This document presents the case of a 39-year-old Thai female patient who presented with acute fever and right shoulder pain. Physical examination revealed erythema and tenderness of the right shoulder with limited range of motion. Blood tests showed elevated inflammatory markers. MRI of the right shoulder showed signs of infection. Arthrocentesis of the right shoulder joint yielded cloudy yellow fluid with a high white blood cell count. Culture of the joint fluid and blood grew Staphylococcus aureus. The patient was diagnosed with septic arthritis of the right shoulder and treated surgically with arthrotomy and antibiotics.

1. TeleconferenceTeleconference CaseCase
Maharat Nakhon Ratchasima Hospital
Extern Khosit Pinmai Code 5502180 Faculty of Medicine, Ramathibodi Hospital,
Mahidol University

2. Patient HistoryPatient History
39
()

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Chief complaintChief complaint
7 ..

4. Present IllnessPresent Illness
9 PTA
8 PTA CT
7 PTA ..admit ATB ceftriazone 2g IV OD x 6 days,
ceftriazone 2g IV q 12 hr x 2 days Clindamycin 600 mg IV
q 8 hr x 1 day
refer .

5. Personal HistoryPersonal History
•
•
• DM HT TB

6. Family HistoryFamily History
• DM HT DLP
•
•

7. Systemic ReviewSystemic Review
• General:
• Skin:
• HEENT: Head:
Eye: 1
Ear:
Nose & Sinus:
Mount & Oral cavity:
Throat:

8. Systemic ReviewSystemic Review (cont.)(cont.)
• Chest:
• Respiratory:
• Cardiovascular:
• Musculoskeletal:
• KUB:
• Gastrointestinal:
• Gynecological:
• Neurologic:
• Hematologic:
• Endocrine:

9. Physical ExaminationPhysical Examination
• Vital Signs: T 38.2°C, P 102 bpm, RR 20/min, BP 125/76 mmHg
Wt 40 kg, Ht 155 cm BMI= 16.65 kg/m2
• GA: Thai female, Age 39 year olds, Looking well, Active, Cooperative
• Skin: Ulceration wound at
Lt lateral foot, mild tender
• Eyes: no pale conjunctiva, anicteric sclerae, Pupil round and equal
diameter 3 mm. Rt = Lt , RTL Both eyes
• Ear: Normal hearing, No abnormal looking, Ear canals are normal
looking, No discharge, Tympanic membranes intact
• Nose: Symmetrical, No septal deviation, No visible blockage, No
inflammation in the nostrils

10. Physical Examination (cont.)Physical Examination (cont.)
• Oral cavity: no oral ulcer, No dental caries or gingivitis, Tongue not
deviated, Pharynx not injected, Tonsils not enlarged, not injected
• Neck: Trachea in midline, Thyroid gland not enlarged, Jugular veins
not engorged, Cervical LN not palpable
• Chest: Symmetrical chest wall, Normal breathing movement,
Expansion full, Rt =Lt, Normal breath sound, no adventitious sound
• CVS: No cyanosis, No clubbing fingers, No heave or thrill, Peripheral
pulses are equal, No carotid bruit, Normal S1 S2, no murmur
• Abdomen: No distension, no dilated veins, Normal movement, No
scar, Bowel sounds normal, Soft, not tender, no mass, Liver and
spleen can’t be palpated, No guarding, No rebound tenderness, No
liver stigmata, Fluid thrill negative, Shifting dullness negative

11. Physical Examination (cont.)Physical Examination (cont.)
• Extremities:
No pitting edema,
no petechiae, no
rash
Mild erythema
Warmth
Marked tenderness
Mild swelling
Limit ROM at Right shoulder
due to pain (Joint immobility)
(Passive & Active)

12. Physical Examination (cont.)Physical Examination (cont.)

13. Physical Examination (cont.)Physical Examination (cont.)
• Neurological: Fully conscious, Good orientation to time, place,
person
Speech: normal
Cranial nerves: normal
Motor: grade V all extremities
Sensory: grossly intact
DTR: 2+ all
Stiffness of neck: negative

14. Problem listsProblem lists
Acute fever
Right shoulder pain
1
2
Blurred vision of both eyes
R/O Septic embolic phenomenon
3

15. Differential diagnosisDifferential diagnosis
Infectious arthritis (Septic arthritis)
Inflammatory arthritis
Crystal-induced arthritis
Systemic infection (Bacterial
endocarditis, HIV infection)
4
1
2
3

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A
E C
D
F B
InvestigationInvestigation
G
H

17. Complete blood count (CBC)Complete blood count (CBC)
• Hb 11.7 g/dL
• Hct 35.2 %
• MCV 89.8 fl
• MCH 29.8 pg
• MCHC 33.2 g/dL
• RDW 13.4
• WBC 7800 cell/mm3
– N 58
– L 30
– E 2
• Plt count 430,000 cell/mm3

18. Rt shoulder AP, transcapularRt shoulder AP, transcapular

19. Joint fluid examinationJoint fluid examination
• Color: Yellow
• Transparence: Cloudy
• Specific gravity: 1.020
pH: 9.0
RBC: 2000 cell/mm3
WBC: 28,960 cell/mm3
Neutrophil: 95%
Lymphocyte: 4%
Monocyte: 1%
Crystal: Not found

20. Electrolytes, BUN, CrElectrolytes, BUN, Cr
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• BUN 5.2 mg/dL
• Cr 0.45 mg/dL
• Uric acid 2.1 mg/dL
• Phosphorus 3.4 mg/dL
• eGFR 127 ml/min/1.73m2
• Na 137 mmol/L
• K 3.9 mmol/L
• Cl 98.2 mmol/L
• CO2 26.3 mmol/L
• Anion gap 16.6

21. ESR, CRPESR, CRP
• ESR 82 mg/L
• CRP 66.9 mg/L

22. CXRCXR

23. Synovial fluidSynovial fluid (Microscopic exam)(Microscopic exam)
• Moderate WBC
• Many RBC
• Organism: Not seen
Synovial fluidSynovial fluid (Aerobic Culture)(Aerobic Culture)
• No bacterial growth after 48 hr

24. Hemoculture after 48 hrHemoculture after 48 hr
• H/C 1
Organism: Staphylococcus aureus
Susceptible: Oxacillin Co-Trimoxazole Erythromycin
Clindamycin Tetracycline Fosfomycin
• H/C 2:
Organism: Gram positive cocci in cluster

25. Anti HIVAnti HIV
• Anti HIV (ELISA) Neg

26. Plan of ManagmentPlan of Managment
Cefazolin 1 g IV q 6 hr
Paracetamol (500) 1 tab po prn q 4-6 hr

27. Operative NoteOperative Note
 Open arthrotomy Right shoulder
 Serosanguinous fluid 2 ml, no pus,
no cartilage destruction

28. Additive treatmentAdditive treatment
 :
 Isometric exercise Prevent muscle atrophy
 ROM exercise Prevent joint stiffness
 :
 Fever & Pain relief
 Dehydration: fluid hydration

29. Post-operative progressionPost-operative progression
• POD0: (38.5°C)
• POD1:(38.7°C), Drain 20 ml, H/C: NG
Joint fluid: not seen org., mod.WBC
• POD2:ps=2 (37.8°C), Drain 20 ml,
H/C: S. aureus, J/C: NG
• POD3:ps=4 , Drain 0 ml
• POD4:ps=3 , Drain 0 ml
• POD5:&
• POD6: ps=5
• POD7:ps=5
ESR 100, CRP= 34.8
POST OP 1ST
WK

30. Post-operative progressionPost-operative progression
• POD8:ps=2 1 peak (37.9°C)
• POD9:ps=3
• POD10:
• POD11:
• POD12:(ROM active 30°)
• POD13:(ROM active 30°, passive 120°)
• POD14:(ROM active 45°, passive 120°) , ESR 64, CRP= 7.93
POST OP 2nd
WK

31. L/O/G/O
Septic Arthritis

32. GeneralGeneral
• known as infectious arthritis, may represent a direct
invasion of joint space by various microorganisms, most
commonly caused by bacteria.
• key consideration in adults presenting with acute
monoarticular arthritis.
• becoming increasingly common among people who are
immunosuppressed and elderly persons.
• Of people with septic arthritis, 45% are older than 65
years; these groups are more likely to have various
comorbid disease states.
• Septic arthritis due to bacterial infections is commonly
classified as either gonococcal or nongonococcal.

33. PathogenesisPathogenesis
• Because of the lack of a limiting basement plate in
synovial tissues, the most common route of entry into the
joint is hematogenous spread during bacteremia.
• Pathogens may also enter through direct inoculation (e.g.,
arthrocentesis, arthroscopy, trauma) or contiguous spread
from local infections (e.g., osteomyelitis, septic bursitis,
abscess).
• Once in the joint, microorganisms are deposited in the
synovial membrane, causing an acute inflammatory
response.
• Inflammatory mediators and pressure from large effusions
lead to the destruction of joint cartilage and bone loss.

34. L/O/G/O
Approach to Septic arthritis
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35. HISTORYHISTORY

36. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
• The physical examination should determine if
the site of inflammation is intraarticular or
periarticular, such as a bursa or skin.
• Intraarticular pathology results in severe
limitation of active and passive range of
motion, and the joint is often held in the
position of maximal intraarticular space.
• Conversely, pain from periarticular pathology
occurs only during active range of motion, and
swelling will be more localized.

37. LABORATORY EVALUATIONLABORATORY EVALUATION
• Serum markers, such as white blood cell
(WBC) count, ESR and C-reactive protein
levels, are often used to determine the
presence of infection or inflammatory
response.
• Patients with confirmed septic arthritis have
been found to have normal ESR and C-
reactive protein levels.
• When elevated, these markers may be used to
monitor therapeutic response.

38. SYNOVIAL FLUID ANALYSISSYNOVIAL FLUID ANALYSIS
In synovial fluid, a WBC count of more than 50,000/mm3
(50 × 109
per L) and a polymorphonuclear cell count
greater than 90 percent have been directly correlated with
infectious arthritis, although this overlaps with crystalline
disease.

39. IMAGINGIMAGING
• There are no data on imaging studies that are
pathognomonic for acute septic arthritis.
• Plain films establish a baseline and may detect fractures,
chondrocalcinosis, or inflammatory arthritis.
• U/S is more sensitive for detecting effusions, particularly
in difficult-to examine joints, such as the hip.
• MRI findings that suggest an acute intraarticular infection
include the combination of bone erosions with marrow
edema.
• Imaging may allow guided arthrocentesis, particularly in
difficult-to-examine joints (e.g., hip, sacroiliac,
costochondral).

40. OrganismsOrganisms
• Almost any microorganism may be pathogenic in septic
arthritis.
• Bacterial causes of septic arthritis include staphylococci
(40%), streptococci (28%), gram-negative bacilli (19%),
mycobacteria (8%), gram-negative cocci (3%), gram-
positive bacilli (1%), and anaerobes (1%).
• There are various characteristic presentations depending
on the pathogen, underlying medical conditions, or
exposures.

41. OrganismsOrganisms
(Trauma in aquatic environment)

42. OrganismsOrganisms
• Elderly patients with UTI, skin breakdown G – rods (E.coli)
• Tick bite, erythema migrans, flu-like illness Borrelia burgdorferi
• Rheumatoid arthritis Staph. aureus
• / Burkholderia pseudomallei
• SLE, HIV non-typhoidal Salmonella spp.
• β-Streptococcal group B
• 1-2 Haemophilus influenzae
• Pharyngitis & tonsillitis Arcanobacterium haemoliticum
• Human bite Eikenella corrodans
• Post-partum woman Mycoplasma hominis
and hypogammaglobulinaemia

43. L/O/G/O
Management
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44. ManagementManagement (Antibiotic Management)(Antibiotic Management)

45. ManagementManagement (Antibiotic Management)(Antibiotic Management)

46. ManagementManagement (Antibiotic Management)(Antibiotic Management)

47. ManagementManagement (Antibiotic Management)(Antibiotic Management)

48. ManagementManagement (Adjunctive Therapies)(Adjunctive Therapies)
Drainage
•Removal of bacteria and inflammatory debris from the joint
is an essential component of the management of infectious
arthritis.
•The most effective method of drainage has yet to be
clearly delineated given a paucity of quality studies.
•Closed needle aspiration has historically been the method
used in less severe cases and in distal, smaller joints.
•It is less invasive than surgical drainage and may be
associated with faster functional recovery, but it has not
been associated with shorter length of stay or decreased
mortality.

49. ManagementManagement (Adjunctive Therapies)(Adjunctive Therapies)
Drainage
•Additionally, lysis of adhesions or drainage of loculated
infection is not possible with needle aspiration.
•When surgical drainage is employed, one must consider
arthroscopy versus open arthrotomy.
•There is no definitive evidence to recommend one over
the other and most studies focus on a specific joint.
•Open arthrotomy is recommended under specific
situations such as in joints with preexisting severe articular
disease, associated osteomyelitis, or not easily accessible
for needle aspiration.

50. Take home messagesTake home messages
• Septic arthritis is a medical emergency that requires
rapid diagnosis and treatment to avoid morbidity and
mortality.
• S. aureus is the most frequent causative pathogen, and
MRSA is emerging as an important cause of community-
and hospital-acquired septic arthritis.
• Joint drainage is paramount in the management of
septic arthritis.

51. ReferencesReferences
• The Sanford Guide to Antimicrobial Therapy Version
1.9 for iTunes By Antimicrobial Therapy, Inc.
• Diane L Horowitz, et al. Approach to Septic Arthritis,
Am Fam Physician. 2011 Sep 15;84(6):653-660.
• Katie A. Sharff, et al. Clinical Management of Septic
Arthritis. Curr Rheumatol Rep.2013. 15:332

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