Septic arthritis in a patien”>Case Report

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American Journal of Emergency Medicine

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Spontaneous septic arthritis in a patient without trauma, coinfection, or immunosuppression

Abstract

Septic arthritis is a rare infection, most often affecting the knee and hip [1]. Infections are often secondary to joint repair or replacement surgery, Systemic Infection, or intravenous recreational drug use [1,2]. Diabetes, rheumatoid arthritis, Hepatic dysfunction, and immunosup- pression are common risk factors [1,2]. Although septic arthritis can occur spontaneously, such occurrences are rare. We report a case of a previously healthy 54-year-old woman with no known risk factors presenting to a freestanding emergency department with 5 days of shoulder pain.

A 54-year-old female school bus driver presented to the freestanding emergency department (FED) with progressive shoulder pain that began 5 days previous. At that time, she opened the hood on her school bus, which is something she does routinely, and she experienced some minor discomfort in her left shoulder. The pain got progressively worse, and in the FED, she rated it a 10/10 and localized it to her left shoulder. It was tender to palpation on the anterior portion of the left Glenohumeral joint. There was no erythema or warmth to the joint. The patient was taking ibuprofen at home without improvement. Her range of motion was limited secondary to pain. The patient reported no recent illness or surgery, and her medical history included Metabolic syndrome, tubal ligation, and surgical removal of a benign chest tumor.

On initial examination, the patient’s vital signs were within normal limits. A 2-view shoulder x-ray revealed no abnormalities (Fig. 1). The patient was given hydromorphone 1 mg IM for pain. Later during her FED visit, the nurse noted that the patient felt feverish. The patient’s temperature was retaken and had increased to 38.8?C. A basic metabolic panel, complete blood cell count, erythrocyte sedimentation rate, urinalysis, C-reactive protein (CRP), and blood cultures were obtained. White blood cells were elevated at 13.8 thou/cm with 13.7% monocytes, CRP 13.9 mg/L, erythrocyte sedimentation rate 43 mm/h, and blood glucose of 144 mg/dL. All other laboratory values were within normal limits.

The patient was transferred to the associated tertiary care center for orthopedic evaluation and joint aspiration. A magnetic resonance imaging (MRI) was preformed and revealed extensive periarticular edema, diffuse enhancement of the subscapularis muscle, and feathery- like edema of the supraspinatus, anterior, and lateral deltoid muscles. There was also edema and enhancement of both superficial and deep Soft tissues without evidence of abscess (Figs. 2 and 3). Septic arthritis was considered the diagnosis of exclusion. The patient was immediately scheduled for arthroscopic debridement and irrigation of her shoulder, which proceeded without incident. She was given ancef 1 g intrave- nously (IV). Antibiotics were later changed to vancomycin 1.5 g and 500 mg IV of daptomycin after an infectious disease consultation. The

cultures obtained were positive for methicillin-sensitive Staphylococcus aureus; at which point the patient was restarted on 1 g cefazolin IV. A second debridement took place 3 days later. The patient was discharged home on IV antibiotics and oxycodone 1 week after initial admission to the hospital.

Differentiating septic arthritis from other musculoskeletal abnor- malities can be difficult. Unlike other forms of sepsis, one study reported that only 60% of patients with septic arthritis present with fever, and only 34% have a history of fever [3]. Other cases have demonstrated normal shoulder x-rays on presentation, and blood cultures were positive in 24% of patients with positive synovial fluid cultures [4,5]. Elevated white blood cell count, erythrocyte sedimentation rate, and CRP often indicate the presence of infection, but are not always observed [6]. Our patient presented with a normal shoulder x-ray and no history of fever.

Several possible pathways exist by which septic arthritis normally occurs. The first is hematogenous spread from a local or distant infection through the vasculature of the synovial membrane. Often, the initial infection is bacteremia or osteomyelitis. Direct implantation via arthrocentesis or penetrating injury can also introduce septic arthri- tis-inducing pathogens. Arthroscopic surgery can be complicated by

Fig. 1. X-ray of shoulder, no visible defect.

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Fig. 2. T2 coronal MRI image showing muscle and joint fluid and synovial enhancement.

infection [1]. Septic arthritis is most common in patients with diabetes, immunosuppression, rheumatoid arthritis with a recent bacteremia, intrasynovial injection or operation, or those using recreational IV drugs [1,2]. Although cases of spontaneous septic arthritis have occurred, they are extremely rare. The most commonly reported spontaneous septic arthritis location is the sternoclavicular joint, with 28 cases reported [7]. Three cases have also been reported of spontaneous septic arthritis of the pubic symphysis [8].

The manner in which this patient developed septic arthritis of the glenohumeral joint is unknown. The patient had no known risk factors, recent illnesses, or surgeries that would have predisposed her to the infection. This is remarkable, as there have been no previously reported cases of patients with no risk factors spontaneously developing septic arthritis of the glenohumeral joint.

Septic arthritis is a relatively Rare condition, most commonly occurring in those already at risk for bacterial infections. This is the first reported case of a spontaneous septic arthritis in the glenohum- eral joint in a patient without risk factors. This case demonstrates the importance of keeping septic arthritis in the differential diagnosis of patients presenting with joint pain.

Peter L. Griffin BS Gregory D. Griffin Erin L. Simon DO

Emergency Department Research, Akron General Medical Center

Akron, OH 44307, USA

Fig. 3. T1 coronal MRI image with contrast showing muscle, joint fluid, and synovial enhancement. It does not show marrow edema typically seen with advanced cases of septic arthritis.

http://dx.doi.org/10.1016/j.ajem.2013.06.029

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