Quick follow-up regarding the humeral greater tuberosity erosion case. Most responses favored calcific tendonitis/HADD vs infection. Due to some uncertainty, a CT-guided biopsy of the greater tuberosity erosion was performed and negative for infection or other etiology. In the end, this must be calcific tendonitis/HADD with exuberant erosion. As some mentioned, we probably caught the case during the resorptive phase hence the faint calcification and exuberant inflammation.
Drew
On Sat, Mar 2, 2024 at 1:46 PM Drew wrote:
Hello-
Looking for advice on this case. All work-up so far at an outside hospital. Referred for second opinion to one of our ortho tumor surgeons.
64 yo with acute onset shoulder pain and weakness beginning of January. No specific injury. See initial xray with subsequent xrays demonstrating fairly rapid humeral erosion or osteolysis at greater tuberosity. Faint rotator cuff calcification.
First non-contrast MRI on 1/23 show supraspinatus tendon tearing, synovitis and bursitis, and edema at the greater tuberosity
Follow-up contrast enhanced MRI on 2/8 shows increased supraspinatus tendon tearing, increased greater tuberosity edema and erosion, and thick enhancing synovitis and bursitis. Little joint fluid (when able to review all images), pretty much all thick synovitis.
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Probably unrelated and to confuse matters, the patient has also experienced an unintentional weight loss. This led to his doctors ordering myeloma labs with elevated serum protein and mildly elevated light chains, but I guess at levels where there was low concern for myeloma. A CT C/A/P was also obtained. You can see part of the proximal humerus erosion.
A shoulder aspiration was performed with only drops of fluid obtained. Cultures have shown no growth. Has had fluctuating but increased inflammatory markers.
The rapid bone erosion/osteolysis is certainly concerning. My main thoughts were infection (so far ruled out but very little fluid aspirated), calcific tendonitis with subsequent bone erosion and cuff tear, or some inflammatory arthritis gone wild following cuff tear. No other notable joint pains. I want this to be calcific tendonitis with corresponding cuff tear, but the other cases I’ve seen of intra-osseous extension of calcific tendonitis with erosion have been a bit more obvious than this case (ie globular calcifications with visualization of the hypointense calcifications at the site of erosion, which I don’t see in this case). It’s hard for me to be totally confident on this diagnosis. I’ve never seen these types of osseous changes after a plain old cuff tear. The orthopedic surgeons are understandably reluctant to address the cuff tear without a confident understanding for the cause of the rapid greater tuberosity erosion. This case was referred due to an outside concern for malignancy, which I feel is unlikely given the rapid evolution and the marrow changes at the greater tuberosity to me looks like edema, not some marrow replacing process. I feel infection remains a possibility despite the minimal joint fluid. Any thoughts or recommendations on this case would be much appreciated. Not sure the best course of action.
