- Email: [email protected]
Septic sternoclavicular arthritis, osteomyelitis and mediastinitis
Available online at www.sciencedirect.com
ScienceDirect Journal of Acute Medicine 6 (2016) 46e48 www.e-jacme.com
Case Report
Septic sternoclavicular arthritis, osteomyelitis and mediastinitis Chih Chiang a, Ying C. Huang a,b,*, Jia-Ming Chang c,d, Kun-Han Chen e a Department of Emergency Medicine, Chiayi Christian Hospital, Chiayi, Taiwan School of Medicine and Medical Center, Kaohsiung Medical University, Kaohsiung, Taiwan c Division of Chest Surgery, Department of Surgery, Chiayi Christian Hospital, Chiayi, Taiwan d Institute of Clinical Medicine, National Cheng-Kung University, Tainan, Taiwan e Division of Plastic and Reconstructive Surgery, Department of Surgery, Chiayi Christian Hospital, Chiayi, Taiwan b
Received 21 November 2015; revised 16 March 2016; accepted 14 April 2016 Available online 23 June 2016
Abstract Background: Septic arthritis in the sternoclavicular joint (SCJ) is uncommon. Early diagnosis is difficult because of its insidious onset and lack of a radiological reference standard. In addition to joint destruction and dysfunction, delayed diagnosis and treatment may result in additional expansion of infection, sepsis, and mortality. Case Report: We present a previously healthy 38-year-old man who presented after 10 days of fever and painful swelling on the upper chest. Septic sternoclavicular arthritis and mediastinitis were diagnosed and treated by parenteral antibiotics and staged surgery. The range of motion in the right shoulder completely returned; however, mild weakness of the right shoulder remained. Conclusion: In patients presenting with upper chest, neck, or shoulder pain, physicians should include SCJ arthritis as a differential diagnosis. Multiple imaging examinations are often needed to reach a diagnosis. In septic SCJ arthritis, early institution of appropriate antibiotics is important, and surgical interventions are often needed to eradicate the infection. Copyright © 2016, Taiwan Society of Emergency Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: mediastinitis; septic arthritis; sternoclavicular joint
1. Introduction Septic arthritis is a serious but uncommon disease with an incidence of 5.7 cases per 100,000 personeyears.1 In addition to damage and dysfunction of the involved joint, it can result in mortality from septic shock, especially in patients infected with Staphylococcus aureus.2 The sternoclavicular joint (SCJ) is a small, non-weightbearing synovial joint. Septic arthritis at the SCJ is rare, accounting for 0.5e2.0% of septic arthritis cases in the general population; however, the incidence may be as high as 17e22% among intravenous drug users.3 Without prompt diagnosis and treatment, patients may have complications, such as abscess, * Corresponding author. Department of Emergency Medicine, Chiayi Christian Hospital, 539 Chuan-Hsiau Road, Chiayi City, 60002, Taiwan. E-mail address: [email protected] (Y.C. Huang).
osteomyelitis, expanding infection to the neck, breast, pleural cavities, spine, and mediastinum, leading to septic shock or death.3e6 Here, we report a case of a young, immunocompetent patient with septic sternoclavicular arthritis extending to the superior mediastinum. 2. Case Report A previously healthy 38-year-old male plasterer presented to our emergency department after 10 days of progressive painful swelling on the upper chest accompanied by fever. He visited a general practitioner 1 day prior to admission. Pus-like fluid was obtained by aspirating the hump on his upper chest. On arrival at our emergency department, his consciousness was clear. Other vital signs included respiration of 20 breaths/min, pulse of 109 beats/min, blood pressure of 128/87 mmHg, and temperature of 38.1 C. On examination, there was an indurated, tender,
http://dx.doi.org/10.1016/j.jacme.2016.04.001 2211-5587/Copyright © 2016, Taiwan Society of Emergency Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
C. Chiang et al. / Journal of Acute Medicine 6 (2016) 46e48
erythematous, warm, and swollen mass over his right SCJ. Other body parts were unremarkable. He denied any history of traumatic chest injury before this event. Blood tests revealed leukocytosis of 21,360/mL; hemoglobin of 12.1 g/dL; and aspartate aminotransferase/alanine aminotransferase of 44/ 57 IU/L, but the other values were within normal limits. Chest radiography of the patient revealed focal, poorly defined opacity (Figure 1). Computed tomography revealed subtle bone erosion and abscess at and around the right SCJ with retrosternal extension into the superior mediastinum (Figure 2). Two blood cultures were obtained, and treatment with intravenous piperacillin/tazobactam and vancomycin was immediately started. An open incision and drainage was performed shortly after admission. Necrotic tissues and ~100 mL of pus were evacuated around the loosened SCJ and contiguous mediastinum. Staphylococcus aureus was isolated from both pus and blood. Although the bacterium was resistant to penicillin, it was susceptible to oxacillin and other antimicrobial agents. Acidfast staining and Mycobacterium cultures of the pus were negative. A second surgical operation was performed 1 week later to resect the necrotic SCJ and the first costosternal joints. A right pectoralis major myocutaneous flap was elevated and rotated to cover the defect. Chronic inflammation with osteomyelitis was diagnosed in a histopathological study. After 14 days of hospitalization, he was discharged with oral sulfamethoxazole/trimethoprim. The motion range of the right shoulder completely returned after 2 weeks of rehabilitation; however, mild weakness of the right shoulder remained.
Figure 1. Chest radiography revealing focal, poorly defined opacity at the right upper chest (arrows). Old left midclavicular fracture is also identified.
47
3. Discussion SCJ septic arthritis is rare. Patients usually present with a more insidious onset than septic arthritis at other sites. Ross and Shamsuddin3 reported a case series of SCJ septic arthritis that had a medium duration of 14 days from symptom onset to hospital arrival. Most patients (78%) presented with chest pain localized to the involved SCJ. One-fifth (24%) of patients also complained of ipsilateral shoulder pain, and fever was present in 65% of patients. However, atypical presentations, such as neck pain, abscess or tumor in the neck, dysphagia, and breast abscess, have been reported.7e9 S. aureus is the most common cause of SCJ septic arthritis.3 Other infectious causes, including Pseudomonas aeruginosa, Brucella melitensis, Escherichia coli, Streptococcus, Mycobacterium tuberculosis, anaerobes, Neisseria gonorrhoeae, and Candida albicans, have been reported.3 The common risk factors of SCJ septic arthritis include intravenous drug use; an indwelling subclavian venous catheter; trauma and immunocompromised status from diabetes mellitus, cirrhosis, end-stage renal diseases, and malignancies. However, an increasing number of cases have been reported in patients who lack predisposing risk factors.10 Because of the insidious onset and lack of a radiological reference standard, early diagnosis of SCJ septic arthritis is difficult and a multimodal approach is often needed.6 Soft tissue swelling may be evident on radiography. Changes in osteomyelitis, including demineralization, destruction, and sequestrum of bone, are usually evident on radiography within 10e12 days of this complication.11 However, up to 85% of initial plain radiographs are reportedly normal.3 Cortical irregularity, joint effusion, synovial thickening, and hyperemia can be revealed by ultrasound; however, it can be difficult to differentiate between infection and inflammation in cases that lack abscess formation.6,12 Advanced imaging examinations, including computed tomography and magnetic resonance imaging can reveal joint fluid accumulation, capsule distension, cortical erosion, osseous destruction, swelling of the surrounding soft tissue, and/or delineated abscess formation. Magnetic resonance imaging offers better visualization of edema in the joint cavity, subchondral bone, bone marrow, and surrounding soft tissue. However, there is an overlap in the imaging abnormalities for infection and degeneration. The imaging findings that were significantly associated with infection included joint distension that was 10 mm, joint capsule distension extending > 5 mm over the clavicle and sternum, and bone marrow edema.6 Ultrasound-guided aspirations is helpful for evaluating patients who have ambiguous diagnoses. All patients with septic sternoclavicular arthritis need parenteral antibiotics. Empiric antibiotics that cover S. aureus should first be used with subsequent adjustment according to the results of microbial tests and the clinical response. Vancomycin should be added for patients with confirmed or suspected infection with methicillin-resistant S. aureus. Although medical treatment may be sufficient in some early-stage patients, surgery is often needed. Surgical operation may involve simple incision and drainage.13,14 For a radical intervention,
48
C. Chiang et al. / Journal of Acute Medicine 6 (2016) 46e48
Figure 2. Computed tomography demonstrating subtle bone erosion, as well as an abscess at and around the right sternoclavicular joint (arrows) with retrosternal extension to the superior mediastinum (*).
debridement, arthroplasty and flap reconstruction are usually necessary. In complicated SCJ septic arthritis, staged surgery with debridement, resection arthroplasty, open wound care, and wound closure with a pectoralis major advancement flap have a lower incidence of complications than single-stage resection and muscle advancement flap.14,15 In patients presenting with upper chest, neck, or shoulder pain, physicians should include SCJ arthritis as a differential diagnosis. If there is local tenderness, erythematous skin or swelling, multiple imaging examinations are often needed to reach an accurate diagnosis. Early institution of appropriate antibiotics is important, and surgical interventions are often needed to eradicate the infection. References 1. Kaandorp CJ, Dinant HJ, van de Laar MA, Moens HJ, Prins AP, Dijkmans BA. Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis. 1997; 56:470e475. 2. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982e1991. Ann Rheum Dis. 1999;58:214e219. 3. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine. 2004;83:139e148. 4. Dhulkotia A, Asumu T, Solomon P. Breast abscess: a unique presentation as primary septic arthritis of the sternoclavicular joint. Breast J. 2005;11: 525e526.
5. Moreno Martinez MJ, Moreno Ramos MJ, Linares Ferrando LF, Marras Fernandez-Cid C, Castano Sanchez M, Penas Martinez E. Sternoclavicular septic arthritis and empyema. Reumatol Clin. 2012;8:102e103. 6. Bodker T, Tottrup M, Petersen KK, Jurik AG. Diagnostics of septic arthritis in the sternoclavicular region: 10 consecutive patients and literature review. Acta Radiol. 2013;54:67e74. 7. Chanet V, Soubrier M, Ristori JM, Verrelle P, Dubost JJ. Septic arthritis as a late complication of carcinoma of the breast. Rheumatol. 2005;44: 1157e1160. 8. Kaewpoowat Q, Prasidthrathsint K, Permpalung N, Suksaranjit P, Bischof E. Mysterious neck pain. Am J Emerg Med. 2013;31, 466 e1e2. 9. Das AK, Monga P. Septic arthritis of the sterno-clavicular joint as a cause of dysphagia: a report of two cases and review of literature. Clin Rheumatol. 2014;33:141e143. 10. Bar-Natan M, Salai M, Sidi Y, Gur H. Sternoclavicular infectious arthritis in previously healthy adults. Semin Arthritis Rheum. 2002;32: 189e195. 11. Restrepo CS, Martinez S, Lemos DF, et al. Imaging appearances of the sternum and sternoclavicular joints. Radiographics. 2009;29:839e859. 12. Johnson MC, Jacobson JA, Fessell DP, Kim SM, Brandon C, Caoili E. The sternoclavicular joint: can imaging differentiate infection from degenerative change? Skeletal Radiol. 2010;39:551e558. 13. Gallucci F, Esposito P, Carnovale A, Madrid E, Russo R, Uomo G. Primary sternoclavicular septic arthritis in patients without predisposing risk factors. Adv Med Sci. 2007;52:125e128. 14. Chun JM, Kim JS, Jung HJ, et al. Resection arthroplasty for septic arthritis of the sternoclavicular joint. J Shoulder Elbow Surg. 2012;21: 361e366. 15. Puri V, Meyers BF, Kreisel D, et al. Sternoclavicular joint infection: a comparison of two surgical approaches. Ann Thorac Surg. 2011;91: 257e261.
ScienceDirect Journal of Acute Medicine 6 (2016) 46e48 www.e-jacme.com
Case Report
Septic sternoclavicular arthritis, osteomyelitis and mediastinitis Chih Chiang a, Ying C. Huang a,b,*, Jia-Ming Chang c,d, Kun-Han Chen e a Department of Emergency Medicine, Chiayi Christian Hospital, Chiayi, Taiwan School of Medicine and Medical Center, Kaohsiung Medical University, Kaohsiung, Taiwan c Division of Chest Surgery, Department of Surgery, Chiayi Christian Hospital, Chiayi, Taiwan d Institute of Clinical Medicine, National Cheng-Kung University, Tainan, Taiwan e Division of Plastic and Reconstructive Surgery, Department of Surgery, Chiayi Christian Hospital, Chiayi, Taiwan b
Received 21 November 2015; revised 16 March 2016; accepted 14 April 2016 Available online 23 June 2016
Abstract Background: Septic arthritis in the sternoclavicular joint (SCJ) is uncommon. Early diagnosis is difficult because of its insidious onset and lack of a radiological reference standard. In addition to joint destruction and dysfunction, delayed diagnosis and treatment may result in additional expansion of infection, sepsis, and mortality. Case Report: We present a previously healthy 38-year-old man who presented after 10 days of fever and painful swelling on the upper chest. Septic sternoclavicular arthritis and mediastinitis were diagnosed and treated by parenteral antibiotics and staged surgery. The range of motion in the right shoulder completely returned; however, mild weakness of the right shoulder remained. Conclusion: In patients presenting with upper chest, neck, or shoulder pain, physicians should include SCJ arthritis as a differential diagnosis. Multiple imaging examinations are often needed to reach a diagnosis. In septic SCJ arthritis, early institution of appropriate antibiotics is important, and surgical interventions are often needed to eradicate the infection. Copyright © 2016, Taiwan Society of Emergency Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: mediastinitis; septic arthritis; sternoclavicular joint
1. Introduction Septic arthritis is a serious but uncommon disease with an incidence of 5.7 cases per 100,000 personeyears.1 In addition to damage and dysfunction of the involved joint, it can result in mortality from septic shock, especially in patients infected with Staphylococcus aureus.2 The sternoclavicular joint (SCJ) is a small, non-weightbearing synovial joint. Septic arthritis at the SCJ is rare, accounting for 0.5e2.0% of septic arthritis cases in the general population; however, the incidence may be as high as 17e22% among intravenous drug users.3 Without prompt diagnosis and treatment, patients may have complications, such as abscess, * Corresponding author. Department of Emergency Medicine, Chiayi Christian Hospital, 539 Chuan-Hsiau Road, Chiayi City, 60002, Taiwan. E-mail address: [email protected] (Y.C. Huang).
osteomyelitis, expanding infection to the neck, breast, pleural cavities, spine, and mediastinum, leading to septic shock or death.3e6 Here, we report a case of a young, immunocompetent patient with septic sternoclavicular arthritis extending to the superior mediastinum. 2. Case Report A previously healthy 38-year-old male plasterer presented to our emergency department after 10 days of progressive painful swelling on the upper chest accompanied by fever. He visited a general practitioner 1 day prior to admission. Pus-like fluid was obtained by aspirating the hump on his upper chest. On arrival at our emergency department, his consciousness was clear. Other vital signs included respiration of 20 breaths/min, pulse of 109 beats/min, blood pressure of 128/87 mmHg, and temperature of 38.1 C. On examination, there was an indurated, tender,
http://dx.doi.org/10.1016/j.jacme.2016.04.001 2211-5587/Copyright © 2016, Taiwan Society of Emergency Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
C. Chiang et al. / Journal of Acute Medicine 6 (2016) 46e48
erythematous, warm, and swollen mass over his right SCJ. Other body parts were unremarkable. He denied any history of traumatic chest injury before this event. Blood tests revealed leukocytosis of 21,360/mL; hemoglobin of 12.1 g/dL; and aspartate aminotransferase/alanine aminotransferase of 44/ 57 IU/L, but the other values were within normal limits. Chest radiography of the patient revealed focal, poorly defined opacity (Figure 1). Computed tomography revealed subtle bone erosion and abscess at and around the right SCJ with retrosternal extension into the superior mediastinum (Figure 2). Two blood cultures were obtained, and treatment with intravenous piperacillin/tazobactam and vancomycin was immediately started. An open incision and drainage was performed shortly after admission. Necrotic tissues and ~100 mL of pus were evacuated around the loosened SCJ and contiguous mediastinum. Staphylococcus aureus was isolated from both pus and blood. Although the bacterium was resistant to penicillin, it was susceptible to oxacillin and other antimicrobial agents. Acidfast staining and Mycobacterium cultures of the pus were negative. A second surgical operation was performed 1 week later to resect the necrotic SCJ and the first costosternal joints. A right pectoralis major myocutaneous flap was elevated and rotated to cover the defect. Chronic inflammation with osteomyelitis was diagnosed in a histopathological study. After 14 days of hospitalization, he was discharged with oral sulfamethoxazole/trimethoprim. The motion range of the right shoulder completely returned after 2 weeks of rehabilitation; however, mild weakness of the right shoulder remained.
Figure 1. Chest radiography revealing focal, poorly defined opacity at the right upper chest (arrows). Old left midclavicular fracture is also identified.
47
3. Discussion SCJ septic arthritis is rare. Patients usually present with a more insidious onset than septic arthritis at other sites. Ross and Shamsuddin3 reported a case series of SCJ septic arthritis that had a medium duration of 14 days from symptom onset to hospital arrival. Most patients (78%) presented with chest pain localized to the involved SCJ. One-fifth (24%) of patients also complained of ipsilateral shoulder pain, and fever was present in 65% of patients. However, atypical presentations, such as neck pain, abscess or tumor in the neck, dysphagia, and breast abscess, have been reported.7e9 S. aureus is the most common cause of SCJ septic arthritis.3 Other infectious causes, including Pseudomonas aeruginosa, Brucella melitensis, Escherichia coli, Streptococcus, Mycobacterium tuberculosis, anaerobes, Neisseria gonorrhoeae, and Candida albicans, have been reported.3 The common risk factors of SCJ septic arthritis include intravenous drug use; an indwelling subclavian venous catheter; trauma and immunocompromised status from diabetes mellitus, cirrhosis, end-stage renal diseases, and malignancies. However, an increasing number of cases have been reported in patients who lack predisposing risk factors.10 Because of the insidious onset and lack of a radiological reference standard, early diagnosis of SCJ septic arthritis is difficult and a multimodal approach is often needed.6 Soft tissue swelling may be evident on radiography. Changes in osteomyelitis, including demineralization, destruction, and sequestrum of bone, are usually evident on radiography within 10e12 days of this complication.11 However, up to 85% of initial plain radiographs are reportedly normal.3 Cortical irregularity, joint effusion, synovial thickening, and hyperemia can be revealed by ultrasound; however, it can be difficult to differentiate between infection and inflammation in cases that lack abscess formation.6,12 Advanced imaging examinations, including computed tomography and magnetic resonance imaging can reveal joint fluid accumulation, capsule distension, cortical erosion, osseous destruction, swelling of the surrounding soft tissue, and/or delineated abscess formation. Magnetic resonance imaging offers better visualization of edema in the joint cavity, subchondral bone, bone marrow, and surrounding soft tissue. However, there is an overlap in the imaging abnormalities for infection and degeneration. The imaging findings that were significantly associated with infection included joint distension that was 10 mm, joint capsule distension extending > 5 mm over the clavicle and sternum, and bone marrow edema.6 Ultrasound-guided aspirations is helpful for evaluating patients who have ambiguous diagnoses. All patients with septic sternoclavicular arthritis need parenteral antibiotics. Empiric antibiotics that cover S. aureus should first be used with subsequent adjustment according to the results of microbial tests and the clinical response. Vancomycin should be added for patients with confirmed or suspected infection with methicillin-resistant S. aureus. Although medical treatment may be sufficient in some early-stage patients, surgery is often needed. Surgical operation may involve simple incision and drainage.13,14 For a radical intervention,
48
C. Chiang et al. / Journal of Acute Medicine 6 (2016) 46e48
Figure 2. Computed tomography demonstrating subtle bone erosion, as well as an abscess at and around the right sternoclavicular joint (arrows) with retrosternal extension to the superior mediastinum (*).
debridement, arthroplasty and flap reconstruction are usually necessary. In complicated SCJ septic arthritis, staged surgery with debridement, resection arthroplasty, open wound care, and wound closure with a pectoralis major advancement flap have a lower incidence of complications than single-stage resection and muscle advancement flap.14,15 In patients presenting with upper chest, neck, or shoulder pain, physicians should include SCJ arthritis as a differential diagnosis. If there is local tenderness, erythematous skin or swelling, multiple imaging examinations are often needed to reach an accurate diagnosis. Early institution of appropriate antibiotics is important, and surgical interventions are often needed to eradicate the infection. References 1. Kaandorp CJ, Dinant HJ, van de Laar MA, Moens HJ, Prins AP, Dijkmans BA. Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis. 1997; 56:470e475. 2. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982e1991. Ann Rheum Dis. 1999;58:214e219. 3. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine. 2004;83:139e148. 4. Dhulkotia A, Asumu T, Solomon P. Breast abscess: a unique presentation as primary septic arthritis of the sternoclavicular joint. Breast J. 2005;11: 525e526.
5. Moreno Martinez MJ, Moreno Ramos MJ, Linares Ferrando LF, Marras Fernandez-Cid C, Castano Sanchez M, Penas Martinez E. Sternoclavicular septic arthritis and empyema. Reumatol Clin. 2012;8:102e103. 6. Bodker T, Tottrup M, Petersen KK, Jurik AG. Diagnostics of septic arthritis in the sternoclavicular region: 10 consecutive patients and literature review. Acta Radiol. 2013;54:67e74. 7. Chanet V, Soubrier M, Ristori JM, Verrelle P, Dubost JJ. Septic arthritis as a late complication of carcinoma of the breast. Rheumatol. 2005;44: 1157e1160. 8. Kaewpoowat Q, Prasidthrathsint K, Permpalung N, Suksaranjit P, Bischof E. Mysterious neck pain. Am J Emerg Med. 2013;31, 466 e1e2. 9. Das AK, Monga P. Septic arthritis of the sterno-clavicular joint as a cause of dysphagia: a report of two cases and review of literature. Clin Rheumatol. 2014;33:141e143. 10. Bar-Natan M, Salai M, Sidi Y, Gur H. Sternoclavicular infectious arthritis in previously healthy adults. Semin Arthritis Rheum. 2002;32: 189e195. 11. Restrepo CS, Martinez S, Lemos DF, et al. Imaging appearances of the sternum and sternoclavicular joints. Radiographics. 2009;29:839e859. 12. Johnson MC, Jacobson JA, Fessell DP, Kim SM, Brandon C, Caoili E. The sternoclavicular joint: can imaging differentiate infection from degenerative change? Skeletal Radiol. 2010;39:551e558. 13. Gallucci F, Esposito P, Carnovale A, Madrid E, Russo R, Uomo G. Primary sternoclavicular septic arthritis in patients without predisposing risk factors. Adv Med Sci. 2007;52:125e128. 14. Chun JM, Kim JS, Jung HJ, et al. Resection arthroplasty for septic arthritis of the sternoclavicular joint. J Shoulder Elbow Surg. 2012;21: 361e366. 15. Puri V, Meyers BF, Kreisel D, et al. Sternoclavicular joint infection: a comparison of two surgical approaches. Ann Thorac Surg. 2011;91: 257e261.