Glenohumeral Joint Sepsis after Joint Injection through a New Tattoo.

We report a case of Propionibacterium acnes septic arthritis of a shoulder following two joint access procedures. Methodical investigation of these two procedures was performed using the Joint Commission root cause analysis matrix, which involved examination of protocols, interviews with technologists and physicians, and inspection of the procedure rooms and equipment. No procedural error or other causal factor for infection was found other than the injection through a five day-old tattoo during the first procedure. We could find no other reported cases of Propionibacterium acnes seeding a joint via an arthrogram needle. This may be an under-reported phenomenon or could be a unique case. In either instance, the occurrence bears notice by anyone performing joint access procedures.