Non-healing arm wound with a discharging sinus in an elderly patient with diabetes

Abstract

A 48-year-old Filipino female presented with unilateral acute onset painful red eye, blurred vision and yellow discharge. On examination she had a corrected visual acuity of 6/5 in the right eye and 6/18 in the left eye.

There was a left-sided periorbital swelling, with chemosis involving the bulbar conjunctiva on the temporal aspect. Ocular motility showed limitation of left-sided abduction with mild limitation of laevoelevation and laevodepression. She was afebrile and systemic examination was unremarkable. Medical history included diagnosis of Crohn's disease since the age of 20. She was on oral mesalamine 1 g for mildly active colitis. Full blood count was normal but erythrocyte sedimentation rate and C reactive protein were raised. Blood culture and conjunctival swab were negative. Contrast-enhanced CT scan demonstrated enlargement of the lacrimal gland. She was managed conservatively with acetaminophen and codeine for pain and swelling.

She recovered completely in 2 weeks with no sequelae.

Description

A 70-year-old male with diabetes presented to the surgical outpatient department with an abscess like a soft tissue swelling on his right upper arm. An incision and drainage procedure (I&D) was carried out on an outpatient basis. The serous fluid thus obtained was sent for culture and sensitivity. The culture report showed sterile material. Following I&D, the patient developed a non-healing wound producing copious serous discharge which did not respond to various systemic and local antibiotics (figures 1 and 2).

Figure 1.

Wound in upper arm.

Figure 2.

Discharging sinus.

The patient also complained of pain in the right shoulder which was aggravated by movement. This was initially considered to be frozen shoulder, which is more common in people with diabetes.

A month later a bone deep sinus was found in the wound and a sonogram was ordered. The sinogram showed a sinus track going up into shoulder joint (figure 3). Exudate was stained for acid-fast bacteria (AFB) but was negative. According to Berney et al, synovial fluid smear stained for AFB is positive only in 27% of patients with tuberculous joints; 10⁴ AFB/ml is required for a result to be considered positive. Soft tissue swelling along with sinuses and cold abscesses are common in tuberculous arthritis.¹

Figure 3.

Sinogram.

Hence, a provisional diagnosis of tuberculous arthritis of the right shoulder with tuberculous sinus extending to the upper arm was made. The patient was given a therapeutic trial of antitubercular drugs.

Within a month, discharge from sinus had subsided and 3 months later the wound had healed completely (figure 4). The patient also reported marked improvement in shoulder arthritis.

Figure 4.

Healed lesion.

Tuberculous mono-arthritis involving the hip and knee is frequently reported in the literature, but there are very few reports of tuberculous shoulder. The incidence of tuberculosis of the shoulder joint is 1–2.8% of skeletal tuberculosis.² In most cases of tuberculous disease of the shoulder, an abscess may eventually occur. It may track down as a sinus to dependent parts and open up in the arm or chest. In a case reported by Panas, the sinus came to the surface below the elbow.³ Infection should be suspected early when arthritis affects a single joint, as tuberculous arthritis may destroy a joint if left untreated. The presence of an underlying debilitating condition such as diabetes mellitus, as in our case, can predispose to tuberculous arthritis.⁴

Tuberculous arthritis should be considered when a single joint is involved in a patient with an underlying debilitating condition such as diabetes mellitus.