Exercise-induced Thoracic Outlet Syndrome and Concomitant Osteomyelitis in Cervical Rib with a Possible Familial Origin, a Case Report.

Abstract

BackgroundCervical ribs are a rare and usually asymptomatic occurrence. Most are identified incidentally by Roentgenogram (X-rays). However, occasionally they can cause nerve impingements and compressive symptoms. In cervical ribs, osteomyelitis secondary to trauma is unheard of. We report such a case made more interesting by the familial presence of bilateral cervical ribs in 2 generations. This indicates a possible familial origin. Case presentationA 26-year-old woman known to have fibromyalgia presented with left shoulder pain and fever episodes. She was recently discharged from intensive physiotherapy for fibromyalgia management, but the pain aggravated instead of getting better unilaterally in the left arm after discharge. Electric shock-like sensations and reduced strength accompanied this. An evaluation revealed leukocytosis and S. aureus positive blood and urine cultures along with bilateral complete cervical ribs showing pseudoarthrosis of anterior left cervical rib. A collection was noted in the left scalene muscle near the pseudoarthrosis accompanying focal edema suggesting osteomyelitis. Transthoracic echocardiogram (TTE) ruled out infective endocarditis. Thoracic surgery recommended conservative management, and appropriate antibiotics were given, which resulted in the negative culture on day 6. The patient was discharged on appropriate analgesia, and her pain was significantly improved on discharge.ConclusionsThis is the first reported case of osteomyelitis in the cervical rib. This report also highlights the possibility of cervical ribs having a familial origin. Additionally, as in our patient, certain exercises can be a risk factor for inducing TOS in patients with cervical rib.