Treatment of a rheumatoid joint with an intra-articular fibrinolytic agent to aid aspiration

Abstract

A 71-year-old woman presented to the Rheumatology Department with a history of an enlarging, painful swellinp over the right shoulder. She had a long history of rheumatoid arthritis with previous effusions of the right shoulder and left knee requiring aspiration. Two attempts were made at blind aspiration on the ward yielding only 8 and 2 ml of thick fluid respectively. Microbiological culture was negative and she was referred for consideration of arthroscopic lavage. Ultrasound was subsequently requested and revealed a large. high reflectivity subacromial-subdeltoid bursal collection. Attempts to aspirate via a l9G needle and subsequently a IOF drain yielded Ruid containing multiple solid ‘rice body’ particles which caused frequent drain blockage and prevented aspiration of the ma.jority of the Huid (Fig. I). Ten ml of I mg/ml Alteplase (recombinant human tissue-type plasminogen activator. Actilyse. Boehringer Ingelheim) was injected into the collection via the drain which was then clamped and the patient returned to the ward. She experienced a little discomfort due to the presence of the drain but no other il l effects due to the procedure. The following day. 300 ml of yellow fluid was aspirated with ease and no visible solid material identilied. Arthrogaphy demonstrated preferential tilling of the dependent parts of the easily distensible bursa and no residual tilling defects (Fig. 2). Communication with the glenohumeral joint space was demonstrated by contrast medium entering the sheath surrounding the long head of biceps tendon. an extension of the synovial lining of the joint. Decompression of the hursa resulted in superior subluxation of the humeral head and severe nnrrowin_p of the subacromial space suggesting a full thickness rotator