Subscapular Bursitis and Calcinosis in a Patient With Dermatomyositis

Abstract

Clinical Images: Subscapular bursitis and calcinosis in a patient with dermatomyositisThe patient, a 59-year-old man with dermatomyositis (DM), presented with fever, chills, and acute right subscapular pain in the setting of chronic bilateral subscapular bursitis. DM had been diagnosed in 2003, based on muscle weakness, typical skin findings including shawl sign and Gottron's papules, and confirmatory muscle biopsy results. Jo-1 antibodies were absent, and the patient had not developed interstitial lung disease. The subscapular fluid collections developed during a DM flare (skin and muscle) several years after the initial diagnosis. These fluid collections persisted despite subsequent remission of the DM with hydroxychloroquine monotherapy. Prior therapies had included prednisone, azathioprine, and methotrexate. At the time of this presentation the patient had recently undergone a dental procedure and reported shaking chills and fever of 2 days' duration. Physical examination revealed significant bulging of the bilateral subscapular regions and erythema and tenderness on the right side (A). There was no evidence of rash or muscle weakness at this time. Laboratory assessments revealed leukocytosis 16.2 ϫ 10 3 /l (normal 4-10) with Ͼ80% neutrophils, a C-reactive protein level of 31 mg/dl (normal Ͻ0.8), and an erythrocyte sedimentation rate of 67 mm/hour (normal 0-20). Computed tomography confirmed bilateral subscapular fluid accumulation (arrows) with calcification of the bursa (B). Calcinosis and bursitis both occur in patients with DM, though more commonly in the juvenile population. Bursitis in this location is rare. If asymptomatic, bursitis is often not treated because it commonly recurs after aspiration. There was concern regarding possible septic bursitis in this patient; thus, the right subscapular fluid collection was aspirated, and cultures grew Streptococcus milleri. He underwent surgical drainage followed by antibiotic therapy and is currently doing well, although he reports asymptomatic reaccumulation of subscapular fluid. His DM remains in remission with hydroxychloroquine treatment.

Subscapular bursitis as a rare manifestation of dermatomyositis: a case report

“…Therefore, pain often indicates involvement of extramuscular structures. Bursitis, inflammation of the bursae, is painful and extremely rare in DM (2,3). Here we report a unique case of subscapular bursitis as the initial presentation of DM.…”