Sternoclavicular Joint (SCJ) Septic Arthritis Presenting as Excruciating Cervical and Chest Pain With Intractable Hiccups

Abstract

SESSION TITLE: Bacterial Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: The SCJ is an unusual site of septic arthritis. It is involved in 0.5-1.0% of all joint infections and <0.5% of joint infections in healthy patients. The clinical signs of SCJ septic arthritis are chest pain localizing to SCJ (78%), fever (65%), and shoulder pain (24%). Here we present a case of SCJ septic arthritis with chest pain and intractable hiccup. CASE PRESENTATION: A 72-yo man, fell 1 month ago, was admitted for bacteremia. He was recently treated for pneumonia (PNA). Patient endorsed 3-day right-sided chest pain radiating from distal sternal border toward neck, with 2-day intractable hiccups. Patient had tender cervical/supraclavicular fullness with limited range of glenohumeral joint movement. WBC 17,300/uL with left shift. CXR showed right lower lobe (RLL) opacity. Rocephin and doxycycline were started. Given recent fall, chest pain, intractable hiccup, neck fullness, CT neck/soft tissue was order to evaluate for fracture, dislocation, subcutaneous emphysema, infection, or referred pain from diaphragmatic/pericardial pleural irritation in setting of RLL PNA. CT showed soft tissue infiltration centered in the right sternoclavicular region which extends inferiorly into the anterior mediastinum. There is superior extension along the right lateral anterior border of the thyroid, deep to the sternocleidomastoid. Infiltrated/inflamed fat interdigitates between the carotid artery and the thyroid on the right. The findings were most consistent with septic right SCJ, cellulitis/myositis of the right sternocleidomastoid, and phlegmon extending into the anterior mediastinum. ESR 72 mm/hr, CRP 248.3 mg/L. Blood cultures grew S. aureus. He was treated with 6-week rocephin. There was no indication for acute surgical intervention. On follow up, WBC 5500/uL, ESR 51 mm/hr, CRP 40.6 mg/L. DISCUSSION: Common risk factors for SCJ septic arthritis include IVDU (21%), infection at distant site (15%), diabetes mellitus (13%), trauma (12%), and infected central venous line (9%). No risk factors were found in 23% of patients with SCJ septic arthritis. The route of infection is often unknown. Management of SCJ septic arthritis consists of surgical debridement and IV antibiotics. The rate of positive cultures with needle aspiration is 77%, surgical debridement 36%, and blood cultures 13%. Typical causative organisms: S. aureus (49%), P. aeruginosa (10%), Brucella melitenis (7%), E. coli (5%), less frequently M. tuberculosis. CONCLUSIONS: SCJ septic arthritis may lead to serious complications such as osteomyelitis, chest wall abscess, mediastinitis, myositis, with irreversible tissue damage. Prompt diagnosis and appropriate surgical and antibacterial treatments are required. Clinical signs/symptoms and physical exam remain the core components to help in diagnosis with the support of imaging. Reference #1: Yoshihito Tanaka et al. Sternoclavicular joint septic arthritis with chest wall abscess in a healthy adult: a case report. Journal of Medical Case Reports (2016) 10:69. DISCLOSURE: The following authors have nothing to disclose: Kim Phung Nguyen, Vandana Pai No Product/Research Disclosure Information