11institutetext:
Knowledge-based Systems and Document Processing Research Group
Faculty of Computer Science
Otto-von-Guericke-University Magdeburg
11email: katrin.krieger@ovgu.de
Investigations:
A preliminary diagnostic workup of the patient revealed several
concerning findings: creatinine was slightly elevated at 1.4 mg/dL
(normal range: 0.8-1.3 mg/dL), bicarbonate was below normal at 18.5
mmol/L (normal range: 22-29 mmol/L) and PCO2 also, indicative of
metabolic acidosis. The CRP level, indicating inflammation, was markedly
elevated at 398 mg/L (normal range: 0-10 mg/L). A complete blood count
(CBC) showed anemia as hematocrit and RBC were reduced, and a notable
elevation in white blood cell count to 15 x10^9/L (normal range:
4.8-11.3 x 10^9/L). Specifically, neutrophils were significantly
elevated at 83.4% (normal range: 34.9-76.2%), while lymphocytes were
severely decreased to 7% (normal range: 17.5-45%). Subsequent liver
function tests (LFTs) showed elevated levels of total bilirubin (2.1
mg/dL; normal range: 0.1-1.2 mg/dL) and direct bilirubin (1.5 mg/dL;
normal range: 0-0.2mg/dL). Glucose levels were also consistently
elevated. Pus culture came back positive for Methicillin-Resistant
Staphylococcus aureus. CT Head and Neck with contrast showed extensive
soft tissue swelling on the left anterior chest wall with active
contrast excavation, representing hematoma with active bleed for which
the patient underwent successful embolization of pseudo aneurysm arising
from the left internal thoracic artery by Histoacryl glue (Figure 1). A
core biopsy of an anterior mediastinal mass was also done to rule out
that the mass was not due to any underlying malignancy and granulomatous
disease. Biopsy revealed severe acute and chronic inflammation, abscess
formation and granulation tissue suggestive of an infectious etiology
(Figure 2). A CT chest with contrast was performed that revealed
heterogeneous enhancing soft tissue identified in the left
sternocleidomastoid muscle, extending infero laterally along the
subcutaneous tissues of the left anterior chest wall (Figure 3). There
was also deep extension into the left upper lobe and superior
mediastinum via the thoracic inlet, causing the contralateral tracheal
shift that diagnosed it as a case of Sternoclavicular Septic Arthritis.
Furthermore, a limited Ultrasound of the arm also revealed significant
subcutaneous edema in the left upper limb.