Prolonged immobilization and, in particular, mechanical ventilation, have been linked to muscle atrophy. Anecdotal reports in the literature describe rhabdomyolysis as a potential late complication of COVID-19 infection which, in severe cases, may coexist with fluid collections. We report a case of a 28-year-old patient that had been recently hospitalized with SARS-CoV-2 pneumonia, with need for invasive ventilation support. Days after being discharged, the patient presents with retrosternal thoracalgia irradiating to the left upper limb. On physical examination, abduction and external rotation were limited due to pain complaints and there was soft tissue swelling of the corresponding shoulder and arm. Imaging evaluation was essential to establish the underlying condition, revealing bilateral arthritis communicating with large rotator cuff collections, which was considered of septic nature.info:eu-repo/semantics/publishedVersio

Alves, P

Caetano, A

Lourenço, AL

Resende Neves, T

Teiga, C

Radiology Case Reports

English

PubMed

Prolonged immobilization and, in particular, mechanical ventilation, have been linked to muscle atrophy. Anecdotal reports in the literature describe rhabdomyolysis as a potential late complication of COVID-19 infection which, in severe cases, may coexist with fluid collections. We report a case of a 28-year-old patient that had been recently hospitalized with SARS-CoV-2 pneumonia, with need for invasive ventilation support. Days after being discharged, the patient presents with retrosternal thoracalgia irradiating to the left upper limb. On physical examination, abduction and external rotation were limited due to pain complaints and there was soft tissue swelling of the corresponding shoulder and arm. Imaging evaluation was essential to establish the underlying condition, revealing bilateral arthritis communicating with large rotator cuff collections, which was considered of septic nature

Teresa Resende Neves, MD

Ana Luísa Lourenço, MD

Pedro Alves, MD

Carlos Teiga, MD

António Proença Caetano, MD

Directory of Open Access Journals

Bilateral shoulder arthritis in COVID-19 patient after prolonged mechanical ventilation assist: a case report

Repositório do Centro Hospitalar de Lisboa Central, EPE

R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8  Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/radcr Case report Bilateral shoulder arthritis in COVID-19 patient after prolonged mechanical ventilation assist: a case report ✩ , ✩✩ Teresa Resende Neves, MD a , b , ∗, Ana Luísa Lourenço, MD c , Pedro Alves, MD d , Carlos Teiga, MD e , António Proença Caetano, MD a , b a Radiology Department, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal b Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal c Radiology Department, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal d Radiology Department, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal e Radiology Department, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal a r t i c l e i n f o Article history: Received 18 June 2021 Revised 27 June 2021 Accepted 29 June 2021 Keywords: Covid-19 SARS-CoV2 arthritis immobilization mechanical ventilation musculoskeletal a b s t r a c t Prolonged immobilization and, in particular, mechanical ventilation, have been linked to muscle atrophy. Anecdotal reports in the literature describe rhabdomyolysis as a potential late complication of COVID-19 infection which, in severe cases, may coexist with fluid col- lections. We report a case of a 28-year-old patient that had been recently hospitalized with SARS-CoV-2 pneumonia, with need for invasive ventilation support. Days after being dis- charged, the patient presents with retrosternal thoracalgia irradiating to the left upper limb. On physical examination, abduction and external rotation were limited due to pain com- plaints and there was soft tissue swelling of the corresponding shoulder and arm. Imaging evaluation was essential to establish the underlying condition, revealing bilateral arthritis communicating with large rotator cuff collections, which was considered of septic nature. © 2021 Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) ✩ Acknowledgments: This research received no specific grant from  sectors. ✩✩ Competing interests: The authors declare that there is no conflict o∗ Corresponding author. E-mail address: teresaneves92@gmail.com (T.R. Neves). https://doi.org/10.1016/j.radcr.2021.06.085 1930-0433/© 2021 Published by Elsevier Inc. on behalf of University of WBY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )Downloaded for Anonymous User (n/a) at Hospital Centre of Cent2021. For personal use only. No other uses without permissiany funding agency in the public, commercial, or not-for-profitf interest. ashington. This is an open access article under the CC  ral Lisbon from ClinicalKey.com by Elsevier on August 10, on. Copyright ©2021. Elsevier Inc. All rights reserved.R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8  2895                                                                                           Introduction Coronavirus disease-2019 (COVID-19), an atypical pneumoniacaused by severe acute respiratory virus 2 (SARS-CoV-2), hasemerged in 2019. Clinical findings in COVID-19 pneumoniago beyond the respiratory tract, which can be explained bythe ubiquitous nature of its major entry receptor, angiotensin-converting enzyme 2 (ACE-2). ACE-2 is found in the endothe-lium of small vessels, bowel, smooth muscle, skeletal muscleand synovial tissue [1] . COVID-19 is mostly known for causing pulmonary man-ifestations, but can also result in multiple extra-pulmonaryconditions [ 2 ,3 ]. Several reports in the literature have re-ported on cardiac, neurologic, abdominal, dermatological, oc-ular and, less commonly, musculoskeletal manifestations.Current musculoskeletal complications reported in patientswith COVID-19 infection, however, are anecdotal. Case report A 28-year-old male patient, otherwise healthy, attended ahealth center with symptoms of fatigue, anosmia and dyspneafor progressively shorter efforts. SpO2 levels were 55%, whichimproved to 75% with nasal cannula oxygen therapy. The patient was hospitalized and evaluated at an emer-gency department. A chest radiography was ordered which re-vealed bilateral lung infiltrates. RT-PCR swab tested positivefor SARS-CoV-2 infection and the patient was admitted in aCOVID-19 infirmary unit. Non-invasive ventilation support was unsuccessful andthere was need for intubation and invasive mechanical ven-tilation with ventral decubitus positioning. Two days after ad-mission, Escherichia coli and methicillin-sensitive Staphylococ-cus aureus were detected on sputum culture and confirmed su-perinfection, which led to prescription of an 8-day regimen ofamoxicillin. Blood culture also revealed methicillin-resistantStaphylococcus aureus , which was dismissed. There was steady clinical improvement in the subsequentdays and the patient was extubated and eventually dis-charged. Seven days later, however, the patient attended the emer-gency department of our hospital with complaints of ret-rosternal thoracalgia irradiating to the left upper limb, whichhad reportedly started shortly after transfer from the inten-sive care unit to the infirmary in the previous hospital. On physical examination, abduction and external rotationwere limited due to pain complaints. There was soft tissueswelling of the shoulder and arm, fever, and increased levelsof C-reactive protein. Hemoculture and urine culture provednegative. A chest radiograph and thoracic CT were performedwhich showed typical changes compatible with sequelae ofCovid-19 pneumonia ( Fig. 1 ). Due to poor progression of the condition, he was admittedfor further investigation and treatment planning. Taking intoaccount the previous blood culture that had been dismissed,gentamicin was prescribed and administered throughout thewhole length of hospital stay. Downloaded for Anonymous User (n/a) at Hospital Centre of Centra2021. For personal use only. No other uses without permissionThoracic CT with intravenous contrast administration per-formed 9 days after admission revealed scapulohumeral syn-ovitis, with multiple intra-muscular collections that showedcontinuity with the glenohumeral joint. On the right shoulder,there was also scapulohumeral synovitis and less pronouncedjoint fluid ( Fig. 2 ). Bilateral shoulder magnetic resonance imaging (MRI) withintravenous contrast administration was performed, due topersistent shoulder pain and weakness. Findings included in-fraspinatus fossa and subscapular fossa collections on theleft shoulder, extending and communicating with the gleno-humeral joint, with capsular thickening and increased sig-nal intensity post-gadolinium administration ( Fig. 3 ); the rightshoulder showed similar changes but they were less pro-nounced. These features were suggestive of septic arthri-tis and rotator cuff collections, possibly associated with my-onecrosis. Aspiration of the infraspinatus fossa collection was per-formed and 20 cc of seropurulent fluid was sent for analysis.An 8,5 Fr drainage catheter was left on the left infraspinatuscollection, but was removed the day after due to patient com-plaints of discomfort. Evaluation of the aspirate included bothdirect and culture tests for Mycobacterium tuberculosis , anaero-bic and aerobic bacteria, which were negative. There was some improvement of left shoulder range of mo-tion, after physical rehabilitation exercises. Patient was even-tually transferred to another hospital with indication to con-tinue physical therapy and rehabilitation exercises. Discussion Prolonged immobilization and, in particular, mechanical ven-tilation, have been linked to muscle atrophy and considered arisk factor for development of heterotopic ossification aroundthe shoulder [ 4 ,5 ,6 ]. Patients who survive after prolonged mechanical ventila-tion are prone to develop delirium, lung damage, muscle at-rophy and weakness. Even after resolution of the pulmonarysymptoms, reconstitution of normal cognitive and physicalaptitude requires a long-term rehabilitation process, wherephysical and occupational therapists play a fundamental role[2] . A potential late complication of COVID-19 infection is rhab-domyolysis [ 7 ,8 ], a life-threatening condition with a diagnosisthat is mainly clinical, manifesting as myalgia, fatigue, pig-menturia and acute renal failure [9] . Imaging findings includeenlargement of the affected muscles, which may be heteroge-neous and hypodense on CT. MRI is the best modality to depict extent and severity ofinjury, with hyperintense signal on fluid-sensitive sequencesand heterogeneous enhancement following intravenous con-trast administration [10] . An alternative presentation mayshow rim enhancement. In severe cases, myonecrosis may co-exist in the form of small heterogeneous muscle foci with hy-perintense signal on fluid-sensitive sequences with rim en-hancement. Aside from rhabdomyolysis, a few cases of arthritisassociated with COVID-19 infection have been reportedl Lisbon from ClinicalKey.com by Elsevier on August 10, . Copyright ©2021. Elsevier Inc. All rights reserved.2896 R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8  Fig. 1 – Chest x-ray (A) and thoracic CT (B) performed at admission at our hospital show typical findings of COVID-19 pneumonia, namely bilateral peripheral ground glass opacities with greater involvement of the lower lobes. Fig. 2 – Post-contrast Thoracic CT (axial view) performed 9 d after admission at our hospital reveals rotator cuff collections and glenohumeral joint fluid with capsule enhancement on the left shoulder. There is some heterogeneity and enhancement of the right infraspinatus muscle. Downloaded for Anonymous User (n/a) at Hospital Centre of Central Lisbon from ClinicalKey.com by Elsevier on August 10, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8  2897 Fig. 3 – Axial (A), coronal (B) fat-saturated PD and axialpost-contrast fat-saturated T1-weighted (C) MRI performed 12 days after admission to our hospital shows a large left shoulder rotator cuff collection communicating with the glenohumeral joint, which is distended with fluid and demonstrates capsule hyperenhancement compatible with synovitis. Axial fat-saturated PD MRI of the right shoulder (D) demonstrates similar but less pronounced findings on the left shoulder.                     [11–16] . Indeed, a systematic review of rheumatologic findingsin COVID-19 patients concludes that muscle pain and fatigueare present in 19% and 32% of patients as an initial presen-tation, with an overall prevalence of 16% and 36% through-out the course of the disease, respectively [17] . Recent reportsclaim that arthralgia is present in about 2,5% of patients af-fected by this disease. [18] Furthermore, there have been somereports regarding triggering of chronic rheumatologic diseasesby COVID-19 infection, which will have features that are char-acteristic of the underlying condition, in the majority of cases[18] . Serological and joint fluid tests help to exclude othercauses of arthropathy [18] , since, to the best of our knowledge,there is no characteristic imaging feature of COVID-19 inducedarthralgia. Regarding our case, the patient had no known arthropa-thy, there were no previous shoulder problems or episodes ofarthritis reported. No causative agent was detected, but hewas under an antibiotic regimen, which may have affectedlab results. Ultimately, the cause of bilateral shoulder arthritisremained unknown, but was presumed of septic nature andtreated accordingly. Patient consent Written informed consent was obtained from the patient. Downloaded for Anonymous User (n/a) at Hospital Centre of Centra2021. For personal use only. No other uses without permissionR E F E R E N C E S  [1] Li MY , Li L , Zhang Y , Wang XS . Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues. Infect Dis Poverty 2020;9(1):45 .[2] Revzin MV , Raza S , Srivastava NC , Warshawsky R ,D’Agostino C , Malhotra A , et al. Multisystem imaging manifestations of COVID-19, Part 2: from cardiac complications to pediatric manifestations. Radiographics 2020;40:1866–92 .[3] Wang T , Du Z , Zhu F , et al. Comorbidities and multiorgan injuries in the treatment of COVID-19. Lancet 2020;395(10228):e52 .[4] Van Lotten ML , Schreinemakers JR , van Noort A ,Rademakers MV . Bilateral scapulohumeral ankylosis after prolonged mechanical ventilation. Clin Orthop Surg 2016;8:339–44 .[5] Christakou A , Alimatiri M , Kouvarakos A , et al. Heterotopic ossification in critical ill patients: a review. Int J Physiother Res 2013;1(4):188–95 .[6] Nauth A , Giles E , Potter BK , et al. Heterotopic ossification in orthopaedic trauma. J Orthop Trauma 2012;26(12):684–8 .[7] Suwanwongse K , Shabarek N . Rhabdomyolysis as a presentation of 2019 novel coronavirus disease. Cureus 2020;12(4):e7561 .[8] Jin M , Tong Q . Rhabdomyolysis as potential late complicationassociated with COVID-19. Emerg Infect Dis 2020;26(7):1618–20 .[9] Ashraf O , Young M , Malik KJ , Cheema T . Systemic l Lisbon from ClinicalKey.com by Elsevier on August 10, . Copyright ©2021. Elsevier Inc. All rights reserved.2898 R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8   complications of COVID-19. Crit Care Nurs Q 2020;43(4):390–9 .[10] Moratalla MB , Braun P , Fornas GM . Importance of MRI in the diagnosis and treatment of rhabdomyolysis. Eur J Radiol 2008;65(2):311–15 .[11] Novelli L , Motta F , Ceribelli A , Guidelli GM , Luciano N ,Isailovic N , et al. A case of psoriatic arthritis triggered by SARS-CoV-2 infection. Rheumatology 2020;60(1):e21–3 .[12] Saricaoglu EM , Hasanoglu I , Guner R . The first reactive arthritis case associated with COVID-19. J Med Virol 2020 (in press) .[13] De Stefano L , Rossi S , Montecucco C , Bugatti S . Transient monoarthritis and psoriatic skin lesions following COVID-19.Ann Rheum Dis 2020 (in press) .[14] Talarico R , Stagnaro C , Ferro F , Carli L , Mosca M . Symmetric peripheral polyarthritis developed during SARS-CoV-2 infection. Lancet Rheumatol 2020;2:e518–19 .Downloaded for Anonymous User (n/a) at Hospital Centre of Cent2021. For personal use only. No other uses without permissi[15] Alivernini S , Cingolani A , Gessi M , Paglionico A , Pasciuto G ,Tolusso B , et al. Comparative analysis of synovial inflammation after SARS-CoV-2 infection. Ann Rheum Dis 2020 (in press) .[16] Ono K , Kishimoto M , Shimasaki T , et al. Reactive arthritis after COVID-19 infection. RMD Open 2020;6(2):1–4 e001350 .[17] Ciaffi J , Meliconi R , Ruscitti P , Berardicurti O , Giacomelli R ,Ursini F . Rheumatic manifestations of COVID-19: a systematic review and meta-analysis. BMC Rheumatology 2020;4:65 .[18] Ramani S , Samet J , Franz C , Hsieh C , Nguyen C , Horbinski C ,et al. Musculoskeletal involvement of COVID-19: review of imaging. Skelet Radiol 2021;1:1–11 .ral Lisbon from ClinicalKey.com by Elsevier on August 10, on. Copyright ©2021. Elsevier Inc. All rights reserved.

Bilateral Shoulder Arthritis in COVID-19 Patient After Prolonged Mechanical Ventilation Assist: a Case Report

Prolonged immobilization and, in particular, mechanical ventilation, have been linked to muscle atrophy. Anecdotal reports in the literature describe rhabdomyolysis as a potential late complication of COVID-19 infection which, in severe cases, may coexist with fluid collections. We report a case of a 28-year-old patient that had been recently hospitalized with SARS-CoV-2 pneumonia, with need for invasive ventilation support. Days after being discharged, the patient presents with retrosternal thoracalgia irradiating to the left upper limb. On physical examination, abduction and external rotation were limited due to pain complaints and there was soft tissue swelling of the corresponding shoulder and arm. Imaging evaluation was essential to establish the underlying condition, revealing bilateral arthritis communicating with large rotator cuff collections, which was considered of septic nature.publishersversionpublishe

Neves, Teresa Resende

Lourenço, Ana Luísa

Alves, Pedro

Teiga, Carlos

Caetano, António Proença

Repositório da Universidade Nova de Lisboa

R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8  Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/radcr Case report Bilateral shoulder arthritis in COVID-19 patient after prolonged mechanical ventilation assist: a case report ✩ , ✩✩ Teresa Resende Neves, MD a , b , ∗, Ana Luísa Lourenço, MD c , Pedro Alves, MD d , Carlos Teiga, MD e , António Proença Caetano, MD a , b a Radiology Department, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal b Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal c Radiology Department, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal d Radiology Department, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal e Radiology Department, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal a r t i c l e i n f o Article history: Received 18 June 2021 Revised 27 June 2021 Accepted 29 June 2021 Available online 1 August 2021 Keywords: Covid-19 SARS-CoV2 arthritis immobilization mechanical ventilation musculoskeletal a b s t r a c t Prolonged immobilization and, in particular, mechanical ventilation, have been linked to muscle atrophy. Anecdotal reports in the literature describe rhabdomyolysis as a potential late complication of COVID-19 infection which, in severe cases, may coexist with fluid col- lections. We report a case of a 28-year-old patient that had been recently hospitalized with SARS-CoV-2 pneumonia, with need for invasive ventilation support. Days after being dis- charged, the patient presents with retrosternal thoracalgia irradiating to the left upper limb. On physical examination, abduction and external rotation were limited due to pain com- plaints and there was soft tissue swelling of the corresponding shoulder and arm. Imaging evaluation was essential to establish the underlying condition, revealing bilateral arthritis communicating with large rotator cuff collections, which was considered of septic nature. © 2021 Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) ✩ Acknowledgments: This research received no specific grant from  sectors. ✩✩ Competing interests: The authors declare that there is no conflict o∗ Corresponding author. E-mail address: teresaneves92@gmail.com (T.R. Neves). https://doi.org/10.1016/j.radcr.2021.06.085 1930-0433/© 2021 Published by Elsevier Inc. on behalf of University of WBY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )any funding agency in the public, commercial, or not-for-profitf interest. ashington. This is an open access article under the CC  R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8  2895                                                                                           Introduction Coronavirus disease-2019 (COVID-19), an atypical pneumoniacaused by severe acute respiratory virus 2 (SARS-CoV-2), hasemerged in 2019. Clinical findings in COVID-19 pneumoniago beyond the respiratory tract, which can be explained bythe ubiquitous nature of its major entry receptor, angiotensin-converting enzyme 2 (ACE-2). ACE-2 is found in the endothe-lium of small vessels, bowel, smooth muscle, skeletal muscleand synovial tissue [1] . COVID-19 is mostly known for causing pulmonary man-ifestations, but can also result in multiple extra-pulmonaryconditions [ 2 ,3 ]. Several reports in the literature have re-ported on cardiac, neurologic, abdominal, dermatological, oc-ular and, less commonly, musculoskeletal manifestations.Current musculoskeletal complications reported in patientswith COVID-19 infection, however, are anecdotal. Case report A 28-year-old male patient, otherwise healthy, attended ahealth center with symptoms of fatigue, anosmia and dyspneafor progressively shorter efforts. SpO2 levels were 55%, whichimproved to 75% with nasal cannula oxygen therapy. The patient was hospitalized and evaluated at an emer-gency department. A chest radiography was ordered which re-vealed bilateral lung infiltrates. RT-PCR swab tested positivefor SARS-CoV-2 infection and the patient was admitted in aCOVID-19 infirmary unit. Non-invasive ventilation support was unsuccessful andthere was need for intubation and invasive mechanical ven-tilation with ventral decubitus positioning. Two days after ad-mission, Escherichia coli and methicillin-sensitive Staphylococ-cus aureus were detected on sputum culture and confirmed su-perinfection, which led to prescription of an 8-day regimen ofamoxicillin. Blood culture also revealed methicillin-resistantStaphylococcus aureus , which was dismissed. There was steady clinical improvement in the subsequentdays and the patient was extubated and eventually dis-charged. Seven days later, however, the patient attended the emer-gency department of our hospital with complaints of ret-rosternal thoracalgia irradiating to the left upper limb, whichhad reportedly started shortly after transfer from the inten-sive care unit to the infirmary in the previous hospital. On physical examination, abduction and external rotationwere limited due to pain complaints. There was soft tissueswelling of the shoulder and arm, fever, and increased levelsof C-reactive protein. Hemoculture and urine culture provednegative. A chest radiograph and thoracic CT were performedwhich showed typical changes compatible with sequelae ofCovid-19 pneumonia ( Fig. 1 ). Due to poor progression of the condition, he was admittedfor further investigation and treatment planning. Taking intoaccount the previous blood culture that had been dismissed,gentamicin was prescribed and administered throughout thewhole length of hospital stay. Thoracic CT with intravenous contrast administration per-formed 9 days after admission revealed scapulohumeral syn-ovitis, with multiple intra-muscular collections that showedcontinuity with the glenohumeral joint. On the right shoulder,there was also scapulohumeral synovitis and less pronouncedjoint fluid ( Fig. 2 ). Bilateral shoulder magnetic resonance imaging (MRI) withintravenous contrast administration was performed, due topersistent shoulder pain and weakness. Findings included in-fraspinatus fossa and subscapular fossa collections on theleft shoulder, extending and communicating with the gleno-humeral joint, with capsular thickening and increased sig-nal intensity post-gadolinium administration ( Fig. 3 ); the rightshoulder showed similar changes but they were less pro-nounced. These features were suggestive of septic arthri-tis and rotator cuff collections, possibly associated with my-onecrosis. Aspiration of the infraspinatus fossa collection was per-formed and 20 cc of seropurulent fluid was sent for analysis.An 8,5 Fr drainage catheter was left on the left infraspinatuscollection, but was removed the day after due to patient com-plaints of discomfort. Evaluation of the aspirate included bothdirect and culture tests for Mycobacterium tuberculosis , anaero-bic and aerobic bacteria, which were negative. There was some improvement of left shoulder range of mo-tion, after physical rehabilitation exercises. Patient was even-tually transferred to another hospital with indication to con-tinue physical therapy and rehabilitation exercises. Discussion Prolonged immobilization and, in particular, mechanical ven-tilation, have been linked to muscle atrophy and considered arisk factor for development of heterotopic ossification aroundthe shoulder [ 4 ,5 ,6 ]. Patients who survive after prolonged mechanical ventila-tion are prone to develop delirium, lung damage, muscle at-rophy and weakness. Even after resolution of the pulmonarysymptoms, reconstitution of normal cognitive and physicalaptitude requires a long-term rehabilitation process, wherephysical and occupational therapists play a fundamental role[2] . A potential late complication of COVID-19 infection is rhab-domyolysis [ 7 ,8 ], a life-threatening condition with a diagnosisthat is mainly clinical, manifesting as myalgia, fatigue, pig-menturia and acute renal failure [9] . Imaging findings includeenlargement of the affected muscles, which may be heteroge-neous and hypodense on CT. MRI is the best modality to depict extent and severity ofinjury, with hyperintense signal on fluid-sensitive sequencesand heterogeneous enhancement following intravenous con-trast administration [10] . An alternative presentation mayshow rim enhancement. In severe cases, myonecrosis may co-exist in the form of small heterogeneous muscle foci with hy-perintense signal on fluid-sensitive sequences with rim en-hancement. Aside from rhabdomyolysis, a few cases of arthritisassociated with COVID-19 infection have been reported2896 R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8  Fig. 1 – Chest x-ray (A) and thoracic CT (B) performed at admission at our hospital show typical findings of COVID-19 pneumonia, namely bilateral peripheral ground glass opacities with greater involvement of the lower lobes. Fig. 2 – Post-contrast Thoracic CT (axial view) performed 9 d after admission at our hospital reveals rotator cuff collections and glenohumeral joint fluid with capsule enhancement on the left shoulder. There is some heterogeneity and enhancement of the right infraspinatus muscle. R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8  2897 Fig. 3 – Axial (A), coronal (B) fat-saturated PD and axialpost-contrast fat-saturated T1-weighted (C) MRI performed 12 days after admission to our hospital shows a large left shoulder rotator cuff collection communicating with the glenohumeral joint, which is distended with fluid and demonstrates capsule hyperenhancement compatible with synovitis. Axial fat-saturated PD MRI of the right shoulder (D) demonstrates similar but less pronounced findings on the left shoulder.                     [11–16] . Indeed, a systematic review of rheumatologic findingsin COVID-19 patients concludes that muscle pain and fatigueare present in 19% and 32% of patients as an initial presen-tation, with an overall prevalence of 16% and 36% through-out the course of the disease, respectively [17] . Recent reportsclaim that arthralgia is present in about 2,5% of patients af-fected by this disease. [18] Furthermore, there have been somereports regarding triggering of chronic rheumatologic diseasesby COVID-19 infection, which will have features that are char-acteristic of the underlying condition, in the majority of cases[18] . Serological and joint fluid tests help to exclude othercauses of arthropathy [18] , since, to the best of our knowledge,there is no characteristic imaging feature of COVID-19 inducedarthralgia. Regarding our case, the patient had no known arthropa-thy, there were no previous shoulder problems or episodes ofarthritis reported. No causative agent was detected, but hewas under an antibiotic regimen, which may have affectedlab results. Ultimately, the cause of bilateral shoulder arthritisremained unknown, but was presumed of septic nature andtreated accordingly. Patient consent Written informed consent was obtained from the patient. R E F E R E N C E S  [1] Li MY , Li L , Zhang Y , Wang XS . Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues. Infect Dis Poverty 2020;9(1):45 .[2] Revzin MV , Raza S , Srivastava NC , Warshawsky R ,D’Agostino C , Malhotra A , et al. Multisystem imaging manifestations of COVID-19, Part 2: from cardiac complications to pediatric manifestations. Radiographics 2020;40:1866–92 .[3] Wang T , Du Z , Zhu F , et al. Comorbidities and multiorgan injuries in the treatment of COVID-19. Lancet 2020;395(10228):e52 .[4] Van Lotten ML , Schreinemakers JR , van Noort A ,Rademakers MV . Bilateral scapulohumeral ankylosis after prolonged mechanical ventilation. Clin Orthop Surg 2016;8:339–44 .[5] Christakou A , Alimatiri M , Kouvarakos A , et al. Heterotopic ossification in critical ill patients: a review. Int J Physiother Res 2013;1(4):188–95 .[6] Nauth A , Giles E , Potter BK , et al. Heterotopic ossification in orthopaedic trauma. J Orthop Trauma 2012;26(12):684–8 .[7] Suwanwongse K , Shabarek N . Rhabdomyolysis as a presentation of 2019 novel coronavirus disease. Cureus 2020;12(4):e7561 .[8] Jin M , Tong Q . Rhabdomyolysis as potential late complicationassociated with COVID-19. Emerg Infect Dis 2020;26(7):1618–20 .[9] Ashraf O , Young M , Malik KJ , Cheema T . Systemic 2898 R a d i o l o g y  C a s e  R e p o r t s  1 6  ( 2 0 2 1 )  2 8 9 4 – 2 8 9 8   complications of COVID-19. Crit Care Nurs Q 2020;43(4):390–9 .[10] Moratalla MB , Braun P , Fornas GM . Importance of MRI in the diagnosis and treatment of rhabdomyolysis. Eur J Radiol 2008;65(2):311–15 .[11] Novelli L , Motta F , Ceribelli A , Guidelli GM , Luciano N ,Isailovic N , et al. A case of psoriatic arthritis triggered by SARS-CoV-2 infection. Rheumatology 2020;60(1):e21–3 .[12] Saricaoglu EM , Hasanoglu I , Guner R . The first reactive arthritis case associated with COVID-19. J Med Virol 2020 (in press) .[13] De Stefano L , Rossi S , Montecucco C , Bugatti S . 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a case report

http://repositorio.chlc.min-saude.pt/bitstream/10400.17/3980/1/Radiol%20Case%20Rep%202021%202894.pdf

Bilateral Shoulder Arthritis in COVID-19 Patient After Prolonged Mechanical Ventilation Assist: a Case Report

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