Dbeis Ammer, Sanderson Brent, Rahman Shawn, Jazayeri Reza
Graduate Medical Education, Orthopaedic Surgery Residency Program, Community Memorial Health System, Ventura, CA, USA.
Graduate Medical Education, Orthopaedic Surgery Residency Program, Community Memorial Health System, Ventura, CA, USA.
Int J Surg Case Rep. 2021 Mar;80:105624. doi: 10.1016/j.ijscr.2021.02.010. Epub 2021 Feb 15.
Septic 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.
Bilateral 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/CONCLUSION: This 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.
化脓性关节炎是一种骨科急症，需要快速诊断和治疗。它通常由隐匿性菌血症引起，菌血症使细菌在关节处定植或软组织感染局部扩散。大多数化脓性关节炎病例由革兰氏阳性菌引起，最常见的病原体是金黄色葡萄球菌。化脓性关节炎之所以是骨科急症，是因为它会迅速破坏软骨。软骨损伤机制有两方面：细菌酶对关节软骨有直接毒性，渗出物积聚可压迫血流并导致缺氧性损伤。通常，膝关节是最常受累的关节。其次是髋关节、踝关节、肘关节、腕关节和肩关节，按发病几率从高到低排列。多关节疾病在这些病例中占比小，若出现，通常不对称，且至少累及一个膝关节。
双侧关节化脓性关节炎相对罕见。我们报告一例不常见的病例，一名患有心脏病的老年男性出现非创伤性双侧化脓性肩关节，在打了18洞高尔夫球后出现隐匿性双侧肩部疼痛。这种表现不仅因其罕见而独特，还因其对我们理解合并内科疾病情况下的化脓性关节炎以及相对不明显的表现有影响。在发病前最近有打高尔夫球的经历，除化脓性关节炎外的鉴别诊断包括三角肌/肩袖肌拉伤、慢性肩袖肌腱病急性发作、慢性肩袖撕裂急性发作、骨关节炎急性发作、类风湿关节炎或结晶性关节病。由于炎症指标升高且体格检查结果不明确，我们的患者接受了磁共振成像（MRI）高级影像学检查，随后进行了双侧盂肱关节诊断性穿刺，穿刺结果与化脓性关节炎相符，因为患者入院后不久就抱怨对侧肩部疼痛。在做出上述诊断后，患者立即被送回进行紧急双侧开放性冲洗和清创，因为化脓性关节炎是骨科急症，患者在接受针对培养结果的静脉抗生素治疗后顺利康复。
讨论/结论：本病例报告在临床实践方面具有重要意义，原因有多个方面。首先也是最重要的，对于所有临床医生而言，这是一个警示故事，提醒他们对于多关节疼痛患者，必须对多关节化脓性关节炎保持高度怀疑。其次，它展示了高级影像学检查在诊断不明确患者中的作用。最后，它强调了及时诊断和治疗的重要性，验证了现有的化脓性关节炎诊疗流程。
