A CASE OF MEDIASTINITS AND SEPTIC THROMBOPHLEBITIS SECONDARY TO SEPTIC STERNOCLAVICULAR JOINT ARTHRITIS

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Septic Sternoclavicular joint (SCJ) is a rare diagnosis. Certain risk factors such as diabetes mellitus have been associated with it. The most serious complication of this condition is mediastinits. CASE PRESENTATION: A 48-year-old male with history of type II diabetes mellitus presented with complaints of a progressively worsening left parasternal discomfort that started 3 days ago, which worsened with movement. He also described subjective fever, chills and diaphoresis at home. He denied upper respiratory symptoms. He has had no recent surgeries or instrumentation. He travelled recently to a but denied sick contacts. On presentation he was febrile, tachycardic, diaphoretic, hypertensive. His labs showed leukocytosis to 32000/mm3, a sodium level of 124 and elevated glucose of 484. On physical examination the patient had reproducible left shoulder and chest wall tenderness with palpation. Levaquin 750 mg intravenously was initiated along with supportive therapy. Computed Tomography (CT) of the chest showed anterior mediastinal fat infiltration consistent with mediastinitis and left sided pleural effusion. CT head and neck was ordered which showed inflammatory changes at the left thoracic inlet with involvement of adjacent mediastinal fat, with nonopacification of left subclavian vein and left innominate vein, suspicious for septic phlebitis and adjacent mediastinitis. Blood cultures grew methicillin-sensitive staphylococci. The patient was then started on cefazolin intravenously. Follow up blood cultures cleared and he was discharged on intravenous cefazolin for 4 weeks and outpatient follow up. DISCUSSION: SJC infection is rare occurring only about 0.5-1% of all infections [1]. Common causes include diabetes mellitus, intravenous drug use, trauma, immunosuppression, infected central lines among others. The clinical signs of SCJ septic arthritis are chest pain localizing to the SCJ (78 %), fever (65 %), and shoulder pain (24 %) and neck pain (2%) [1,2]. Joint swelling and overlying erythema is common. A CT scan of the chest or magnetic resonance imaging is recommended as the initial imaging study that helps identify bone destruction, however the final diagnosis is made from culture of the joint fluid obtained using needle aspiration or open biopsy. Common organisms that has been described are staphylococcus aureus coli, H influenza, Streptococcus pneumonia, streptococcus pyogenes [1,2]. The most potential and serious complication is mediastinitis, which occurs in less than 15% of cases [1,2] as in our case. Our case is unique because it also lead to septic thrombophelibitis of left subclavian vein. Antibiotics with or without drainage and surgical debridement is the treatment of choice. CONCLUSIONS: Sternoclavicular joint septic arthritis is a rare condition. Anterior mediastinitis and septic thrombophlebitis should be suspected as possible complications in uncontrolled diabetes. Reference #1: Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore). 2004;83(3):139-48. Reference #2: 2. Yood RA, Goldenberg DL. Sternoclavicular joint arthritis. Arthritis Rheum. 1980;23:232–9. DISCLOSURES: No relevant relationships by Janak Adhikari, source=Web Response No relevant relationships by Karim Anis, source=Web Response No relevant relationships by AHMET HAKKI KAPICI, source=Web Response No relevant relationships by Fnu Zafrullah, source=Web Response