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Special Feature
May 2013

Picture of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Paediatrics, University of Melbourne, Parkville, Australia (Dr Tebruegge); and Department of Paediatric Infectious Diseases and Immunology, University Hospitals Southampton NHS Foundation Trust (Drs Tebruegge, Sukhtankar, Patel, and Faust), Academic Unit of Clinical & Experimental Sciences, Faculty of Medicine and Institute for Life Sciences, University of Southampton (Drs Tebruegge and Faust), and National Institute for Health Research Wellcome Trust Clinical Research Facility (Drs Sukhtankar and Faust), Southampton, England.

JAMA Pediatr. 2013;167(5):483. doi:10.1001/jamapediatrics.2013.7a

A 17-year-old boy presented to our hospital with a 4-week history of pain and restriction of movement in his left shoulder. Two weeks prior to presentation, he had developed a skin lesion on the anterior aspect of the same shoulder. At that point, radiographs of the shoulder (Figure 1) and chest (Figure 2) were obtained. It was assumed that he had a superficial skin infection, which prompted treatment with amoxicillin–clavulanate potassium without improvement.

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Figure 1. Plain radiograph of the left shoulder at initial presentation. While the radiograph was initially interpreted as normal, arrows indicate an osteolytic lesion in the acromion.

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Figure 2. Plain chest radiograph at initial presentation.

The patient had been born in Nepal, where he had lived until 2 years prior when he had migrated to the United Kingdom with his family. He had persistent back pain for the last 3 years as well as intermittent pyrexia for the last 4 weeks. There was no history of recent travel or exposure to farm animals.

On physical examination, a round ulcer (1.0 cm in diameter) with purulent discharge but without surrounding erythema was found on his left shoulder and he had marked kyphoscoliosis; no further abnormal findings were noted. However, magnetic resonance imaging of his spine revealed further significant pathology (Figure 3).

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Figure 3. Spinal magnetic resonance image.

What is your diagnosis?