Clavicular eosinophilic granuloma causing adult shoulder pain

Abstract

Though rarely reported, neoplasms of the clavicle occur, and their symptoms can be mistaken for more common shoulder conditions. We present the case of a benign clavicular neoplasm, rarely seen in adults, presenting with pain, and eventual pathologic fracture in a 49 year-old. A 49 year-old male firefighter underwent arthroscopic rotator cuff repair for shoulder pain after magnetic resonance imaging revealed supraspinatus tendon tear. The patient's pain persisted after surgery, and was described as routine until he developed severe pain after minor blunt trauma. A local Emergency Room performed the first x-rays, which revealed a pathologic fracture of the distal clavicle through a destructive lesion. The patient was referred to an orthopedic oncologist, who performed incisional biopsy, which initially diagnosed osteomyelitis. The patient was subsequently taken to surgery for debridement. Pathology then yielded the diagnosis of eosinophilic granuloma. The patient was taken back to surgery for formal curettage with open reduction and internal fixation. The patient's pain resolved, the pathologic fracture fully healed, and the patient returned to full time work as a firefighter. Though workup for common shoulder conditions often identifies incidental benign lesions of bone, the converse can be true. Persistent pain despite intervention should raise concern for further investigation. An x-ray alone can reveal a destructive bone lesion as the source of shoulder pain.

Keywords: bone tumors; oncology; pathologic fracture..

Figure 1

This radiograph reveals the patient's destructive lesion in the right distal clavicle.

Figure 2

This bone scan reveals increased uptake (mineralization) localized to the right clavicle.

Figure 3

The computed tomography scan reveals a destructive clavicular lesion with associated pathologic fracture.

Figure 4

A) This high power Haematoxylin & Eosin stain reveals histiocytes, lymphocytes, and polymorphonuclear leukocytes amidst hyalinized vesses and a fibrous stroma, consistent with osteomyelitis or hematologic neoplasm; B) this S100 immunostain shows weak positivity or negativity, suggesting against the diagnosis of eosinophilic granuloma.

Figure 5

This intraoperative photograph shows the clavicle after I&D and antibiotic bead placement.

Figure 6

A) This high power immunostain demonstrates CD1a positivity, favoring the diagnosis of eosinophilic granuloma; B) this high power specialized immunostain displays Langerin positivity, further confirming the diagnosis of eosinophilic granuloma.

Figure 7

A) This intraoperative photograph shows the clavicle after open reduction and internal fixation with bone grafting; B) this intraoperative radiograph of the right clavicle demonstrates the open reduction and internal fixation of the clavicular pathologic fracture.

Figure 8

This radiograph taken 1 year postoperatively shows the healed pathologic fracture with consolidation of the former lesion.