Working Diagnosis:
1) Sepsis secondary to right sternoclavicular joint septic arthritis with associated abscess and acute renal failure.
2) Hypophonia secondary to compressive edema on the right recurrent laryngeal nerve.

Treatment:
Patient initially treated with aggressive IVF resuscitation as well as Vancomycin, Zosyn, and Clindamycin. Eventually the abscesses were drained and cultures grew E. Coli sensitive to Ciprofloxacin.

Outcome:
By discharge he was able to move his right arm without pain and near normal ROM, he had no more visible erythema, was afebrile and his WBC had returned to normal.

A repeat abscessogram revealed residual pocket of at least 20 ml volume. Case Photo #10 He was discharged with the drain in place and scheduled for repeat imaging and possible drain removal.

Infectious disease recommended 3 weeks of Ciprofloxacin followed by repeat imaging and ID follow up.

Patient was scheduled for colonoscopy given E. Coli infection & concern for neoplasm.

Author's Comments:
Once the drain was removed he participated more effectively in physical therapy and eventually returned to painting and tennis. He now plays singles.

Editor's Comments:
The prevalence of nongonococcal septic arthritis in ED patients with a single acutely painful joint is approximately 27%. Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. The white blood cell count of peripheral blood, the erythrocyte sedimentation rate, and the white blood cell count of the joint fluid obtained from arthrocentesis are extremely variable in adults with septic arthritis.

References:
Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18(8):781-796.

Kaandorp CJ, van Schaardenburg D, Krijnen P, Habbema JD, van De Laar MA. Risk factors for septic arthritis in patients with joint disease. Arthritis Rheum. 1995;38:1819–1825.

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