F (37.8°C). Visual inspection of the right shoulder girdle demonstrated moderate erythema and edema of the scapular and axillary regions. The patient had scapular winging. There was severe tenderness along the swollen medial and inferior borders of the scapula as well as in the adjacent axillary region. The patient reported no pain during palpation of the anterior glenohumeral joint region, the subacromial region, the acromioclavicular joint, or the sternoclavicular joint. Range of motion was severely limited secondary to pain: active forward elevation to 70°, abduction to 45°, and external rotation to 10° were all associated with extreme discomfort. Motor and sensory examinations revealed that the axillary, radial, ulnar, and median nerve functions were intact. Brisk radial and ulnar pulses were palpable at the wrist.
The serum white blood-cell count on the day of admission was 22,000/mm3 (22.0 × 109/L) (normal, 4000 to 11,000/mm3 [4.0 to 11.0 × 109/L]), with 79% neutrophils, 2% lymphocytes, 8% monocytes, and 0% eosinophils and basophils. The platelet count was 571,000/mm3 (571.0 × 109/L) (normal, 140,000 to 400,000/mm3 [140.0 to 400.0 × 109/L]). The Westergren erythrocyte sedimentation rate was 105 mm/hr (normal, 0 to 20 mm/hr). The C-reactive protein level was 14.24 µg/dL (142 µg/L) (normal, 0 to 0.4 µg/dL [0 to 4 µg/L]). Cultures of blood specimens were obtained at the time of admission and ultimately were found to be negative. Urinalysis and a chest radiograph did not identify a source of infection. Liver-function tests were normal, and hepatitis screening tests were negative for hepatitis B (HBsAg) and hepatitis C (HCV Ab). The test for the human immunodeficiency virus was negative. MRI examinations of the shoulder were acquired.
Fig. 1 |
Fig. 1 Axial T1-weighted magnetic resonance image (with fat saturation following intravenous injection of gadolinium) through the middle portion of the chest.
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Fig. 2 |
Fig. 2 Coronal magnetic resonance image.
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