Brief Answer:
Your condition requires detailed assessment as below

Detailed Answer:
Hi XXXXXXX,
Thanks for writing in.

I have read through your query in detail.
Please find my observations below.

1. Report dated 27-12-2014 confirms the presence of necrotising granulomatous lymphadenitis and this is a possible diagnosis of tuberculosis ref apollo hospital.

2. Report dated 07-03-2015 shows a firm to hard mass in the right scapular region in upper back region (supra spinal) that can be from bone or muscle ref walk in clinic.

3. Report dated 07-03-2015 is continuation of above prescription and says about your treatment history and the swelling in upper back ref walk in clinic.

4. Report dated 20-02-105 is prescription for TB medication ref omega hospital.

5. Repeat of 1 above ref apollo hospital.

6. Report dated 13-12-2014 says about necrotizing granulomatous inflammation and possibility of conditions including atypical TB.

7. and 8. Report of MRI shoulder dated 14-02-2015 with below findings ref vista imaging

trapezius muscle swelling
mild acromioclavicular joint arthrosis
distal supraspinatus mauscle impingement
supraspinatus and subscapularis tendinosis
small T 2 hyperintensity spots on greater tuberosity and upper shaft of humerus bone.

8. Report dated 04-03-2015 shows almost normal values except for slightly A G ratio and raised sugar (acceptable) and raised triglycerides (acceptable) ref XXXXXXX diagnostics

9. Prescription dated 13-02-2015 suggesting the presence of a 2 x 2 cm nodule in trapezius muscle on right side ref vcare hospital.

From the above documents, it appears that the 3 doctors have been giving you treatment for TB since 2014. In one of the reports, there is a mention of atypical TB as a possible diagnosis. This point is important and I suggest that you have a detailed discussion on this with a TB specialist doctor. The problem is that there are medications suitable for various types of TB but prescribing medications is only after clinical examination.

Clarithromycin is one antibiotic that has shown good efficacy against a broad range of atypical mycobacteria, but again it will not work in all cases. However it is better to have the acceptance of atypical TB as the diagnosis by atleast two doctors before changing medicines in TB .As per online healthcare policy guidelines no doctor can prescribe any medication online.

Attention must also be given to the nodule in your back which was recently found. The MRI report shows the trapezius muscle to be swollen and it might help to discuss this finding with the TB specialist and if any muscle biopsy is required.

The doctor at walk in clinic wants to make sure that the shoulder nodule is from muscle or bone and that is why he has asked for F18 bone scan. This is because of the small findings in the upper end of humerus bone on MRI.

Your case is little complicated and I understand your frustration at not getting a clear diagnosis even after seeing 3 doctors. Since I am a MRI specialist, I have read about TB involving muscles called as tuberculosis myositis. It might be possible that you are having an infection in the muscle and the nodule that is felt is a focus of infection. This is rare but still found in patients. As this type of infection is spread by blood, doing a bone scan can help in knowing the exact extent of disease. Final diagnosis is by doing a FNAC or biopsy from the muscle before giving you any new medication for atypical tuberculosis or anything else.

Hope this answers your question. Please feel free to correct any oversight in my interpretation of your problems and discuss them in detail as per your requirements.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek

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Brief Answer:
Please remove old reports and upload F 18 scan report and film copy again

Detailed Answer:
Hi XXXXXXX,
Thanks for writing back with an update.

I am sorry to say that the F 18 bone scan report is not attached. Our system allows only 10 reports to be uploaded. Therefore please remove earlier reports and upload the F 18 report and film copy once again for me to go through.

Regards,
Dr.Vivek

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Brief Answer:
Your bones are normal, any change in size of swelling requires observation

Detailed Answer:
Hi XXXXXX,
Thanks for writing back with an update.

The F 18 bone scan does not show any abnormal activity in the bones. This means that your bones are not affected by any infection like tuberculosis. Therefore the MRI report showing some spots in the humerus bone are not significant. This is good news for you.

The swelling in the muscle must be examined in clinically. It is small and does not show any particular focal problem. However the trapezius muscle appears swollen as per MRI report. I was wondering if you got injured any time in the last 2 months and that cause the swelling in back and also the muscle.

Unless I clinically examine your swelling in upper back, it is difficult to suggest any test like FNAC/ biopsy at present. FNAC/ biopsy is done only from a highly specific area suspicious for disease. So if the swelling in your back is slowly increasing in size for next few days or weeks then I might suggest a FNAC/ biopsy.

During your next visit to the doctor, I would like to know the opinion of the doctor at walkin clinic regarding any change in size that he observes during last one week as you last consulted him on 07-03-2015.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek

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