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Picture of the Month Quiz

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Figure 1.

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Figure 3.

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.

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).

For a complete discussion of this month's case, read next month's Picture of the Month—Quiz Case. For a complete discussion of last month's case, read this month's Picture of the Month—Quiz Case.