Bilateral shoulder septic arthritis due to suspected bacterial endocarditis: A case report

IntroductionSeptic arthritis is an orthopedic emergency that requires rapid diagnosis and treatment. It is typically caused by occult bacteremia which allows bacteria to seed the joint or local invasion of a soft tissue infection. Most cases of septic arthritis are caused by gram-positive bacteria, with the most common culprit being Staphylococcus Aureus. The reason septic arthritis is an orthopedic emergency is because of rapid destruction to cartilage. The mechanism of injury to cartilage is two-fold: bacterial enzymes are directly toxic to joint cartilage, and buildup of exudate can tamponade blood flow and cause anoxic injury. Typically, the knee is the most commonly involved joint. This is followed by the hip, ankle, elbow, wrist, and shoulder in descending order of occurrence. Polyarticular disease makes up a small percentage of these cases and if present, it is usually asymmetric and will involve at least one knee joint.Presentation of caseBilateral joint septic arthritis is relatively rare. We present an uncommon case of atraumatic bilateral septic shoulders in an elderly man with a history of heart disease and insidious bilateral shoulder pain after golfing 18 holes. This presentation is unique not only in its rarity but also in its impact on our understanding of septic arthritis in the setting of medical comorbidities and a relatively unimpressive presentation. With a recent golfing day just prior to presentation, differential diagnoses other than septic arthritis included deltoid/rotator cuff muscle strain, acute on chronic rotator cuff tendinosis, acute on chronic rotator cuff tearing, acute flare up of osteoarthritis, rheumatoid arthritis, or crystalline arthropathy. With elevated inflammatory markers and an equivocal physical examination, our patient underwent advanced imaging via MRI and subsequent bilateral glenohumeral joint diagnostic aspirations that were consistent with septic arthritis due to his complaining of contralateral shoulder pain shortly after his admission. Immediately after said diagnosis was made, the patient was taken back for emergent bilateral open irrigation and debridement, as septic arthritis is an orthopedic emergency, and went on to recover appropriately on culture-directed intravenous antibiotic therapy.Discussion/conclusionThis case report is impactful with regard to clinical practice for multiple reasons. First and foremost it is a cautionary tale for all clinicians with regard to the level of suspicion one must have for polyarticular septic arthritis in the setting of the multiply painful patient. Second, it demonstrates the utility of advanced imaging in the equivocal patient. Lastly, it underscores the importance of prompt diagnosis and treatment, validating the existing algorithm for septic arthritis.     

Secondary frozen shoulder following septic arthritis – An unusual complication of magnetic resonance arthrogram

IntroductionMagnetic resonance (MR) arthrogram is a commonly used investigation tool to detect various pathologies in the shoulder. The complications following this procedure is minor and rare. Septic arthritis is one of the rare complications which can develop after MR arthrogram. We report a case of secondary frozen shoulder after MR arthrogram induced septic arthritis.Presentation of caseA young, fit and well female patient underwent MR arthrogram to detect any labral tears. Two days following the procedure, she developed signs and symptoms suggestive of septic arthritis of the shoulder. The patient underwent repeated arthroscopic debridement and washout. The organisms isolated was Staphylococcus epidermidis. She was treated with six weeks of intravenous antibiotics. The patient developed stiffness of the shoulder due to secondary frozen shoulder which was treated with arthroscopic capsular release with good functional outcomes at three months.DiscussionMR arthrogram is a rare cause of septic arthritis of the shoulder. The common method introducing the organisms is from the skin flora or contaminated arthrogram trays. The treatment is repeated arthroscopic washouts and six weeks of appropriate intravenous antibiotics. Residual pain, stiffness and chondrolysis are common sequelae of septic arthritis.ConclusionSeptic arthritis is a recognised and rare complication of MR arthrogram. Early and prompt diagnosis with arthroscopic washout and debridement combined with intravenous antibiotics helps to eradicate the infection. Secondary frozen shoulder is a late complication of sepsis in the joint.     

Rheumatologic aspects of painful conditions affecting the shoulder

Patients with shoulder arthritis present to the orthopedic surgeon due to joint pain and loss of shoulder motion. A differential diagnosis is established, based on the history and physical examination and selected laboratory tests and roentgenograms. Synovial fluid analysis is often very helpful in the diagnosis of shoulder arthritis and critical for differential diagnosis of inflammatory, degenerative, and septic arthritis. Shoulder involvement in primary osteoarthritis is uncommon. The shoulder is rarely the initial joint involved in rheumatoid arthritis. Several uncommon conditions, e.g., amyloid arthropathy and reflex sympathetic dystrophy syndrome, may present early and frequently in the form of shoulder pain. The results of treatment are determined by etiology of shoulder joint disease. Patients with shoulder involvement in rheumatoid arthritis generally respond to the basic management for rheumatoid arthritis. Physical therapy to improve the range of motion of the shoulder and anti-inflammatory medications, including intra-articular corticosteroids, are helpful in most cases.     

Septic knee-induced deep venous thrombosis in a young adult

This article describes a case of a 26-year-old man presenting with left knee pain of 1 week's duration, fever, and acute onset of shortness of breath the day of admission. An arthrocentesis of the knee joint was grossly positive for methicillin-resistant Staphylococcus aureus. A left lower extremity venous duplex showed thrombosis of the superficial femoral, popliteal, posterior tibial, peroneal, and gastrocnemius veins. Pulmonary computed tomography-angiography was positive for acute pulmonary emboli. Initial management consisted of anticoagulation, intravenous antibiotics, and 2 arthroscopic irrigation and debridement procedures. After a normal transesophageal echocardiogram, a diagnosis of septic knee-induced deep venous thrombosis (DVT) of the left lower leg with subsequent septic pulmonary emboli was established. The patient was discharged to a long-term care facility for a 6-week monitored course of intravenous antibiotics. His DVT and pulmonary emboli were managed successfully with oral warfarin. Two months after his initial presentation, the patient returned with acute worsening knee pain. A knee arthrocentesis was unremarkable; however, radiographic imaging revealed fulminant osteomyelitis of the distal femur. He has since undergone open arthrotomy with excisional irrigation and debridement and is on a chronic oral antibiotic regimen. Sparse pediatric literature has shown an association between musculoskeletal sepsis and thrombosis. Only 1 case of septic knee-induced DVT exists in the adult literature, and it was not associated with pulmonary emboli. Our case provides evidence that DVT must be considered by the treating physician as a possible and devastating complication of septic arthritis.     

Septic gonococcal arthritis in a pediatric patient: Rare case report

IntroductionSeptic arthritis is an orthopedic emergency that requires rapid diagnosis and treatment due to the rapid destruction to cartilage. The responsible organism and etiology differs depending on patient age, especially in children. Gonococcal Arthritis in toddlers is a rare occurrence with few documented cases in the literature. An orthopedic surgeon is likely not to come across this either in training or through their careers. Consequently, its presentation and subsequent treatment algorithms leave several gray areas.Presentation of caseIn this case report, we present a rare and not so straightforward presentation of a toddler with septic gonococcal arthritis along with a summary of treatment considerations described in the current literature and the course of treatment for this patient.Our patient is a toddler who originally presented to the emergency department with shoulder and knee pain for several days after an unwitnessed fall. He was subsequently discharged and presented again the next day with a knee effusion and elevated inflammatory markers. An MRI showed a large joint effusion without any underlying abscess or osteomyelitis to explain his elevated inflammatory markers. A knee aspiration was subsequently preformed which eventually grew out Neisseria Gonorrhea on hospital day 3 after the patient had been on antibiotics. He was taken back for an arthroscopic irrigation and debridement for definitive treatment.Clinical discussion/conclusionDisseminated gonococcal infection in toddlers is a rare occurrence without much information in the literature and should not be dismissed as a differential. We recommend a high index of suspicion with thorough work up. We also recommend surgical management of a septic joint due to DGI diagnosed via arthrocentesis (gross purulence, symptoms not improving on medical therapy, positive aspiration cultures, elevated synovial cell counts, and medically unstable patients) given the sequelae of medical management alone. The importance of interdisciplinary team collaboration that include pediatrician, infectious disease specialist, social worker, and government child safety associations is pivotal.     

Pseudoseptic arthritis of the shoulder following pneumococcal vaccination

Pseudoseptic arthritis is primarily described in rheumatoid arthritis and other systemic inflammatory conditions. To our knowledge, only 1 case report of pseudoseptic arthritis associated with intra-articular injection of a pneumococcal polyvalent vaccine (PPV) has been published. Here, a second case is presented in which a patient presented with swelling, pain, and erythema of the affected shoulder. A 59-year-old woman presented to the emergency department with a 3-day history of severe pain and decreased mobility of her left shoulder after receiving a PPV vaccination. Her clinical and laboratory workup was suspicious for septic arthritis; however, magnetic resonance imaging of the affected shoulder with and without contrast showed only a partial thickness tear of the rotator cuff, fluid in the subacromial/subdeltoid bursa, and subcutaneous edema without evidence of an abscess. Based on the clinical and laboratory data, she underwent arthroscopic debridement. There was inflammatory tissue throughout the shoulder but no obvious purulent material. She did well postoperatively with a supervised range of motion rehabilitation protocol. Her cultures remained negative. At 12 weeks, she was discharged from follow-up. We suspect that the vaccination was inadvertently injected into the glenohumeral joint directly through the rotator cuff given the lack of a full-thickness tear and the patient's thin body habitus, which could explain her aseptic inflammatory arthritis.     

A Case Report of Pneumococcal Septic Arthritis Following a Respiratory and Gastrointestinal Prodrome with Accompanying Literature Review

We report an uncommon case of septic arthritis of the ankle from a Streptococcus pneumoniae infection and provide an update of the literature reported since 2002. A 58-year-old female presented to the hospital with right ankle pain and an inability to bear weight. She reported a history of productive cough, vomiting, diarrhea, and subjective fevers 4 days earlier. Streptococcus pneumonia was identified in her ankle aspirate, and she was treated urgently with operative incision and debridement, followed by postoperative intravenous antibiotics. At her 7-week follow-up, she demonstrated complete resolution of symptoms and near-complete recovery of range of motion. This case demonstrates the importance of early identification, as the majority of patients recover fully with prompt treatment. The literature review included 44 cases of pneumococcal septic arthritis and found that the knee was the most commonly affected joint, followed by the shoulder and ankle. Blood cultures were positive for S. pneumoniae in 27 of 38 adults (71%) and 4 of 6 children (67%). Comorbid conditions were present in 32 of 38 adults (84%) and 4 of 7 children (57%), the most frequent of which were alcoholism and osteoarthritis in adults and malignancy or immunosuppression in children. Additionally, roughly half of included adults had an extra-articular focus of pneumococcal disease, most frequently pneumonia. Operative treatment was undertaken in 32 of 38 adults (84%) and all 7 children. Of adults with data available, 24 of 33 (73%) recovered with complete joint function, compared with 5 of 7 children (71%).     

Glenohumeral tuberculous arthritis complicated with beta haemolytic streptococcus: An extraordinary rare association: A case report

INTRODUCTIONSeptic arthritis of the glenohumeral joint is a rare entity and its diagnosis is difficult with a superadded infection in the presence of underlying tuberculosis. We report the first case of group B beta haemolytic streptococcal glenohumeral arthritis with underlying tuberculosis.CASE PRESENTATIONA 40 year old lady previously diagnosed to have poliomyelitis, rheumatoid arthritis, hepatitis C, and diabetes mellitus for the last 10 years, presented to the emergency room with diabetic ketoacidosis. Two weeks prior to presentation she developed fever along with pain and swelling in left shoulder with uncontrolled blood sugars. Local examination of the shoulder revealed global swelling with significant restricted range of motion. MRI showed a large multiloculated collection around the left shoulder joint extending into the axilla, and proximal arm. Urgent arthrotomy performed and about 120 ml thick pus was drained. The patient was started on clindamicin and antituberculous chemotherapy and her symptoms dramatically improved.DISCUSSIONBone and joint involvement accounts for approximately 2% of all reported cases of tuberculosis (TB), and it accounts for approximately 10% of the extra pulmonary cases of TB. Tuberculosis of the shoulder joint constitutes 1–10.5% of skeletal tuberculosis. Classical symptoms of fever, night sweats, and weight loss may be absent, and a concurrent pulmonary focus may not be evident in most cases.CONCLUSIONDespite acute presentation of septic arthritis, in areas endemic for tuberculosis and particularly in an immunocompromised patient, workup for tuberculosis should be part of the routine evaluation.     

Acromioclavicular joint septic arthritis in an immunocompetent child: A case report

Septic arthritis of acromioclavicular (AC) joint is a rare entity. It is generally seen in patients who are immunocompromised. Only 15 cases have been reported till now, with only one case series of 6 patients. We report a case of septic arthritis of AC joint in an immunocompetent child. A 9 years old girl presented with history of pain in left shoulder for 4 days associated with fever. No history suggestive of any immunocompromised state was complained. On local examination, a swelling of around 3 cm in diameter was found over left AC joint region with raised local temperature, tenderness on palpation and positive response in fluctuation test. Total leukocyte count was 18.7 × 10⁹/L with 80% of neutrophils. Erythrocyte sedimentation rate (ESR) was 28 mm/1 h. C-reactive protein (CRP) was 12 mg/L. X-ray showed enlarged left AC joint space. Ultrasound revealed hypoechoic collection in the AC joint and the surrounding area. The aspirate was thick and purulent in nature, revealing Gram positive cocci at staining. Arthrotomy and thorough lavage of AC joint was done. Culture of the aspirate showed Methicillin Resistant Staphylococcus Aureus (MRSA) after 48 hours that was sensitive to amikacin, gentamicin, erythromycin and teicoplanin. Patient was symptom-free at 2 months of follow-up with no signs of osteomyelitis on the radiographs. Thus this is the first case of AC joint septic arthritis in healthy individual. Being proximal to the shoulder joint, AC joint septic arthritis can be confused with the shoulder joint septic arthritis. Thus, high index of suspicion is required for accurate diagnosis.     

Calcific tendinitis of the biceps-labral complex: a rare cause of acute shoulder pain

Calcific tendinitis most commonly affects the rotator cuff and has not been previously reported affecting the biceps-labral complex. We report a case of calcific tendinitis of the biceps-labral complex attachment, a rare cause of acute, severe shoulder pain. Clinically, it can be misdiagnosed as supraspinatus tendinitis or septic arthritis of the shoulder joint. Non-operative treatment failed to resolve the symptoms. Arthroscopic debridement of the calcific deposit resulted in resolution of symptoms. Knowledge of this clinical condition and its imaging features is crucial for a correct diagnosis of this uncommon cause of shoulder pain.     

A rare case of septic arthritis of the knee caused by Salmonella typhi with preexisting typhoid fever in a healthy,immunocompetent child – A case report

IntroductionSeptic arthritis is a rapid and progressive infection caused by invasion of bacteria into the synovial joint. Disease of the joint causedby Salmonella spp in healthy children is an unusual event, with an estimated incidence of 0.1 to 0.2% of septic arthritis cases among children. The incidence of knee septic arthritis caused by Salmonella typhi with preexisting typhoid fever is very rare.MethodWe reported a case of 2-years old boy with a history of saddle-type fever 2 weeks prior to right knee pain. Typhoid fever was confirmed by immunoassay test. Knee septic arthritis was established from clinical findings, increased CRP level, ultrasonography, and joint aspiration. Culture of the aspirate subsequently grew Salmonella typhi. This case report had been reported in line with SCARE criteria.ResultArthrotomy and debridement were immediately performed.Intravenous piperacillin tazobactam was given for 6 days and replaced by amoxicillin clavulanic acid after the culture and sensitivity test was available. Patient recovered completely 5 months post surgery and showed excellence result with normal range of knee joint motion.ConclusionThis case report suggests that any episode of joint swelling following preexisting typhoid fever should arise the physician’s awareness toward the possibility of septic arthritis and warrant immediate as well as proper management.     

Knee pain in patients with cancer after chemotherapy, radiotherapy, and bone marrow transplantation

The causes of knee pain in patients with cancer with are different from those without cancer, and the purpose of this study was to evaluate these differences. Thirty-six patients with cancer who had knee pain who had undergone 1 or more modalities of treatment, including chemotherapy, radiotherapy, and bone marrow transplant, for a primary diagnosis of cancer were compared with a cohort of 40 patients without cancer who had knee pain. All patients were evaluated clinically and underwent radiographic examination, and some underwent computed tomography or magnetic resonance imaging examination. Among patients with a primary diagnosis of cancer, the most common diagnosis was lymphoma (n=10), and the most common causes of knee pain were avascular necrosis of bone, osteoarthritis, insufficiency fractures, and septic arthritis. In 5 patients, the classical signs of a septic knee were not present. Other causes of knee pain included meniscus tear and anterior cruciate ligament rupture with instability. The most common diagnosis in patients without cancer was osteoarthritis of the knee. No patient without cancer was diagnosed with avascular necrosis, metastatic lesion, or insufficiency fracture. Two patients without cancer were diagnosed with septic arthritis of the knee.This study showed that the causes of knee pain in patients with cancer are different from those without cancer. Septic arthritis may present without the classical clinical signs in patients with cancer, and a high index of suspicion should be maintained for it.     

Gram staining in the diagnosis of acute septic arthritis

This study aimed at determining the sensitivity and specificity of Gram staining of synovial fluid as a diagnostic tool in acute septic arthritis. A retrospective study was made of 22 patients who had arthroscopic lavage following a provisional diagnosis of acute septic arthritis of the knee joint. Gram stains and cultures of the knee aspirates were compared with the clinical and laboratory parameters, to evaluate their usefulness in diagnosing acute arthritis. All patients who had septic arthritis had pain, swelling and limitation of movement. CRP was elevated in 90% of patients. The incidence of elevated white blood cell count was higher in the group of patients with a positive Gram stain study (60%) as compared to patients with a negative Gram stain study (33%). Gram staining sensitivity was 45%. Its specificity was however 100%. Gram staining is an unreliable tool in early decision making in patients requiring urgent surgical drainage and washout.     

The Alpha-Defensin Prosthetic Joint Infection Test Has Poor Validity for Native Knee Joint Infection

BackgroundThe alpha-defensin test known as Synovaure has been very effective in diagnosis of prosthetic joint infections (PJIs). Being able to easily and accurately differentiate septic and inflammatory arthropathies in native joints would improve diagnostic workup and management. We tested the ability of an alpha-defensin test to distinguish septic from inflammatory or crystalline arthropathy in the native knee.Methods40 native knee joint fluid specimens were tested with cell count, fluid analysis, and culture and alpha-defensin testing. We determined the sensitivity and specificity of the alpha-defensin test using culture-positive fluid as the gold standard for septic arthropathy and positive crystals as the gold standard for crystalline arthropathy.ResultsThe Synovasure PJI test had 100% specificity for septic arthritis coupled with a 28% false-positive rate when applied to native knee aspirations. False-positive rate was 5.3 times higher in patients with crystals found in the joint fluid.ConclusionAlpha-defensin testing, in the form of the Synovasure PJI test, has a high-false-positive rate when used to distinguish septic and inflammatory arthritis in the native knee joint. Future work will need to determine the sensitivity and specificity of the newer native joint panel. Clinicians should be cognizant of the specific alpha-defensin test used when sampling native knee synovial fluid.     

Acute pseudoseptic arthritis after intraarticular sodium hyaluronan

A 70-year-old woman with a history of knee osteoarthritis was admitted for acute arthritis 9 days after a second intraarticular injection of sodium hyaluronan (Ostenil). The joint fluid was purulent, with no crystals, and laboratory tests showed marked inflammation, leading to antibiotic treatment for suspected septic arthritis. Incapacitating symptoms persisted, prompting surgical lavage of the knee, which failed to relieve the severe pain. The persistent symptoms and negative results of joint fluid and blood cultures led to discontinuation of the antibiotic therapy after 10 days. Antiinflammatory therapy relieved the symptoms, and the patient was discharged home 1 month after her admission. Nevertheless, the pain persisted, requiring rehabilitation therapy of the knee. Aseptic arthritis induced by repeated sodium hyaluronan injection is the most likely diagnosis. Physicians should be aware of this extremely severe complication.     

关节镜下前交叉韧带重建术后膝关节感染的临床诊断与治疗

目的 探讨前交叉韧带重建术后膝关节感染的临床诊断与治疗方法.方法 回顾性研究1997年1月至2007年7月关节镜下前交叉韧带重建术后膝关节感染的患者,通过对术后关节感染的发病率、危险因素、临床表现、实验室检查结果、治疗方法及临床预后情况的观察,分析总结临床诊断与治疗方法.结果 关节镜下前交叉韧带重建手术共3638例,术后关节感染者16例,感染率0.44%.临床表现有体温增高,膝关节肿胀、疼痛,关节活动度受限.细菌培养阳性11例,以表皮葡萄球菌最多见.治疗包括静脉抗炎、关节冲洗注药、关节镜下清理术等方法,所有患者均治愈.清创术后1年以上的12例患者中失访3例,9例术后获得随访,随访时间平均19.7个月,膝关节活动度及韧带功能良好.结论 前交叉韧带重建术后膝关节感染的发牛率较低,但可能会导致关节功能障碍、软骨破坏及韧带移植物失效等严重后果.因此早期诊断、早期治疗尤为重要.尽早行关节镜下清理手术,术后结合抗生素治疗,辅以积极有效的功能康复,可以取得很好的临床效果.     

关节镜下清创及灌洗引流治疗急性化脓性膝关节炎

目的探讨关节镜下清创、持续闭式灌洗引流治疗急性化脓性膝关节炎的临床效果,研究其相关指标,提高急性化脓性膝关节炎的诊治水平。 方法2006年10月至2016年10月,盐城市第一人民医院骨科共对43例(43膝)急性化脓性膝关节炎患者进行了关节镜下清创、持续闭式灌洗引流治疗。纳入标准为关节疼痛、积液、体温高于38℃;排除标准为关节液白细胞少于<11×10⁸个/L。男性,22例;女性,21例。年龄14～71岁,平均(43±12)岁。研究其术前及术后的相关指标,包括：体温、膝关节疼痛、活动度、C反应蛋白(CRP)、血沉(ESR)、降钙素原(PCT),关节液镜检,关节液一般细菌培养＋药敏试验,组织培养。末次随访采用美国膝关节协会评分(KSS)进行功能评分。 结果术后随访平均(22±10)个月,末次随访时KSS功能评分平均(85±11)分,治疗总有效率为95.3%。术后患者体温在术后3～5 d均恢复正常,膝关节疼痛明显减轻,活动度明显改善,CRP、ESR、PCT明显下降。术后第3、5、7天关节液细菌培养共3次,均为无菌生长。 结论关节镜下清创、持续闭式灌洗引流治疗膝关节腔感染,病原菌消失快,感染控制可靠,抗生素使用时间短,疗效满意。     

Calcification of the lateral collateral ligament of the knee: a rare cause of acute knee pain

Calcification of the lateral collateral ligament is a rare phenomenon, which can cause acute knee pain. The management is usually conservative and there is subsequent resolution of the calcification seen on initial radiographs. It is important to exclude more sinister pathology such as septic arthritis as a cause of pain. We report the case of an elderly lady who presented with acute knee pain. Initial radiographs showed calcification at the lateral aspect of the knee joint. The pain settled with conservative management. Resorption of calcification was demonstrated on subsequent radiographs.     

Arthroscopic treatment for septic arthritis of the shoulder in an infant

We report a case of septic arthritis in the shoulder of an infant treated with a combination of arthroscopic irrigation, débridement, and synovectomy. The results were encouraging. The patient was a boy who was 2 years 6 months of age. His first symptoms were a body temperature of 40°C and right upper arm pain. Five days after the onset, he was brought to our institution. His shoulder was swollen and erythematous. Yellowish fluid (7ml) was aspirated from his shoulder joint; the causative organism was group A Streptococcus. On admission, arthroscopic surgery was performed. His temperature gradually decreased, and inflammatory markers including the white blood cell count and C-reactive protein level improved. At his 1-year follow-up there was no sign of infection, and a full range of motion in the shoulder was maintained. The interval between the onset and the start of treatment is an important factor affecting the prognosis. The patient was brought to our institution 5 days after onset and underwent arthroscopic surgery on the same day. This early treatment was one of the factors that contributed to a successful result. Arthroscopic surgery, including irrigation and débridement, may be one of the options for treating septic arthritis of an infants shoulder.