Document Detail

Bilateral Acromioclavicular Septic Arthritis as an Initial Presentation of Streptococcus pneumoniae Endocarditis.
Jump to Full Text
MedLine Citation:
PMID:  24987538     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Infective endocarditis (IE) is infrequently associated with septic arthritis. Moreover, septic arthritis of the acromioclavicular (AC) joint is rarely reported in the literature. We report a case of Streptococcus pneumoniae IE in a patient who presented with bilateral AC joint septic arthritis and we review the literature on the topic.
Neda Hashemi-Sadraei; Rohan Gupta; Jorge D Machicado; Rukma Govindu
Related Documents :
20015798 - Sarcoidosis of the submandibular gland: a systematic review.
23695408 - Henoch-schönlein purpura without systemic involvement beginning with acute scrotum and ...
6420448 - A circulating lupus-like coagulation inhibitor induced by chlorpromazine.
15517448 - Kikuchi-fujimoto's disease associated with systemic lupus erythematosus: case report an...
265938 - Critical review of biopsy and cytologic examination of oral cancer.
14504878 - Long retained intravaginal foreign body: a case report.
Publication Detail:
Type:  Journal Article     Date:  2014-06-01
Journal Detail:
Title:  Case reports in infectious diseases     Volume:  2014     ISSN:  2090-6625     ISO Abbreviation:  Case Rep Infect Dis     Publication Date:  2014  
Date Detail:
Created Date:  2014-07-02     Completed Date:  2014-07-02     Revised Date:  2014-07-07    
Medline Journal Info:
Nlm Unique ID:  101573243     Medline TA:  Case Rep Infect Dis     Country:  Egypt    
Other Details:
Languages:  eng     Pagination:  313056     Citation Subset:  -    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Case Rep Infect Dis
Journal ID (iso-abbrev): Case Rep Infect Dis
Journal ID (publisher-id): CRIID
ISSN: 2090-6625
ISSN: 2090-6633
Publisher: Hindawi Publishing Corporation
Article Information
Download PDF
Copyright © 2014 Neda Hashemi-Sadraei et al.
Received Day: 6 Month: 3 Year: 2014
Accepted Day: 15 Month: 5 Year: 2014
Print publication date: Year: 2014
Electronic publication date: Day: 1 Month: 6 Year: 2014
Volume: 2014E-location ID: 313056
PubMed Id: 24987538
ID: 4058585
DOI: 10.1155/2014/313056

Bilateral Acromioclavicular Septic Arthritis as an Initial Presentation of Streptococcus pneumoniae Endocarditis
Neda Hashemi-SadraeiI1*
Rohan GuptaI1
Jorge D. MachicadoI1
Rukma GovinduI1
Department of Internal Medicine, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 1.134, Houston, TX 77030, USA
Correspondence: *Neda Hashemi-Sadraei:
[other] Academic Editor: Larry M. Bush

1. Introduction

Infective endocarditis (IE) is frequently associated with osteoarticular manifestations. Though, septic arthritis associated with IE is rare [1]. Moreover, septic arthritis of the acromioclavicular (AC) joint is rarely reported in the literature, with majority of the cases described in patients with underlying predisposing conditions. Herein, we report a case of a 43-year-old man with bilateral AC joint septic arthritis due to Streptococcus pneumoniae who was found to have infective endocarditis (IE). This is the first case reported of IE caused by S. pneumoniae presenting with bilateral septic arthritis of the AC joint, and we review the literature on the topic.

2. Case Report

A 43-year-old African American man presented to the emergency department with five days of arthralgias. The patient initially developed bilateral shoulder pain and swelling, followed by bilateral hip pain and swelling of the third digit of the right hand. He recalled local trauma to this finger while playing basketball three weeks earlier, causing transient swelling and pain that had resolved 2 days later.

Otherwise, he had no previous medical history, recent travels, tick bites, or illicit drug use. A 20-pack-year history of tobacco smoking and a daily alcohol consumption of 75–95 grams were reported. His vital signs were remarkable for heart rate of 110 beats/minute and oral temperature of 100.4 Fahrenheit. The physical exam showed decreased range of motion, erythema, swelling, and tenderness to palpation in both AC joints. Right third proximal interphalangeal (PIP) joint appeared swollen. The rest of the physical exam was benign.

Initial laboratory investigation included a white blood count of 14,800/mm3 (82% neutrophils, 4% lymphocytes, and 12% monocytes), erythrocyte sedimentation rate of 68 mm/h, and C-reactive protein of 34.6 mg/L (upper normal 0.30 mg/L). The remaining blood counts, biochemistry, urinalysis, HIV serology, and chest films were normal. After blood cultures were obtained, he was started empirically on ceftriaxone and vancomycin.

Bilateral shoulder plain radiographs did not reveal abnormalities. Ultrasound of the affected joints showed overlying anechoic fluid contiguous with the AC joints and periarticular soft tissue swelling with a thin rim of anechoic fluid in the right 3rd PIP. An arthrocentesis was performed, and grossly purulent fluid was drained from the right AC joint. Subsequent incision and drainage revealed gross purulence in both AC joints and in flexor sheath at the level of right third PIP. All these data were diagnostic for bilateral AC joint septic arthritis and right third PIP tenosynovitis.

Both AC synovial fluid and blood cultures grew S. pneumoniae susceptible to cefotaxime (minimum inhibitory concentration (MIC) 0.25μg/mL), intermediately resistant to penicillin (MIC 0.064μg/mL) and susceptible to vancomycin (MIC 0.38μg/mL). Urine antigen was also positive for S. pneumoniae. The patient was continued on ceftriaxone, while vancomycin was stopped at day 3. A transthoracic echocardiography (TTE) failed to reveal any vegetation or valvular abnormalities.

He remained febrile for 1 week despite antibiotic therapy. Physical exam remained normal, including careful cardiovascular, neurologic, and fundoscopic evaluation.

Repeated blood cultures on days 2, 3, 6, and 8 were all negative. Transesophageal echocardiogram (TEE) showed moderate aortic regurgitation, with an irregular and perforated 10-mm mass attached to the left cusp of the aortic valve (Figure 1).

Computed tomography of the head did not reveal septic emboli. A final diagnosis of IE with bilateral AC septic arthritis was made. Surgical aortic valve replacement was performed at day 12, as fever was persistent for more than 10 days despite antibiotic therapy. Native valve showed histopathology consistent with valve infection but did not reveal any organism.

The patient clinically improved after the surgery, with complete resolution of fever. Ceftriaxone was given for a total of 4 weeks, with no recurrence of his fever and slow recovery of his osteoarticular symptoms during 90 days of followup.

3. Discussion

Musculoskeletal manifestations are not uncommon in IE [2]. In a review of 9 studies of 1,312 patients with IE and musculoskeletal symptoms, 19–44% had at least one manifestation, mostly arthralgias and low back pain. Though, only 3.4% (n = 45) had documented osteoarticular infection (range: 0–15%) including septic arthritis and osteomyelitis [1]. Among these patients, the most common organisms reported were Staphylococcus aureus (23 cases), followed by Streptococcus viridans (8 cases) and enterococcus (4 cases). There was only one case that found S. pneumoniae as the causing organism. This was a 37-year-old woman, with history of IV drug use who was diagnosed with IE involving the mitral valve. Bone/gallium scan showed 2nd and 3rd costochondral joint involvement and blood cultures revealed S. pneumoniae [2]. Among the patients with IE and documented osteoarticular infection, multiple joints were usually affected, mostly the major joints of upper or lower extremity and the axial skeleton [1].

There was one case which mentioned IE with AC joint involvement, but no further clinical description was given [3].

Acromioclavicular joint septic arthritis has rarely been described. After an extensive review of the published literature, we found 30 documented cases of AC joint septic arthritis. Table 1 describes the demographics, comorbidities, echocardiographic findings, causative organisms, and treatments administered in these cases. Out of 27 cases where an etiology was documented, S. aureus was the leading organism (52%). S. pneumoniae was isolated in 2 of these patients, both with hematologic malignancies [4, 5]. Echocardiography was reported in 4 cases and described IE in 2 of them [68]. One of these reports described a 74-year-old man who presented with unilateral AC joint septic arthritis caused by S. aureus and was ultimately found to have IE of the mitral and aortic valves, complicated by cerebellar septic emboli [6]. On the other report, a 41-year-old man initially presented with multiple joint involvement including bilateral AC joints. Cultures of the synovial fluid from his ankle as well as blood cultures were positive for a beta hemolytic group B Streptococcus and TTE indicated mitral valve IE [7].

S. pneumoniae accounts for less than 3% of etiology of IE [9]. Pneumococcal endocarditis is associated with poor outcomes due to the rapid destruction of endothelial tissue followed by valvular insufficiency, embolic complications, and eventually heart failure. Therefore, early diagnosis and treatment are crucial to prevent these complications [9, 10].

To our knowledge, this is the first documented case of bilateral AC joint septic arthritis as the manifestation of S. pneumoniae endocarditis. In summary, clinicians should recognize septic arthritis as a possible manifestation of IE, especially when an uncommon joint is involved or a rare organism is identified, as illustrated in this case.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

1. Vlahakis NE,Temesgen Z,Berbari EF,Steckelberg JM. Osteoarticular infection complicating enterococcal endocarditisMayo Clinic ProceedingsYear: 20037856236282-s2.0-003806910012744551
2. Sapico FL,Liquete JA,Sarma RJ. Bone and joint infections in patients with infective endocarditis: review of a 4-year experienceClinical Infectious DiseasesYear: 19962257837872-s2.0-00300171318722931
3. Churchill MA Jr.,Geraci JE,Hunder GG. Musculoskeletal manifestations of bacterial endocarditisAnnals of Internal MedicineYear: 19778767547592-s2.0-0017590396145198
4. Widman DS,Craig JG,van Holsbeeck MT. Sonographic detection, evaluation and aspiration of infected acromioclavicular jointsSkeletal RadiologyYear: 20013073883922-s2.0-003491324411499779
5. Chiang AS,Ropiak CR,Bosco JA III,Egol KA. Septic arthritis of the acromioclavicular joint: a report of four casesBulletin of the NYU Hospital for Joint DiseasesYear: 20076543083112-s2.0-3744902757518081551
6. Bossert M,Prati C,Bertolini E,Toussirot E,Wendling D. Septic arthritis of the acromioclavicular jointJoint Bone SpineYear: 20107754664692-s2.0-7795786841120729119
7. Good AE,Hague JM,Kauffman CA. Streptococcal endocarditis initially seen as septic arthritisArchives of Internal MedicineYear: 197813858058062-s2.0-0018079717348136
8. Hammel JM,Kwon N. Septic arthritis of the acromioclavicular jointJournal of Emergency MedicineYear: 20052944254272-s2.0-2714447675316243200
9. Aronin SI,Mukherjee SK,West JC,Cooney EL. Review of pneumococcal endocarditis in adults in the penicillin eraClinical Infectious DiseasesYear: 19982611651712-s2.0-00318897369455526
10. Siegel M,Timpone J. Penicillin-resistant Streptococcus pneumoniae endocarditis: a case report and reviewClinical Infectious DiseasesYear: 20013269729742-s2.0-003586707711247720
11. Adams R,McDonald M. Cryptococcal arthritis of the acromio-clavicular jointNorth Carolina Medical JournalYear: 198445123242-s2.0-00213142276583512
12. Blankstein A,Amsallem JL,Rubinstein E,Horoszowski H,Farin I. Septic arthritis of the acromioclavicular jointArchives of Orthopaedic and Traumatic SurgeryYear: 198510364174182-s2.0-0021837758
13. Zimmermann B III,Erickson AD,Mikolich DJ. Septic acromioclavicular arthritis and osteomyelitis in a patient with acquired immunodeficiency syndromeArthritis and RheumatismYear: 1989329117511782-s2.0-00244159302673250
14. Hughes RA,Rowe IF,Shanson D,Keat ACS. Septic bone, joint and muscle lesions associated with human immunodeficiency virus infectionThe British Journal of RheumatologyYear: 19923163813882-s2.0-0026651586
15. Neault MA,Nuber GW,Marymont JV. Infections after surgical repair of acromioclavicular separations with nonabsorbable tape or sutureJournal of Shoulder and Elbow SurgeryYear: 1996564774782-s2.0-00302798808981274
16. Laktasic-Zerjavic N,Babic-Naglic D,Curkovic B,Potocki K,Soldo-Juresa D. Septic acromioclavicular arthritis in a patient with diabetes mellitusCollegium AntropologicumYear: 20052974374616417193
17. Zicat B,Rahme DM,Swaraj K,Qurashi S,Loneragan R,van der Wall H. Septic arthritis of the acromioclavicular joint: Tc-99m leukocyte imagingClinical Nuclear MedicineYear: 20063131451462-s2.0-3374499014116495732
18. Murdoch DM,McDonald JR. Mycobacterium avium-intracellulare cellulitis occurring with septic arthritis after joint injection: a case reportBMC Infectious DiseasesYear: 20077, article 92-s2.0-40749162459
19. Tan WP,Tang MBY,Tan HH. Scrofuloderma from the acromioclavicular joint presenting as a chronic ulcer in an immunocompetent hostSingapore Medical JournalYear: 2007489e243e2452-s2.0-3584893799017728950
20. Battaglia TC. Ochrobactrum anthropi septic arthritis of the acromioclavicular joint in an immunocompetent 17 year oldOrthopedicsYear: 2008316p. 6062-s2.0-64949172749
21. Cone LA,Gauto A,Kazi A,et al. Staphylococcal septic arthritis of the small joints of the shoulder girdleJournal of Clinical RheumatologyYear: 20081431811822-s2.0-4824912544918525441
22. Iyengar KP,Gudena R,Chitgopkar SD,et al. Primary septic arthritis of the acromio-clavicular joint: case report and review of literatureArchives of Orthopaedic and Trauma SurgeryYear: 2009129183862-s2.0-5624910835218810473
23. Noh KC,Chung KJ,Yu HS,Koh SH,Yoo JH. Arthroscopic treatment of septic arthritis of acromioclavicular jointClinics in Orthopedic SurgeryYear: 2010231861902-s2.0-7995587256020808591
24. Carey TW,Jackson K,Roure R,Abell BE. Acromioclavicular septic arthritis: a case report of a novel pathogenThe American Journal of OrthopedicsYear: 20103931341362-s2.0-7795549423320463985

Article Categories:
  • Case Report

Previous Document:  Combined liver and kidney transplant in a patient with budd-Chiari syndrome secondary to autosomal d...
Next Document:  Acute myeloid leukemia presenting with pulmonary tuberculosis.