MANUBRIOSTERNAL JOINT SEPTIC ARTHRITIS IN A MAN WITH A HISTORY OF IV DRUG USE

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Septic arthritis is a well-documented disease, much of which contains specific guidelines and recommendations for management. Manubriosternal joint septic arthritis is a rare entity described in literature that lacks consistently successful treatment options. (1) We present the case of a patient found to have a tender chest wall mass and imaging concerns for manubriosternal septic arthritis. CASE PRESENTATION: A 47-year-old male with history of heart failure with reduced ejection fraction, drug-induced non-ischemic cardiomyopathy, cirrhosis, and history of intravenous drug use was admitted to the hospital from heart failure clinic for acute on chronic heart failure exacerbation and mild encephalopathy. He was afebrile but tachycardic with a leukocytosis (13 k/ul) upon presentation. During examination a tender, fluctuant mass was discovered over the sternum. He reported pain in this area began three weeks prior with a mass developing over the previous one week. Chest roentgenogram showed an enlarged cardiac silhouette. Follow-up chest computed tomography revealed a 5 cm x 6 cm mass containing gas surrounding the manubriosternal joint anteriorly and posteriorly. He underwent incision and drainage by cardiothoracic surgery where purulent material was found and appeared to connected to the posterior sternal fluid collection. Wound culture grew Streptococcus agalactiae. Sternal bone biopsy was negative for osteomyelitis. He was placed on IV penicillin G for four weeks of therapy. DISCUSSION: Primary manubriosternal joint infections have been rarely documented in literature with approximately 20 (adult and pediatric) cases noted in a PubMed literature search. (1) Cases appear to be more common in men approaching middle-age. Predisposing risk factors are often present and similar to those for septic arthritis of more typical joint locations including intravenous drug use, immunosuppression, and secondary sources of infection. (1,2,3) Specific treatment guidelines are not clearly defined in literature, likely due to the rarity of this disease process. (1) Various treatment methods have been reported which include various combinations of IV antibiotics, incision and drainage, and aggressive manubriosternal joint resection. (1,2,3) The most common treatment noted during the literature review was conservative management with IV antibiotics. CONCLUSIONS: Manubriosternal joint infections are infrequently seen. A majority of cases reported have presented with typical risk factors for septic arthritis. Consistent treatment guidelines are not available due to the rarity of this disease process though many are treated conservatively with IV antibiotics. Patients should be evaluated by a multidisciplinary team of cardiothoracic surgeons and infectious disease specialists for patient-centered decision making efforts. REFERENCE #1: Ali B, Shetty A, Borah G, Demas C, Schwartz JD. Successful management of sternomanubrial joint septic arthritis with pectoralis muscle flap closure: a case series. J Surg Case Rep. 2020;2020(4):rjaa035. Published 2020 Apr 29. REFERENCE #2: Peng EW, McKillop G, Prasad S, Walker WS. Septic arthritis of the manubriosternal joint. Ann Thorac Surg. 2007;83(3):1190-1194. REFERENCE #3: Carnevale A, Righi R, Maniscalco P, et al. Primary septic arthritis of the manubriosternal joint in an immunocompetent young patient: A case report. Radiol Case Rep. 2017;12(4):682-685. Published 2017 Sep 11. DISCLOSURES: No relevant relationships by Joseph Frederickson, source=Web Response No relevant relationships by Bryton Perman, source=Web Response no disclosure on file for Akshat Sood; No relevant relationships by David Wessling, source=Web Response