Elbow Pain & Rash in Adult Fisherman

Abstract

HISTORY: HISTORY: 53 year male seen for rash with painful, swollen elbow 4 days after a weekend of ocean surf cast fishing. He denied trauma, stings or envenomation exposure. Onset at end of 2nd day of fishing; treated with ice, topical analgesics and diphenhydramine and oral NSAIDs & narcotics. Red pruritic rash started one day prior. He denied fever, chills or constitutional symptoms. Travel exposure 1 month prior included 3 week vacation to British Columbia where he experienced a diarrhea illness, self-limiting. PMH: Gout, obesity, hypertension, hyperglycemia, and ED. Surgical Hx: Right ulnar nerve transposition. PHYSICAL EXAMINATION: PHYSICAL EXAM Wt: 134.5 kg, T: 37.4, P: 84, Bp: 164/100, R: 20 The RUE from the proximal medial forearm into the mid upper arm: swollen & erythematous with focal tenderness medial joint line & small effusion. Supination and pronation pain free. Flexion and extension limited secondary to pain and swelling. Neurovascular: normal. Macular papular erythematous rash without vesicles or purulence extending to right pectoral region; no lymphadenopathy. Hand, wrist and shoulder exam normal. No other joint symptoms or findings. DIFFERENTIAL DIAGNOSIS: cellulitis septic arthritis infectious dermatitis fasciitis tendonitis venomous injury gout TEST AND RESULTS: Elbow: Hypertrophic degenerative changes, joint effusion, ossicle adjacent to medial epicondyles & deformity distal shaft humerus; both probable old fractures. Soft tissue swelling medially. MR (limited): Moderate elbow joint effusion and soft tissue edema primarily along the dorsal surface of the elbow without suggestion of osteomyelitis or abscess. Fluoroscopic guided needle aspiration: 10 cc cloudy yellow, WBC: 21,450, 92% segs, no organisms, no crystals, aerobic and anaerobic cultures: negative, AFB: negative. Admitting Labs: CBC, INR, Na, K, CL, uric acid, Cr, BUN, all normal. ESR: 24 ANA 1.2, CRP: 75.5. Blood cultures: neg. Lyme titer: neg. FINAL WORKING DIAGNOSIS: Septic arthritis TREATMENT AND OUTCOMES: IV clindamycin and piperacillin/tazabactam × 48 hours; D/C on oral clindamycin and IV ceftriaxone for a total of 14 days therapy. Follow-up at 4 days: no pain nor rash and full ROM and function.