Article, Rheumatology

Pseudoseptic arthritis after accidental intra-articular deposition of the pneumococcal polyvalent vaccine: a case report

Case Report

PseudoSeptic arthritis after accidental intra-articular deposition of the pneumococcal polyvalent vaccine: a case report

The pneumococcal polyvalent vaccine (PPV) is a 23-val- ent pneumococcal polysaccharide vaccine. Given the prox- imity of deltoid injections to the Glenohumeral joint, inadvertent intra-articular injections are conceivable. We describe a case of an acute monoarticular pseudoseptic arthritis after accidental intra-articular deposition of the PPV. A 73-year-old woman with a history of rheumatoid arthritis and osteoporosis presented to the emergency department with an acutely painful right shoulder approxi- mately 5 hours after receiving a Pneumovax injection (Merck & Co, Inc, Whitehouse Station, NJ). A glenohumeral joint aspirate was performed. The Gram stain was negative. Clindamycin and vancomycin hydrochloride were started. The patient continued to have pain. Joint aspirates showed raised White blood cell counts but no crystals or organisms. Diagnostic arthroscopy of the shoulder was normal. All joint aspirate cultures were negative. Given the acute onset of the patient’s symptoms relative to the time and location of the PPV injection and persistently negative synovial aspirate cultures, it was concluded that this patient had a pseudoseptic arthritis from an accidental intra-articular injection of the PPV. The pneumococcal polyvalent vaccine (PPV) is a 23-val- ent pneumococcal polysaccharide vaccine that contains 23 of the most common capsular polysaccharides from Strepto- coccus pneumoniae. As demonstrated in clinical trials, the vaccine is effective in the prevention of pneumococcal pneumonia and pneumococcal bacteremia and thus is recommended for routine vaccination in patients 50 years or older [1]. The vaccine is administered as a 0.5-mL sterile liquid injection either subcutaneously or intramuscularly. The preferred site is the deltoid muscle or lateral midthigh. Adverse reactions primarily include local reactions at the injection site and range from soreness and warmth to the more

serious cellulitislike reactions.

Given the proximity of deltoid injections to the gleno- humeral joint, it is conceivable that inadvertent intra-articular injections may occur, causing other rare but entirely possible adverse reactions. One obvious reaction would be septic arthritis from bringing surface contaminates into the intra- articular space, and another not so obvious is aseptic or pseudoseptic arthritis simply due to the immunogenicity of the vaccine being injected. Pseudoseptic arthritis is the term

applied to conditions that mimic septic arthritis but in which the synovial fluid culture is truly negative [2]. A search of the Vaccine Adverse Event Reporting System (VAERS) database reveals 7 cases potentially involving the administration of a vaccine intra-articularly with a subsequent pseudoseptic arthritis/synovitis. However, a search of the medical literature does not reveal any case reports that detail the nature of this condition. In the following case report, we describe what we believe is the first documented case in the medical literature of an acute monoarticular pseudoseptic arthritis after the accidental intra-articular deposition of the PPV.

A 73-year-old woman with a history of rheumatoid arthritis and osteoporosis presented to the emergency department with an acutely painful right shoulder approx- imately 5 hours after receiving a PPV (Pneumovax) injection in her right arm. Two hours after the injection, the patient started noticing some pain and swelling in her right shoulder, which progressively got worse to the point that she had difficulty moving her arm and subsequently presented to the emergency department.

On examination, the patient’s right arm was held in adduction, and a moderate-sized glenohumeral Joint effusion was easily appreciated. The shoulder was quite tender to palpation as well as painful with active and passive range of motion testing. The area over the joint appeared mildly erythematous and was slightly warm. Further inspection revealed the vaccine injection site to be quite proximal on the arm and over the glenohumeral joint rather than in the deltoid muscle itself. The patient had an initial white blood cell count of 14 000 with 87% polymorphic neutrophils (PMN) and 6% bands. Initial C- reactive protein level was 2.0. An orthopedic consult for a suspected septic arthritis was obtained after vaccine administration. A glenohumeral joint aspirate was per- formed the next morning and revealed a turbid fluid with the following analysis: WBC count, 10700 (85% PMN, 4% lymphocytes [lymph], 11% monocytes [mono]); glucose, 96; protein, 4.9; and LDH, N1200. No crystals were found. The gram stain showed no organisms. Because the joint aspirate revealed a mixed picture, with the cell count and differential suggestive of a bacterial infection and the glucose and Protein Suggestive of an Aseptic arthritis, the patient was started on clindamycin pending culture results. The following morning, the patient continued to have pain, and a second joint aspirate was performed and

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revealed a bloody turbid fluid with the following analysis: WBC Count, 70100 (93% PMN, 1% lymph, 6% mono); glucose, 80; protein, 4.0; and LDH, N1200. No crystals were found. There were again no organisms on gram stain. A second set of cultures was also taken at this time. A second C-reactive protein test was done at this time, and levels were markedly elevated at 111. The patient was switched from clindamycin to vancomycin hydrochloride pending culture results after a consult for infectious disease was made. The next morning, the patient was taken for a diagnostic arthroscopy of her right shoulder for incision and drainage of the deltoid region to wash out any possible abscess that may have been present. During this procedure, it was noted that the patient had what appeared to be a chronic rotator cuff tear and a proximal biceps tendon rupture of undetermined age. All fluid aspirates during this procedure revealed normal joint glucose levels. The patient tolerated the procedure well.

The next day, the final cultures were reported as negative, and antibiotics were stopped. The patient continued to improve and was discharged home in a sling with the final diagnosis of pseudoseptic arthritis of the right shoulder secondary to the PPV being injected intra-articularly. The patient continued to improve at a 2-week follow-up but did have limited mobility of her right arm and will require extensive Physical therapy.

Pseudoseptic arthritis is a diagnosis of exclusion. Before the diagnosis can be made, the more serious and potentially fatal septic arthritis must be ruled out. The differential diagnosis of septic arthritis is long but generally includes crystal-induced arthritis (gout and pseudogout), rheumatoid arthritis exacerbation, viral arthritis, Lyme disease, reactive arthritis (eg, Reiter syndrome, psoriatic arthritis, systemic lupus erythematosus), and, of course, pseudoseptic arthritis. All can present classically with an acute onset of a single swollen painful joint with or without fevers, increased leukocyte count, and elevated sedimentation rate. Generally, an elevated synovial fluid leukocyte count of more than 50000 is indicative of a septic arthritis, although this can be seen with crystal arthropathies. Clinically, the only way to differentiate patients with pseudoseptic arthritis from those with true septic arthritis is by Gram-stained smear negative for synovial fluid, negative cultures, and response to steroids [2]. In our case, given the acute onset of the patients’ symptoms relative to the time and location the PPV injection was given and persistently negative synovial aspirate cultures, it was concluded that this patient had a pseudoseptic arthritis from an accidental intra-articular injection of the PPV.

Several factors contributed to this patient’s development of pseudoseptic arthritis. One major factor is her history of rheumatoid arthritis. Rheumatoid arthritis is generally well known to increase a patient’s risk for developing bacterial septic arthritis [3]. However, Call et al [4] suggest in a series of case studies that rheumatoid arthritis might also predispose patients toward the development of pseudoseptic

Case Report

63

F

PPV

Not reported

73

F

PPV

Arm

78

M

PPV

Arm

89

F

PPV

Arm

5

F

VARCEL

Arm

48

F

FLU

Arm

39

F

HEP

Arm

11

M

PNC

Arm

arthritis. Another contributing factor is this patient’s history of a chronic rotator cuff tear and biceps tendon rupture, which more than likely provided inadequate protection of the glenohumeral joint and further facilitated the intra- articular deposition of the PPV injection.

Table 1 Cases reported to the VAERS database for pseudo-

septic arthritis after probable intra-articular vaccine injection

Age (y) Sex Vaccine type Site

VARCEL indicated Varicella vaccine; FLU, Influenza vaccine; HEP,

hepatitis B vaccine; PNC, 7-valent pneumococcal conjugate vaccine.

Very few studies have been done looking at the immunogenicity of intra-articular vaccine administration. However, one study that looked at the administration of the influenza vaccine given intra-articularly stated that all

6 healthy volunteers who were injected intra-articularly developed joint swelling and stiffness within 2 to 4 hours after injection, which disappeared within some days [5]. This would suggest that the volunteers developed a mild pseudoseptic arthritis that resolved on its own. Given the polyvalent nature of the PPV and the already-damaged joint of our patient, it is understandable how she might have developed a more severe case of arthritis. Interestingly, of all 8 similar cases reported in the VAERS database (Table 1), half are reported as being due to the PPV. It is unclear why PPV accounts for half, but perhaps this reflects the multivalent nature of this vaccine, which might cause a greater immunogenic and inflammatory response than other vaccines.

This case reflects one possible outcome of accidentally giving a PPV injection intra-articularly. It should be noted that because the total number of reported cases is low, either most vaccine injections are given correctly or most intra- articular injections do not cause a problem and thus go unnoticed. The true incidence of vaccines accidentally given intra-articularly is unknown.

Brian P. McColgan DO Frank A. Borschke MD Department of Emergency Medicine Genesys Regional Medical Center

Grand Blanc MI 48439, USA

E-mail address: [email protected]

doi:10.1016/j.ajem.2007.02.021

Case Report 864.e3

References

  1. Merck & Co., Inc. Pneumovax 23 (pneumococcal vaccine poly- valent) package insert. Accessed October 27, 2006, http://www. merck.com/product/usa/pi_circulars/p/pneumovax_23/pneumovax_

pi.pdf.

  1. Ho Jr G. Pseudoseptic arthritis. R I Med 1994;77(1):7 – 9.
  2. Carrey WD, Gupta R. Septic arthritis. July 26, 2003, http://www. clevelandclinicmeded.com/diseasemanagement/rheumatology/ septicarthritis/septicarthritis1.htm.
  3. Call RS, Ward JR, Samuelson Jr CO. dPseudosepticT arthritis in patients with rheumatoid arthritis. West J Med 1985;143:471 – 3.
  4. Trollmo C, Carlsten H, Tarkowski A. Intra-articular immunization induces strong systemic immune response in humans. Clin Exp Immunol 1990;82(2):384 – 9.