An 80-year-old man presented to the emergency department with a 5-day history of fever and right shoulder pain. His temperature was 37.9 °C (100.2 °F); heart rate, 74/min; and blood pressure, 90/49 mm Hg. He had tenderness to palpation and decreased range of motion of his right shoulder. Laboratory testing showed a white blood cell count of 9.6 × 109/L (reference, 4.0-9.0 × 109/L); C-reactive protein level, 35.6 mg/dL (reference, <0.3 mg/dL), and creatine kinase level, 1036 U/L (17.30 μkat/L) (reference, 60-270 U/L [1.00-4.51 μkat/L]). Magnetic resonance imaging revealed an effusion and synovial thickening with enhancement in the right shoulder joint and inflammation in the right subscapularis muscle. Gram stain of the synovial fluid revealed gram-positive cocci in clusters. Intravenous cefazolin therapy was initiated, and he underwent right shoulder joint arthroscopic irrigation, synovectomy, and surgical drainage for subscapularis pyomyositis. Blood and synovial fluid cultures grew methicillin-susceptible Staphylococcus aureus, and intravenous cefazolin was continued. One week after hospitalization, the patient developed asymptomatic black discoloration of the dorsal surface of his tongue (Figure). He reported no prior lingual discoloration and did not smoke cigarettes, use chewing tobacco or illicit drugs, or drink alcohol.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Yasuhiro Kano, MD, Department of Emergency and General Medicine, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524, Japan (firstname.lastname@example.org).
Published Online: May 12, 2023. doi:10.1001/jama.2023.5894
Conflict of Interest Disclosures: None reported.
Additional Information: We thank the patient for providing permission to share his information.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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