Mr. C is a 56 y.o. WM with PMH gout, DM, HTN who presented to the wade park ED with a 2 week history of increasing pain and swelling in his right elbow. The pt. denied any h/o trauma to the joint. Mr. C. reported 2 prior visits to the ED of an OSH where he was first given a 5 day prednisone burst for suspected gouty flare, and later a 7 day course of keflex for presumed cellulitis. His elbow continued to worsen to the point that he could no longer move the joint because of pain; he also noted a fever of 102 o . He returned to the ED where he was given IV vancomycin and admitted to a gen med service with the diagnosis of cellulitis.
Upon arrival to the floor, the pt. remained febrile and examination of RUE revealed a diffusely swollen, erythematous R elbow with exquisite pain on palpation and active and passive ROM. Ortho was consulted for evaluation; arthrocentesis revealed 30 mls of cloudy, purulent fluid with >120,000 wbcs/mm3 and 90% PMNs; there were no crystals, culture later grew MSSA. Xrays revealed a large joint effusion and subtle erosions. He was taken to the OR the following morning and underwent extensive drainage and surgical debridement.
Clues to diagnosis: trauma with possible sporotrichosis inoculation, recent surgical procedure, prosthetic joint, travel to specific regions in U.S. or endemic countries, immune deficiency (predisposes to candidal arthritis in particular)
Cause only 1% of infected prosthetic joints
Diagnosis is made by culture of synovial fluid or tissue biopsy
A 70 y.o. WM with h/o HTN, PUD, CRI, and DM presents with an acutely swollen and painful L knee. Vital signs and PE are unremarkable. The knee has an obvious effusion and is warm, swollen, and red. Arthrocentesis reveals a WBC count of 20K/mm3, and a negative Gram stain.
You are working in urgent care. A female patient presents to you with complaints of L knee pain. Temp is 38.3, and her L knee is swollen with warmth and overlying erythema. Which of the following associated medical conditions puts this pt. at highest risk of developing nongonococcal bacterial arthritis?
Pts. with RA have the highest incidence of infective arthritis (most commonly staph aureus), because of chronically inflamed joints, chronic steroid use, and breakdown of skin overlying joint deformities. The DMARDs such as etanercept and infliximab also predispose to mycobacterial infectious arthritis.