Peer Reviewed

Case in Point

Spontaneous Bilateral Septic Shoulder Arthritis in an Immunocompetent Patient

AUTHORS:
Nicole Terrigno, MD
Hospital Medicine Department, Cooper University Hospital, Camden, New Jersey

Rocco Terrigno, MD
Pulmonary and Interventional Pulmonary Medicine Department and Critical Care Medicine Department, Cooper University Hospital, Camden, New Jersey

CITATION:
Terrigno N, Terrigno R. Spontaneous bilateral septic shoulder arthritis in an immunocompetent patient [published online February 10, 2020]. Consultant360.

 

Septic arthritis from any joint has a reported annual incidence of 2 to 3 cases per 100,000 in the worldwide population,1 with native shoulder septic joint infections representing less than 3% of these cases.2 Polyarticular septic arthritis is uncommon, accounting for only 12% to 15% of all septic joint cases.1,3,4 Septic arthritis is often caused by direct inoculation of bacteria (eg, through a surgical procedure or trauma) or by hematogenous spread. Rarely, it can occur spontaneously. Patients who are immunocompromised, who have diabetes, who have rheumatoid arthritis, or who have risk factors such as intravenous drug use are more susceptible to infections.5,6

In the right clinical context, a septic joint infection is an important differential diagnosis to consider, since it can be a rapidly destructive disease process on the joints, with significant morbidity and mortality rates reported as high as 50%.7 Managing these infections promptly and before cartilaginous and soft tissue damage occurs is imperative. The authors of a review of 180 cases of sternoclavicular septic arthritis reported that needle aspiration can yield positive bacterial cultures in up to 77% of cases, while surgical debridement can yield positive bacterial cultures in up to 36% of cases.2 Staphylococcus aureus is the most common organism in native joint infective arthritis of any site.8

Very few reports of polyarticular septic arthritis in immunocompetent patients have been published in the literature.1,3,9,10 We present a case of a woman without risk factors who presented with bilateral shoulder pain associated with decreased range of motion; she was found to have bilateral septic arthritis of the shoulders.

CASE REPORT

A 46-year-old woman presented to our hospital for orthopedic evaluation of bilateral, constant shoulder pain with swelling and stiffness. She had a history of well controlled asthma, depression, and anemia, along with uterine fibroids for which she had undergone a hysterectomy years ago.

History. The patient had been to an emergency department (ED) 1 week prior to presentation with concern for pain in her right arm and shoulder, along with bilateral shoulder stiffness. During this ED visit, radiographs of the right shoulder showed mild degenerative changes but no evidence of acute fracture or dislocation. She was sent home with pain medications and was advised to follow up as outpatient.

She returned to the ED a few days later with worsening right-sided pain, as well as progressive pain in the left shoulder and arm. At that time, she was hemodynamically stable. She denied any trauma to the area, any recent procedures, and any history of intravenous drug use, and she reported no fevers or chills. Magnetic resonance imaging of the left and right upper extremities showed bilateral full-thickness rotator cuff tendons with retraction of the tendons medially, severe edema within the muscles, a large abscess, and osteomyelitis of the humeral head. She was sent to our hospital for orthopedic evaluation.

Physical examination. On arrival at our hospital, she reported pain in the bilateral anterior shoulders that she rated as 10 of 10. She had decreased range of motion (both passive and active) of the bilateral shoulder joints, and pain and swelling of the upper extremities. The patient reported pain with palpation of all aspects of the shoulders, but her arms were well perfused and warm. Cardiac, pulmonary, and gastrointestinal examination findings were unremarkable.

Diagnostic tests. Laboratory test results showed an elevated C-reactive protein level of 153.9 mg/L (reference value, <5.0 mg/dL), an elevated erythrocyte sedimentation rate greater than 100 mm/h (reference range, 0-20 mm/h), thrombocytosis (platelet count, 510 × 103/µL; reference range, 150-400 × 103/µL), leukocytosis (white blood cell count, 11,200/µL; reference range, 4500-11,000/µL), and a low hemoglobin level of 8.0 g/dL (reference range, 12.0-14.0 g/dL). She was given pain medications, and orthopedics and interventional radiology specialists were consulted.

She underwent aspiration and bilateral drainage of both shoulders with 10F drainage catheters under ultrasound guidance by the interventional radiology team. Analysis of the aspirate showed 126,720 nucleated cells. Cultures from the aspirate grew methicillin-sensitive Staphylococcus aureus. She was initially placed on vancomycin, which was changed to cefazolin once the culture results were finalized. Blood cultures were negative for bacteria. Echocardiography showed no evidence of vegetations or endocarditis.

The patient underwent washout of the bilateral shoulders by the orthopedics team 2 days after the initial aspiration. During the operation, the patient was noted to have deep abscesses of the right shoulder measuring 5 × 5 cm, and she had capsulotomy of the bilateral shoulders with irrigation and excisional debridement of the septic arthritis. An additional 2 drains were placed during the operation.

While hospitalized, the patient underwent immunodeficiency testing; the results of an HIV test and a hepatitis panel were negative. Rheumatologic workup results were negative for all of the following antibodies: antinuclear antibodies, rheumatoid factor, antineutrophil cytoplasmic antibodies, antimitochondrial antibodies, anti–smooth-muscle antibodies, and Lyme disease antibodies.

Outcome of the case. She had a peripherally inserted central catheter placed and was discharged to rehabilitation on a 6-week regimen of intravenous cefazolin for 6 weeks and with scheduled orthopedics and infectious disease follow-up.

At a follow-up visit 5 weeks after the surgical procedure, the patient reported improved pain and progress in range of motion from working with physical therapists.

DISCUSSION

The manner in which our patient developed septic arthritis of the bilateral shoulders is unknown. She had no risk factors, had undergone no recent surgical procedures, and had no health conditions predisposing her to infection. In their case report, Griffin and colleagues describe the rarity of a patient with a spontaneous unilateral septic glenohumeral joint.3 Two other case reports, one by Mamarelis and colleagues9 and another by Hotonu and colleagues,10 describe patients who had acquired spontaneous bilateral septic arthritis of the shoulders (one case with bilateral sternoclavicular infections, and the other with bilateral glenohumeral infections) with S aureus. Microbiology results from the aspirate of our patient showed S aureus, coinciding with the causative pathogen in most reported shoulder septic arthritis cases.

Certain comorbidities can predispose a person to the development of a septic arthritis, such as intravenous drug use, immunocompromised states (such as HIV infection), rheumatoid arthritis, recent other illness, and diabetes. In our patient’s case, screening with immunologic testing, rheumatologic testing, and cardiac imaging were all negative for these risk factors.

Because bilateral shoulder septic arthritis is rare, the literature is sparse on the management and overall outcomes of patients with bilateral shoulder septic arthritis. Ideally, intravenous antibiotics, drainage or surgical debridement, and articular rest would be the treatment of choice. If a patient’s septic arthritis of the shoulder does not improve with needle aspiration, or if there is coexisting osteomyelitis, surgical drainage is mandatory.12 Some authors state that patients have more favorable outcomes when they undergo aspiration followed by early arthroscopic washouts,7 as our patient did. To our knowledge, only 3 other case reports have been published of similar infections in healthy adults with no risk factors.3,9,10

Our patient’s case illustrates that although they are rare, septic joints should be included in the differential diagnosis of a patient presenting with pain and decreased range of motion at a joint, and it shows that early detection, aspiration/washout, and administration of antibiotics can lead to a favorable outcome.

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