Sternoclavicular joint septic arthritis manifesting as a neck abscess: a case report.

Abstract

Septic arthritis of the sternoclavicular joint is an uncommon condition, and the diagnosis can be missed until a complication occurs. The sternoclavicular joint is more often involved in ankylosing spondylitis, degenerative arthritic conditions (i.e., rheumatoid arthritis and osteoarthritis), and primary and secondary metastatic conditions. The patient described in this case report came to the otolaryngology department on two occasions for treatment of a unilateral cutaneous neck abscess. The correct diagnosis was not made until the second visit. The author reviews the clinical course, diagnosis, and treatment of this uncommon disease.

Introduction

Septic arthritis of the sternoclavicular joint occurring secondary to a pneumococcal chest infection was first described by Vogelieus in 1896. (1) In 1988, Wohlgethan et al performed a comprehensive review of the literature and described 65 cases of sternoclavicular joint infection. (2) They found that abscesses were present in 20% of these cases, irrespective of the type of organism or underlying systemic disease; in almost all cases, the abscess was unilateral.

In this article, the author reports a new case of sterno-clavicular joint septic arthritis. This case had some interesting features, including a recurrence of a neck abscess 2 years after the initial treatment and an absence of fever.

Case report

A 47-year-old man, a heavy-vehicle mechanic, came to the otolaryngology department with a 1-week history of pain on moving his right shoulder. The pain was dull in character and throbbing at night. The patient had experienced no fever or chills. He had previously been seen at our clinic for treatment of a unilateral neck abscess, which was incised and drained. His medical history included noninsulin-dependent diabetes.

Clinical examination revealed the presence of a tender, 6 x 6-cm erythematous swelling over the right sternoclavicular joint. The patient had a surgical scar in the neck along the long axis of the clavicle from his previous incision and drainage. Findings on ear, nose, and throat examination were unremarkable. His complete blood count and urea, electrolyte, rheumatoid factor, and antinuclear factor levels were all within normal limits. However, his erythrocyte sedimentation rate was elevated (45 mm/hr).

The patient was treated with intravenous antibiotics and admitted for further evaluation. A diagnosis of sternoclavicular joint septic arthritis was made by computed tomography (CT), which confirmed osteomyelitis of the sternoclavicular joint (figure). The patient underwent surgical debridement of the sternoclavicular joint. He was discharged a few days later and made an uneventful recovery.

Discussion

Sternoclavicular joints are diarthroidal and lined with synovia. They are made up of three elements: the inferior segment of the medial head of the clavicle, the notch on the upper lateral part of the sternum, and the cartilage of the first rib. The joint is separated by a fibrocartilaginous disk into two cavities. It is one of the most used joints. (3)

The sternoclavicular joint is commonly involved in ankylosing spondylitis, degenerative arthritic conditions (i.e., rheumatoid arthritis and osteoarthritis), and primary and secondary metastatic conditions. Yood and Goldenberg reported that this joint was also involved in as many as 9% of cases of septic arthritis. (3) The differential diagnosis of a swollen sternoclavicular joint includes rheumatoid arthritis, osteoarthritis, Tietze's syndrome, rheumatic fever, gout, and tumors. (1) Risk factors for sternoclavicular joint infection include diabetes mellitus, rheumatoid arthritis, alcohol abuse, hemodialysis, trauma, and subclavian venipuncture. (4,5)

The onset of sternoclavicular joint infection is insidious, and the duration of clinical symptoms ranges from a few days to 2 months. (2) Pain on movement is present in the ipsilateral shoulder. Akkasilpa et al found that all 21 patients they studied exhibited fever and pain on shoulder movement during the course of their illness. (6) Fever is usually of low grade, and chills are absent. Our patient experienced shoulder pain, but no fever. An elevated erythrocyte sedimentation rate and a normal leukocyte count are usual, as was the case with our patient.

CT and magnetic resonance imaging are diagnostic, but simple x-rays are not always conclusive. (4) CT may reveal clavicular erosions after the disease has been active for a few weeks, as was seen in our patient. (3) Unlike other forms of septic arthritis, sternoclavicular joint septic arthritis may not manifest as a swollen and painful joint. Symptoms of sternoclavicular joint infection may be minimal and go unrecognized until the infection spreads beyond the joint capsule. Cutaneous abscesses over the sternal area should alert the clinician to the possibility of sternoclavicular joint infection until such a diagnosis is definitively ruled out. Once the diagnosis has been established, treatment should be delivered promptly because there have been reports of fatal complications. (7)

Akkasilpa et al reported that the most common pathogens in sternoclavicular joint infections were Staphylococcus aureus (66.7%), Escherichia coli (22.2%), and Burkholderia pseudomallei (11.1%). (6) Other authors also reported that S aureus was the most common organism in sternoclavicular septic arthritis. (2,7,8) Still others have found that the most common pathogen in intravenous drug abusers was Pseudomonas aeruginosa. (9,10) Other organisms that have been implicated are Streptococcus pneumoniae, Brucella spp, Hemophilus influenzae, Salmonella spp, Serratia marcescens, and Candida albicans. (3,11)

Complications include cutaneous abscesses, fistulae, mediastinitis, and superior vena cava syndrome. (4) In addition, Akkasilpa et al (6) found retrosternal abscesses in six of 21 patients (28.6%), a rate that is similar to the 20% reported by Wohlgethan et al. (2) These complications could be related to the anatomy of the joint, which is divided by the intra-articular disk and surrounded by a dense ligamentous capsule. Examination and fluid aspiration of the joint are difficult, which impedes recognition of infection and hence leads to a delay in diagnosis and treatment. Also, the fact that the joint capsule does not distend freely creates high intra-articular pressure and favors the dissemination of infection through the lymphatics and into adjacent tissue. (6)

Sternoclavicular joint infection is treated both medically and surgically. Closed arthrocentesis is recommended for septic infections of all joints except the hip. (12) In most cases, surgical debridement is also recommended if the initial course of medical treatment fails to resolve the disease, especially in patients with osteomyelitis. (4)

References

(1.) Taylor LJ, Belham GJ. Monarticular septic arthritis of the sternoclavicular joint [letter]. Arch Emerg Med 1985:2:177-8.

(2.) Wohlgethan JR. Newberg AH, Reed JI. The risk of abscess from sternoclavicular septic arthritis. J Rheumatol 1988;15:1302-6.

(3.) Yood RA. Goldenberg DL. Sternoclavicular joint arthritis. Arthritis Rheum 1980;23:232-9.

(4.) Goldenberg DL. Bacterial arthritis. In: Kelley WN, ed. Textbook of Rheumatology. Philadelphia: W.B. Saunders. 1993; 1449-66.

(5.) Mathews M. Shen FH, Lindner A, Sherrard DJ. Septic arthritis in hemodialyzed patients. Nephron 1980:25:87-91.

(6.) Akkasilpa S, Osiri M, Ukritchon S, et al. Clinical features of septic arthritis of sternoclavicular joint. J Med Assoc Thai 2001: 84:63-8.

(7.) Brancos MA. Peris P, Miro JM. et al. Septic arthritis in heroin addicts. Semin Arthritis Rheum 1991;21:81-7.

(8.) Pollack MS. Staphylococcal mediastinitis due to sternoclavicular pyarthrosis: CT appearance. J Comput Assist Tomogr 1990: 14:924-7.

(9.) Bayer AS, Chow AW, Louie JS, Guze LB. Sternoarticular pyoarthrosis due to gram-negative bacilli. Report of eight cases. Arch Intern Med 1977:137:1036-40.

(10.) Roca RP, Yoshikawa TT. Primary skeletal infections in heroin users: A clinical characterization, diagnosis and therapy. Clin Orthop 1979:144:238-48.

(11.) Berrocal A, Gotuzzo E, Calvo A. et al. Sternoclavicular brucellar arthritis: A report of 7 cases and a review of the literature. J Rheumatol 1993:20:1184-6.

(12.) Broy SB. Schmid FR. A comparison of medical drainage (needle aspiration) and surgical drainage (arthrotomy or arthroscopy) in the initial treatment of infected joints. Clin Rheum Dis 1986; 12:501-22.

From the Department of Otolaryngology, Manchester Royal Infirmary Hospital, Manchester. U.K.

Reprint requests: Atta Mohyuddin, FRCS, FRCS(Oto), Flat 2, 9 Brigadier Close, Withington, Manchester M20 3BX, UK. Phone: [phone]; fax: [phone]; e-mail: [e-mail]