Orthopedics

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STERNOCLAVICULAR GONOCOCCAL ARTHRITIS IN AN ADOLESCENT GIRL

Joseph J Mesa, MD; Sheldon S Lin, MD; John Catalano, MD; Lawrence S Deutch, MD

Abstract

Gonococcal arthritis is the most common form of septic arthritis among young adults of low socioeconomic status and accounts for up to two thirds of septic arthritis and tenosynovitis seen in North America.1 While any joint may be involved, the knees, wrists, hands, and ankles are most commonly affected.2 Sternoclavicular septic arthritis is a rare disorder and is associated with predisposing factors such as contiguous foci of infection, parental drug use, rheumatoid arthritis, and diabetes mellitus. Sternoclavicular arthritis also has been reported as a rare complication of subclavian vein catheterization,3 The etiological agent in most cases is Staphylococcus aureus, although Pseudomonas aeruginosa is thé most common pathogen with parenteral drug abuse.

A review of the literature revealed only one case of gonococcal arthritis affecting the sternoclavicular joint in a young HIV-positive man.4 This case report describes and evaluates the clinical presentation of gonococcal arthritis in the sternoclavicular joint of an otherwise healthy, 15-year-old, pregnant girl.

CASE REPORT

A 15-year-old girl was admitted to the hospital with a 1-week history of pain in the right sternoclavicular joint. The patient had been taking a nonsteroidal anti-inflammatory drug (NSAJD) for pain without relief and was seen in the emergency room twice. The patient was given intramuscular injections of an NSAID again without relief.

Due to increasing symptoms, the patient returned to the emergency room for the third time, and the orthopedic service was consulted. At this time, the patient denied any history of trauma, sexual intercourse, or any sexually transmitted diseases. The patient's medical history was significant for asthma, for which she took theophylline and metaproterenol. The patient also claimed to have an unspecified allergy to penicillin.

On physical examination, the patient was a well-developed, well-nourished adolescent girl. The patient's temperature was 98.4°C. The patient exhibited a swollen right sternoclavicular joint, which was painful to touch and to movement of her right arm and neck. A fixed, painful 1 cm X 1 cm mass in the right sternoclavicular joint was demonstrated. Anteroposterior and lateral radiographs of the right shoulder and clavicle showed no evidence of fracture, dislocation, or bony destruction (Fig 1). Laboratory data revealed a white blood cell count of 13 and an erythrocyte sedimentation rate of 124. Blood cultures obtained in the emergency room were negative. A right sternoclavicular joint aspiration was performed with the gram-stain being inconclusive.

The patient was admitted to the hospital for a right sternoclavicular joint mass with a possible diagnosis of septic arthritis. Laboratory data on the following day showed a white blood cell count of 12.6 and an erythrocyte sedimentation rate of 80. A computed tomography scan of the sternoclavicular joint was performed without contrast. This study showed no evidence of bony erosion or destruction to suggest osteomyelitis. There was an asymmetry of the anterior soft tissues of the right pectoralis major muscle and cutaneous fat pad when compared to the left, consistent with cellulitis (Fig 2). A three-phase bone scan was performed, which demonstrated increased uptake in the right sternoclavicular junction of undetermined etiology (Fig 3).

On the second day of admission, the patient was taken to the operating room for an open biopsy of the right sternoclavicular mass. A 1 cm x 1 cm mass was dissected from the anterior aspect of the sternoclavicular joint with cultures as well as frozen and permanent histological section obtained. The sternoclavicular joint and the distal clavicle were found to be in excellent condition with no evidence of gross osteomyelitis. Histology results of the mass showed only chronic inflammatory tissue with no evidence of carcinoma on frozen section. Cultures taken in the operating room were positive for…

Gonococcal arthritis is the most common form of septic arthritis among young adults of low socioeconomic status and accounts for up to two thirds of septic arthritis and tenosynovitis seen in North America.1 While any joint may be involved, the knees, wrists, hands, and ankles are most commonly affected.2 Sternoclavicular septic arthritis is a rare disorder and is associated with predisposing factors such as contiguous foci of infection, parental drug use, rheumatoid arthritis, and diabetes mellitus. Sternoclavicular arthritis also has been reported as a rare complication of subclavian vein catheterization,3 The etiological agent in most cases is Staphylococcus aureus, although Pseudomonas aeruginosa is thé most common pathogen with parenteral drug abuse.

A review of the literature revealed only one case of gonococcal arthritis affecting the sternoclavicular joint in a young HIV-positive man.4 This case report describes and evaluates the clinical presentation of gonococcal arthritis in the sternoclavicular joint of an otherwise healthy, 15-year-old, pregnant girl.

CASE REPORT

A 15-year-old girl was admitted to the hospital with a 1-week history of pain in the right sternoclavicular joint. The patient had been taking a nonsteroidal anti-inflammatory drug (NSAJD) for pain without relief and was seen in the emergency room twice. The patient was given intramuscular injections of an NSAID again without relief.

Due to increasing symptoms, the patient returned to the emergency room for the third time, and the orthopedic service was consulted. At this time, the patient denied any history of trauma, sexual intercourse, or any sexually transmitted diseases. The patient's medical history was significant for asthma, for which she took theophylline and metaproterenol. The patient also claimed to have an unspecified allergy to penicillin.

On physical examination, the patient was a well-developed, well-nourished adolescent girl. The patient's temperature was 98.4°C. The patient exhibited a swollen right sternoclavicular joint, which was painful to touch and to movement of her right arm and neck. A fixed, painful 1 cm X 1 cm mass in the right sternoclavicular joint was demonstrated. Anteroposterior and lateral radiographs of the right shoulder and clavicle showed no evidence of fracture, dislocation, or bony destruction (Fig 1). Laboratory data revealed a white blood cell count of 13 and an erythrocyte sedimentation rate of 124. Blood cultures obtained in the emergency room were negative. A right sternoclavicular joint aspiration was performed with the gram-stain being inconclusive.

Fig 1 : AP radiograph of the right shoulder and clavicle showed no evidence of fracture or bony destruction.

Fig 1 : AP radiograph of the right shoulder and clavicle showed no evidence of fracture or bony destruction.

Fig 2: Axial CT scan of the sternoclavicular joint without contrast showed no evidence of bony erosion or destruction to suggest osteomyelitis. There was an asymmetry of the anterior soft tissues of the right pectoraiis major muscle and cutaneous fat pad (arrow) when compared to the left, consistent with cellulitis.

Fig 2: Axial CT scan of the sternoclavicular joint without contrast showed no evidence of bony erosion or destruction to suggest osteomyelitis. There was an asymmetry of the anterior soft tissues of the right pectoraiis major muscle and cutaneous fat pad (arrow) when compared to the left, consistent with cellulitis.

Fig 3: A three-phase bone scan demonstrating increased uptake in the right sternoclavicular junction.

Fig 3: A three-phase bone scan demonstrating increased uptake in the right sternoclavicular junction.

The patient was admitted to the hospital for a right sternoclavicular joint mass with a possible diagnosis of septic arthritis. Laboratory data on the following day showed a white blood cell count of 12.6 and an erythrocyte sedimentation rate of 80. A computed tomography scan of the sternoclavicular joint was performed without contrast. This study showed no evidence of bony erosion or destruction to suggest osteomyelitis. There was an asymmetry of the anterior soft tissues of the right pectoralis major muscle and cutaneous fat pad when compared to the left, consistent with cellulitis (Fig 2). A three-phase bone scan was performed, which demonstrated increased uptake in the right sternoclavicular junction of undetermined etiology (Fig 3).

On the second day of admission, the patient was taken to the operating room for an open biopsy of the right sternoclavicular mass. A 1 cm x 1 cm mass was dissected from the anterior aspect of the sternoclavicular joint with cultures as well as frozen and permanent histological section obtained. The sternoclavicular joint and the distal clavicle were found to be in excellent condition with no evidence of gross osteomyelitis. Histology results of the mass showed only chronic inflammatory tissue with no evidence of carcinoma on frozen section. Cultures taken in the operating room were positive for Neisseria gonorrhoeae. Due to the patient's penicillin allergy, an antibiotic regimen of floxacillin after desensitization was initiated.

Additional tests for syphilis (RPR) and human immunodeficeincy virus were performed Both results were negative. A cervical smear, performed for both chlamydia and neisseria, was negative. A urine pregnancy test also was performed and came back positive with a serum quantitative bHCG of 2410. Abdominal ultrasound evaluation confirmed a 5-week intrauterine pregnancy.

The patient's floxacillin was stopped, and the patient was switched to ceftriaxone. The patient completed her course of ceftriaxone and was discharged on cefuroxime in stable condition with no pain in the right sternoclavicular joint. The patient's care was continued under the auspice of the pediatric service. There was no evidence of recurrence with long-term follow up.

DISCUSSION

Disseminated gonococcal arthritis is the most common bacterial arthritis reported by urban medical centers in the United States.5 The classical clinical presentation is in a young, healthy woman. Risk factors for disseminated gonococcal infection include menses, pregnancy, and late-acting complement deficiency.6 Although disseminated gonococcal infection is quite common, the involvement of the sternoclavicular joint is exceedingly rare. The only other reported case in the literature involved a patient who was HIV positive and immunocompromised.4

This case report demonstrates the importance of niling out gonococcal arthritis in an otherwise healthy patient who presents with a mass in the sternoclavicular region. Patients with the suppurative form of disseminated gonococcal arthritis often present with arthritis as the only major manifestation.7 Patients often are afebrile and exhibit only a swollen, painful joint on physical examination. The majority of patients who develop disseminated gonococcal infections may be asymptomatic in regards to their primary gonococcal infection of the genitourinary tract.8

Little research has evaluated the reliability of a sexual history given by an adolescent.9-13 While most physicians agree that obtaining a sexual history from adolescents is important, many are not obtaining the information"; those physicians who do take a sexual history usually gather inadequate information.12 One recent study concluded that adolescents generally provide reliable sexual history, but health-care providers may not be documenting these histories adequately.13

In this particular patient, care was taken to ensure privacy of the adolescent with information being obtained in a timely and private manner without any family members present. The findings of a sexually transmitted disease, N gonorrhoeae, and the discovery of an unexpected pregnancy demonstrate that psychosocial issues of adolescence may hinder the diagnosis of a sexually transmitted disease. This case report exemplifies the need to consider the possibility of an inaccurate or incomplete sexual history with an adolescent when a sexually transmitted disease is suspected or in the differential diagnosis.

When considering this diagnosis, the need for adequate cultures cannot be overemphasized. Needle aspirations of a painful joint are useful in determining infectious etiology. In many cases of disseminated gonococcal infection, blood cultures often are negative. In addition, aerobic and anaerobic cultures should be obtained to avoid missing this possible diagnosis. Patients should be evaluated with cultures of all mucous membranes for neisseria and chlamydia, RPR test, blood cuLtures, and an aspiration of the involved joint. In addition, young female patients who demonstrate this clinical presentation should undergo a pregnancy test as part of their routine evaluation.

Supplementary radiographic modalities, such as a CT scan, are usually unnecessary. A bone scan, on the other hand, is useful in determining the extent of potential bony involvement.

Because disseminated gonococcal infection is treatable with antibiotic therapy, prompt recognition of symptoms and proper evaluation of the clinical scenario with the inclusion of gonococcal arthritis in the differential diagnosis is crucial.

REFERENCES

1. Sharp JT, Lidsey MD, Duffy J, et al. Infectious arthritis. Arch intern Med. 3979; 139:1125-1130.

2. Brogadir SP, Schimmer BM, Myers AR. Spectrum of the gonococcal arthritis-dennitis syndrome. Semin Arthritis Rheum. 1979; 8:177183.

3. Muir SK, KinseUa PL, Trcbilock RG, Blackstone IW. Infectious arthritis of the sternoclavicular joint. Can Med Assoc J. 1985; 132:1289-1290.

4. Strongin IS, Kale SA, Raymond MK, Luskin RL, Weisberg GW, Jacobs JJ. An unusual presentation of gonococcal arthritis in an HTV positive patient Ann Rheum Dis. 1991; 50:572573.

5. Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med. 1985; 312:764-771.

6. Petersen BH, Lee TJ, Snyderman R, Brooks GF. Neisseria meningitidis and Neisseria gonorrhoeae bacteremia associated with C6, C7, or C8 deficiency. Ann Intern Med. 1979; 90:917920.

7. Holmes KK, Counts GW, Beaty HN. Disseminated gonococcal infection. Ann Intern Med. 1971;74:979-993.

8. O'Brien JP, Goldenberg DL, Rice PA. Disseminated gonococcal infection: A prospective analysis of 49 patients and a review of the pathophysiology and immune mechanisms. Medicine. 1983;62:395-406.

9. Davoli M, Perucci CA, Sangalli M. Reliability of sexual behavior data among high school students in Rome. Epidemiology. 1992; 3:531-535.

10. Biro FM, Rosenthal SL, Wildly LS. Selfreported healtii concerns and sexual behaviors in adolescents with cervical dysplasia. J Adolesc Health. 1991; 12:391-394.

11. Nussbaum MP, Shenker IR, Feldman JG. Attitudes versus perfonnanee in providing gynecologic care to adolescents by pediatricians. J Adolesc Health. 1989; 10:203-208.

12. Lewis CE, Freeman HE. The sexual history-taking and counseling practices of primary care physicians. West J Med. 1987;147:165-167.

13. Hornberger LL, Rosenthal SL, Biro FM, Stanberry LR. Sexual histories of adolescent girls: comparison between interview and chart. J Adolesc Health. 1995; 16:235-239.

10.3928/0147-7447-19980101-19

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