Ext. Kunnawut Pohpeera 5402014

The last Conference

Patient profile : ผู้ป่วยชายไทย อายุ 64 ปีChief complaint : ไข้ 1 วนัก่อนมาโรงพยาบาลPresent illness :

6 เดือนก่อนมาโรงพยาบาลมแีผลกดทับเรื้อรงัท่ีก้น ทำาแผลโรง พยาบาลเซนต์แมรีต่ลอด

1 วนัก่อนมาโรงพยาบาล ปวดขอ้มอืขวามาก มบีวมแดง ขยบัได้ ตลอด มไีขส้งูหนาวสัน่

Pain score 10/10 ไปรพช. ถกูเจาะขอ้มอืขวาเพื่อนำานำ้าในขอ้ไป ตรวจ แต่เจาะไมไ่ด้นำ้า

Past illness :Underlying BPH with neurogenic bladder

Personal history : แพย้า Peniciliin มผีื่นคัน

Case scenario

Vital signs : T 39 c, BP 135/53 mmHg, PR 104 bpm, RR 22/min

GA : A Thai man, alert, good conscious, look distressHEENT : not pale, no jaundiceSkin : Infected bedsore grade 3 with foul smell

discharge at right buttock.Lungs : Clear , equally, no adventitious soundCVS : normal S1,S2, no murmurAbdomen : Soft, not tender , normoactive bowel sound,

no rebound, no guarding, no mass palpable, no hepatosplenomegaly

Neurological : Grossly intact.

Physical examination

Extremities – Marked swelling with redness and warming at right wrist. Tender with movement. Limit all ROM of right wrist due to pain.

CBC : WBC 17,700/uL, Hb 8.3 g/dL, Hct 26%, Platelet 283,000/nL

Electrolyte : Na 133 mmol/L, K 3.16 mmol/L, Cl 92.9 mmol/L,CO2 24.9 mmol/L. BUN 34.6 mg/dL, Cr 0.37

LFT : AST/ALT = 31/32, ALP 186U/L, TB/DB 0.9/0.3, Choleterol 120 mg/dL

Urinalysis : WBC 5-10/HPF, RBC over 100/HPFCRP 1.830 mg/L (0-5)ESR 100 mm/Hour (0-9)Uric acid 5.o mg/dL (3.5-7.2)

Investigation

Joint fluid analysis :Color – PusTransparence - TurbidRBC – 4,000 cell/mm3Nucleated cell count – 250,000 cell/mm3 (N97%, L3%)Crystal not found

Joint fluid gram stain : Moderate gram positive cocci

Joint Fluid culture : Staphylococcus aureusHemoculture : Staphylococcus aureusUrine culture : no growth

Film right wrist (AP,LAT)

MSSA Septic arthritis at right wrist.

Diagnosis

Septic arthritis

Most common sitesKnee > hip > shoulder > Elbow > Ankle >

Sternoclavicular jointRisk factors

Age >80Medical conditions [DM,RA,Cirrhosis,HIV]Hx of crystal arthropathyRecent bacteremiaIV drug userRecent joint surgery

EtiologiesBacteremiaDirect inoculationContigious spread (osteomyelitis)

Most common pathogenStaphylococcus aureus

OrganismStaph. (MRSA, S.epidermidis)Strep. (Strep. Pyogenes)Neisseria GonorrheaGram negative bacilli (E.Coli, Proteus, Klebsiella)

Pathophysiology

PresentationPain in affected jointFever

Physical examinationInspection

ErythemaEffusion

PalpationWarmthTender

MotionLimit ROM

Radiographmay show joint space widening or effusion periarticular osteopenia

UltrasoundJoint effusion in large joint

MRIJoint effusion and bone

involvement (osteomyelitis)

Imaging

WBC > 10,000 with left shiftESR >30 (rises within 2 days of infection and

can rise 3-5 days after initiation of appropriate antibiotics, and returns to normal 3-4 weeks)

CRP >5Joint fluid aspirate

Gold standardCell diff, Cell count (WBC>50,000)Gram stainCultureCrystal analysis

Investigation

IV antibioticsOperative irrigation and drainage of joint

Approachcan be performed open or arthroscopically (depending on

joint) Irrigation

remove all purulent fluid and irrigate joint

Debridementsynovectomy can be performed as needed

Culturesobtain joint fluid and tissue for culture

Treatment