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Staphylococcus Aureus Bacteremia from Sternoclavicular Septic Arthritis
Coleman, N, D.O., Domingo, E, D.O.
Kent Hospital, Warwick, RI
Introduction: Septic arthritis of the sternoclavicular joint is rare in otherwise healthy adults. Classic risk
factors include intravenous drug use, diabetes mellitus, rheumatoid arthritis and other
immunocompromised states. In the general population less than 1% of septic arthritis is attributable to
sternoclavicular septic arthritis, however is as high as 17% in intravenous drug abusers. It is thus
important to have a high suspicion in individual that present with sepsis syndrome and ill-defined upper
extremity pain. Septic arthritis of the SCJ is a true medical emergency as worsening infection and
abscess development increases the risk for involvement to surrounding structures such as the great
vessels, trachea and esophagus.
Case: A 67 year old white male with a history of paroxysmal atrial fibrillation and hypertension
presented to our emergency department (ED) with right shoulder/neck pain, fever and generalized
weakness. This was his third visit to the ED in three days for the shoulder pain. He developed a fever of
103.4 degrees F at home with progressive generalized weakness prompting his return to the ED. Pain
began four days ago while driving. No recent trauma. No complaints other than a mild cough and sore
throat. Previous work-ups in the ED including negative shoulder and chest x-ray, WBC 16.4, and a
normal ekg.
Initial vitals were BP 147/49, HR 108, RR 17, 89% on RA, T 37.1 degrees C, later developed fever of
39 degrees C. He was Ill-appearing in NAD. Lungs were diminished at the right base. Heart was
tachycardic but regular. RUE had decreased ROM secondary to pain worse with shoulder adduction and
tenderness over the right mid trapezius. No deformity at right shoulder. Skin was cool and diaphoretic,
no clear skin changes at the shoulder joint, no crepitus. There was also a well healed scar on right
pretibial area. He was alert and oriented x 3 without focal deficits.
Given his ill appearance, tachycardia and hypoxemia, he was started on a heparin drip by protocol for
the possibility of pulmonary embolism. He was also given 2 liters of normal saline and empirically started
on Zosyn, Vancomycin and Ciprofloxacin for possible septic arthritis of the glenohumeral joint.
Labs were significant for WBC 17.6, SED rate 80 mm/hr, CRP 46.7 mg/dL, BUN 18 mg/dL, creatinine
1.79 mg/dL, troponin-I 0.12 mg/mL, INR 1.4, and negative rapid strep. EKG reveled sinus tachycardia
with a rate 103 with no ST changes. Initial imaging including chest x-ray and KUB were only remarkable
for minimally dilated loops of bowel. A non-contrast CT of the chest/abdomen/pelvis was done to
evaluate for other causes of his sepsis syndrome. Except for minimal bibasilar atelectasis, the CT was
negative. After the CT he became increasingly toxic appearing and the ICU team was called for
admission at which time he was noted to have more localized tenderness in the area of his right SCJ.
With the full clinical picture, he was thus presumed to have septic arthritis of the right SCJ. The next day
he had skin changes at the right SCJ and a CT neck showed inflammatory changes at the right SCJ,
both of which further supported the diagnosis. Five blood cultures later grew Oxacillin sensitive
Staphylococcus aureus. He did not undergo joint aspiration because he responded well to intravenous
antibiotics.
It is likely that our patient developed bacteremia related to seeding of his SCJ from a previous lower
extremity abscess which required local incision and drainage and took a total of 8 weeks to drain and
heal.
Discussion: Patients with SCJ septic arthritis will complain of poorly localized pain in the neck, chest or
shoulder region which is accompanied by fever. Onset is often sudden but can vary from days to weeks.
There is often no clear history of trauma to the area. Diagnostic imaging includes CT or MRI to confirm
the diagnosis, as well as to evaluate for potential complications. Definitive diagnosis is based on culture
results of aspirated joint fluid. The most common cause of infection is S. aureus which accounts for 50%
of cases. Other organisms such as Pseudomonas have been implicated in immunocompromised hosts.
Initial treatment should include anti-staphylococcal penicillins.
Initial diagnosis of SCJ septic arthritis may be difficult in an otherwise healthy individual. If not treated
early and aggressively with antibiotics, there is a greater risk for the development of a local abscess,
mediastinitis, osteomylitis and the requirement of joint debridement. These life threatening
complications make it imperative to have a high suspicion for SCJ septic arthritis when a patient
presents with sepsis syndrome and ill- defined upper extremity pain.