Case Based for May

UNUSUAL CASE OF CHEST PAIN

The Patient Presentation:

A 57-year-old male with a history of IV methamphetamine use, Hepatitis C, and hypertension presented to the ED because of a one-week history of tenderness and discomfort along the right anterior chest wall. It began with an audible pop and subsequent pain felt at the right sternoclavicular area. Symptoms were worsening in severity, acetaminophen or ibuprofen were not beneficial. The were no associated symptoms of shortness of breath, fevers, nausea or vomiting. He denied any history of injecting drugs into the area or trauma. Social history was notable for homelessness, medication noncompliance, marijuana use and prior 10-year history of IV substance abuse and denied recent drug or alcohol abuse.

Upon presentation vital signs were notable for temperature of 97.2°F, blood pressure 128 / 76, heart rate 87 beats per minute, respiratory rate 16 breaths per minute and room air oxygen saturation of 98%. Physical exam was notable for tender raised right SCJ (sternoclavicular joint) without any fluctuance.

Diagnostic Studies:

Notable for a white blood cell count of 12,300 platelets 639,000 ESR of 120mm per hour (0 to 15 mm/hr) and C reactive protein of 34 milligrams per liter (8 to 10 mg/L). POC US Revealed a fluid collection and captured extension along the SCJ concerning for septic arthritis. CT imaging revealed an SCJ effusion bony erosions in the clavicle and adjacent sternal manubrium and associated extensive soft tissue inflammation concerning for septic arthritis and osteomyelitis. Orthopedic surgery was unable to aspirate the joint, interventional radiology successfully aspirated and biopsied the joint area.

Treatment:

In the emergency room the patient was begun on piperacillin tazobactam pending cultures result. Aspiration cultures after admission to the hospital were positive for gram positive cocci in chains and antibiotics were changed to ceftriaxone. The patient ultimately was taken to the operating room for right medial clavicle excision SCJ debridement and irrigation. Cultures were positive for streptococcus pneumonia, and he was discharged to continue a six-week course of antibiotics and follow up with infectious disease and orthopedics.

Discussion:

SCJ Septic arthritis is a rare but potentially fatal condition, representing less than 1% of all bone and joint infections (1). It often presents insidiously with vague and poorly localized signs. Without proper medical or surgical management, it can progress to osteomyelitis (55%), chest wall abscess (25%), mediastinitis (13%) or myositis and be associated with high-risk systemic complication to include bacteremia, endocarditis, meningitis, sepsis (2,3).  Most laboratory markers are non-diagnostic. Risk factors include intravenous drug use (21%), infections in other locations (15%), diabetes (13%), trauma (12%), infected central venous catheter (9%) and chronic renal failure (1,4).  More than 25% of patients have no risk factors (5,6). Staphylococcus aureus is the most common cause of pathogen among culture proven cases of SC joint septic arthritis (49%), followed by Pseudomonas aeruginosa (10%), Brucella melitensis (7%), and Escherichia coli (5%) (4,7). Other causative pathogens, such as Group B streptococcus, Mycobacterium tuberculosis, Streptococcus pneumonia, and polymicrobial bacteria have also been reported (7). Conservative treatment with antibiotics, surgical drainage and debridement have shown a high failure rate thus the importance of early diagnosis and treatment (8).

Summary –

1. Sternoclavicular joint septic arthritis is a rare but serious condition, constituting less than 1% of bone and joint infections
2. Early diagnosis is critical with institution of wide antibiotic coverage. In this case ultrasound revealed intraarticular effusion with capsular distension suggesting septic arthritis with early antibiotic therapy
3. Given that greater than 90% of cases do not have joint swelling and symptoms are vague, the clinician should have a high index of suspicion for SCJ septic arthritis in the appropriate clinical setting.
4. Point of care ultrasound maybe used in the initial diagnostic consideration when advanced imaging or orthopedic consultation is not readily available.

References –

1. Bar-Natan M, Salai M Sidi Y, et al. Sternoclavicular, infectious arthritis and previously healthy adults. Semin Arthritis Rheum. 2002;32(3):189-95.
2. Tanaka Y, Kato H, Shirai K, et al. Sternoclavicular joint septic arthritis with Cheswell abscess and healthy adult. A case report. J Med Case Rep 2016:10:1-5.
3. Von Gilnski A, Yilmaz E, Rausch V, et al. Surgical management of sternoclavicular joint septic arthritis. J Cli Ortho Trauma. 2019;10(2):406-13.
4. Ross JJ, Shamsuddin H, sternoclavicular septic arthritis; review of, 180 cases. Medicine 2004; 83:139-48
5. Kwon HY, Cha B, Im JH, et al. Medical management of septic arthritis of sternoclavicular joint, a case report. Medicine. 2020;99(44):e22938
6. Alhariri S, Kalas MA, Hassan M, et al. Medical management of septic arthritis of the sternoclavicular joint with extended-spectrum beta-lactamase-producing Escherichia coli: a case report. Cureus 2022;14(4); e23969
7. Savcic-Kos RM, Mali P, Abraham A, et al. Streptococcus pyogenes sternoclavicular septic arthritis in a healthy adult. Clin Med Res 2014; 12:155-9.
8. Song HK, Guy TS, Kaiser LR, et al. Current presentation and optimal surgical management of sternoclavicular joint infections. Ann Thorac Surg 2002;73:427-31.
9. General References: Clinical practice in case of an emergency medicine. Medicine (journal).

Written by William Fialkowski, MD

ERx Clinical Partners Medical Director

This is for informational purposes only. For medical advice or diagnosis, consult a physician