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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 166-168

Rice body formation in a case of subdeltoid bursa tuberculosis: An uncommon presentation


Department of Radiodiagnosis, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Web Publication23-Nov-2017

Correspondence Address:
Mohd Ilyas
Department of Radiodiagnosis, Government Medical College, Jammu - 180 001, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_88_17

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  Abstract 


Rice bodies looking like swelling on specific magnetic resonance sequences are an unusual presentation of subdeltoid tuberculous inflammatory involvement. Rice bodies represent the infarcted or sloughed off synovium due to the inflammatory process. We present a case of a 21-year-old male patient who complained of a soft-tissue swelling around the right shoulder presumed to be a lipoma. The aim of presenting this case is to expand the differential diagnosis of soft-tissue swelling around the shoulder whenever such a condition is encountered.

Keywords: Magnetic resonance imaging, rice body shoulder, tuberculous subdeltoid bursitis


How to cite this article:
Ilyas M, Bhat TA, Dev G. Rice body formation in a case of subdeltoid bursa tuberculosis: An uncommon presentation. Biomed Biotechnol Res J 2017;1:166-8

How to cite this URL:
Ilyas M, Bhat TA, Dev G. Rice body formation in a case of subdeltoid bursa tuberculosis: An uncommon presentation. Biomed Biotechnol Res J [serial online] 2017 [cited 2021 Dec 6];1:166-8. Available from: https://www.bmbtrj.org/text.asp?2017/1/2/166/219117




  Introduction Top


Acidophilic collagenous center encased in fibrin, grossly resembling the grains of polished rice on T2-weighted magnetic resonance imaging, represents the rice bodies most commonly seen in cases of tuberculosis (TB), rheumatoid arthritis, and less commonly in osteoarthiritis, juvenile arthritis, septic joint, and trauma.[1] This case of subdeltoid bursitis presenting as soft-tissue swelling holds importance as in developing countries we have to take this condition into the differential diagnosis due to high prevalence of TB and order appropriate investigations to guide appropriate and timely management.


  Case Report Top


A 21-year-old male patient presented to the orthopedic outpatient department with a swelling around his right shoulder joint which was gradually increasing for the past 2 months. He had a prior history of pulmonary tuberculosis (TB) for which he had taken full treatment 2 years back. On clinical examination, the swelling was firm and mildly tender on palpation, apparently separate from the muscles with normal joint mobility. There was a history of evening rise of temperature for the past 15 days. Clinically, suspicion of a lipoma and collection was made. An anteroposterior radiograph [Figure 1] was performed which revealed an oblong radiodense soft-tissue lesion along the lateral aspect of the shoulder joint with maintained cortical integrity of the underlying bone. The right shoulder joint space appeared normal. Magnetic resonance imaging (MRI) with gadolinium-based contrast material was ordered of the right shoulder. MRI performed using 1.5 Tesla Magnetom (Siemens Healthcare, Germany) revealed a peripherally enhancing large T2-hyperintense collection in the right subdeltoid bursal location with multiple intralesional T2-hypointense foci of nonenhancing debris, consistent with rice body formation [Figure 2] and [Figure 3]. The underlying bones and joint spaces appeared unremarkable. The preliminary diagnosis of infective subdeltoid bursal collection with rice body formation was made. Ultrasonographic-guided aspiration of the contents was performed which revealed caseous material, and Ziehl–Nelson staining was positive for Mycobacterium tuberculosis. The patient was treated for extrapulmonary TB for 6 months. The swelling resolved within 2 months and currently the patient is disease free.
Figure 1: Anteroposterior radiograph of the right shoulder joint and upper humerus showing normal bony architecture with an oblong radiodensity along the lateral aspect of the shoulder without any internal calcification, suggesting a deep-seated lesion

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Figure 2: Precontrast T2-weighted (left and right upper panel) and T1-weighted (right lower panel) magnetic resonance images of right shoulder joint showing the typical rice body appearance of the subdeltoid bursal collection with typically hypointense rice bodies in the typically hyperintense collection and predominant hypointensity on T1-weighted image

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Figure 3: Postgadolinium injection T1-weighted magnetic resonance images in sagittal, axial, and coronal planes describing the large peripherally enhancing subdeltoid bursal collection with preserved underlying bone morphology

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  Discussion Top


Rice bodies were initially identified in 1895 in a patient with TB infection. There are two theories to the origin of these rice bodies. One, depicting the origin from the synovial fluid due to aggregation of fibronectin/fibrin, and other, due to sloughing off of the synovium.[2] Two most important conditions associated with rice body shoulder are tuberculous bursitis and rheumatoid arthritis. The tuberculous bursitis is always secondary to some other primary focus of infection (pulmonary TB in the present case). Hematogenous spread is the etiology of deep-seated bursitis (as in the present case).[1] Among all the investigations, gadolinium-based contrast agent-enhanced MRI forms the best modality to diagnose the rice body bursitis with characteristic appearance of the rice bodies on T1- and T2-weighted images.[3] The collection appears hypointense on T1-weighted images with peripheral enhancement on postgadolinium scans whereas the collection appears hyperintense on T2-weighted images with distinct intralesional hypointense nonenhancing rice bodies.


  Conclusion Top


Subdeltoid bursitis should be considered as an important differential in patients presenting with periarticular soft-tissue swelling. MRI should be performed in all such cases to assess the rice body formation if tuberculous bursitis is suspected.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Forse CL, Mucha BL, Santos ML, Ongcapin EH. Rice body formation without rheumatic disease or tuberculosis infection: A case report and literature review. Clin Rheumatol 2012;31:1753-6.  Back to cited text no. 1
    
2.
Kataria RK, Chaiamnuay S, Jacobson LD, Brent LH. Subacromial bursitis with rice bodies as the presenting manifestation of rheumatoid arthritis. J Rheumatol 2003;30:1354-5.  Back to cited text no. 2
    
3.
Urruela AM, Rapp TB, Egol KA. Massive subacromial-subdeltoid bursitis with rice bodies secondary to an orthopedic implant. Am J Orthop (Belle Mead NJ) 2012;41:418-21.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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