An uncommon cause of severe XXXX .

@entity1 @entity662 @entity4 @entity1337 @entity281 @entity158 @entity272 @entity26645 @entity1580 @entity130 @entity1851
Case A @entity1 of Greek descent, employed as a furniture installer, aged 38 years and generally well, presented with gradual-onset, progressive, excruciating @entity662 with severe limitation of left shoulder movements. He first noticed a @entity158 around the left upper chest region, which was exacerbated by shoulder movements. Within a few hours, the @entity158 worsened and was accompanied by left shoulder stiffness. He presented twice to the emergency department within 2 days, but his condition was diagnosed as @entity158 following normal shoulder X-ray and electrocardiogram (ECG), and he was discharged with oral opioid @entity1337 . He presented a third time to the emergency department with extreme upper anterior @entity662 , refractory to oral @entity1337 . He was otherwise systemically well and had no fever, @entity281 . He denied @entity130 , new tattoos, intravenous drug use or @entity272 on the chest. He had not been sexually active for the @entity26645 year and had been in a monogamous heterosexual relationship for 4 years prior. Examination revealed mild erythema in the left sternoclavicular region with no overt swelling or @entity272 . The upper anterior chest wall was tender to palpation, especially in the left medial clavicular region, and range of movement of the left shoulder was very limited. The initial diagnosis was pectoralis muscle tear and treatment included @entity1337 and a shoulder immobiliser sling for 2 days. However, his severe @entity158 continued to worsen, despite non-opioid and opioid @entity1337 , and was disproportionate to the working diagnosis. He remained afebrile throughout his hospital stay. Results of laboratory tests performed on day 3 of admission showed a white cell count (WCC) of 11.6 x 10/L (normal range 4.5-13.5 x 10/L) and @entity1851 ( @entity1851 ) of 119 mg/L (normal range <5 mg/L). Weight-bearing X-rays of his left shoulder and acromioclavicular joint were unremarkable. Computerised tomography (CT) chest angiography revealed no cause for @entity662 , particularly no @entity1580 . Magnetic resonance imaging (MRI, Figure 1) showed severe @entity4 involving the upper chest wall, predominantly centred around the left sternoclavicular joint, and surrounding @entity4 within the pectoralis major muscle superficial to the joint, as well as deep to the joint and the sternum. No frank bony destruction was noted. Figure 1. T2 weighted images (transverse and coronal) show severe @entity4 involving the upper left chest wall, predominantly around the left sternoclavicular joint. @entity4 is present within the pectoralis major muscle superficial to the joint as well as the mediastinum deep to the joint and the sternum.
