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