The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.05.006
Clinical Communications: Adults AN UNUSUAL CAUSE OF CHEST PAIN IN A YOUNG HEALTHY FEMALE Jennifer J. Robertson, MD, MSED Emergency Services Institute, The Cleveland Clinic, Cleveland, Ohio Reprint Address: Jennifer J. Robertson, MD, MSED, Emergency Services Institute, The Cleveland Clinic, Mail Code E19, 9500 Euclid Ave., Cleveland, OH 44195
, Abstract—Background: Infection of the sternoclavicular joint is an uncommon disease that is usually seen in patients with underlying risk factors such as prior trauma, intravenous drug use, or diabetes mellitus. The true pathophysiology remains unknown, but underlying bacteremia has been found in a number of cases. Without proper diagnosis and treatment, severe complications such as mediastinitis, sepsis, or death can occur. Case Report: This is a case of spontaneous stenoclavicular septic arthritis in an otherwise healthy female. The patient’s lack of risk factors and minimal examination findings highlight the unusual nature of the case, as well as the challenges it presents in making an early diagnosis. Why Should an Emergency Physician Be Aware of this Condition?: Emergency physicians should consider sternoclavicular joint infections in patients who present to the emergency department with chest pain, even in patients without risk factors. They should especially consider the diagnosis in patients with suspected musculoskeletal etiologies or in those with return visits for chest pain. Although most patients do well with treatment, the infection can be life threatening without appropriate interventions. Ó 2015 Elsevier Inc.
liver and kidney disease, and rheumatologic diseases (1–8). Although this infection, in otherwise healthy individuals, has been documented in the literature, it is quite rare (5,9). In fact, in the healthy population, sternoclavicular joint infections have been estimated to comprise only 0.5% of all bone and joint infections (9). Due to the rarity of this condition, sternoclavicular osteomyelitis is not something that emergency physicians first consider in healthy patients with chest pain. This case report is unusual due to its spontaneous occurrence in a young healthy female without any known risk factors or initial abnormal examination findings. This is the first reported case of sternoclavicular joint infection in the emergency medicine literature in a patient with no predisposing conditions. CASE REPORT A 28-year-old woman presented to our Emergency Department (ED) after going to several other EDs with the chief complaint of left-sided chest pain of 10 days duration. She had no significant past medical history. The patient denied trauma, fever, or intravenous drug use. The chest pain was nonradiating, constant, but worsened with arm movement. On physical examination, the patient’s vital signs were a temperature of 36.8 C, a blood pressure of 135/98 mm Hg, a pulse of 68 beats/min, and respirations of 18 breaths/min. The patient had tenderness along her left chest wall and clavicle without evidence of swelling, warmth,
, Keywords—unusual chest pain; sternoclavicular joint; osteomyelitis
INTRODUCTION Infection of the sternoclavicular joint is uncommon and is typically seen in patients with risk factors such as prior trauma, intravenous drug use, diabetes mellitus, central vein catheterization, human immunodeficiency virus,
RECEIVED: 26 February 2015; FINAL SUBMISSION RECEIVED: 18 April 2015; ACCEPTED: 14 May 2015 1
2
J. J. Robertson
Figure 1. Computed tomography of the chest with contrast shows (A) soft tissue inflammation of the sternoclavicular joint, (B) osseous destruction of the left manubrium, and (C) a sclerotic appearance of the superior sternum.
erythema, or masses of the chest wall, clavicle, or left shoulder. Her electrocardiogram showed normal sinus rhythm, and her chest and sternoclavicular joint roentgenograms showed no acute abnormalities. Her white blood cell count was 8.49 k/uL. The patient’s symptoms and evaluation were not consistent with acute coronary syndrome, aortic dissection, pulmonary embolism, or pneumonia. The tenderness along her left chest wall suggested a musculoskeletal etiology of her pain. Given that the patient had no history of intravenous drug use or immunodeficiency syndrome, and she presented with a normal white blood cell count, a normal temperature, and no warmth, swelling, or masses of the chest wall or left shoulder joint on physical examination, we had a low suspicion for an infectious etiology of her chest pain. The patient was discharged with the diagnosis of chest pain, likely musculoskeletal in nature, with the recommendation for close follow-up and to return immediately if symptoms worsened or changed. Two weeks later, the patient presented again to our ED with persistent symptoms. She had been diagnosed with left sternoclavicular osteomyelitis after receiving a computed tomography (CT) scan at an outside hospital. She also had undergone surgical incision and drainage at the outside hospital, but was complaining of persistent symptoms. CT of the chest during the second visit to our ED showed soft tissue inflammation of the sternoclavicular joint, osseous destruction of the left manubrium, and a sclerotic appearance of the superior sternum (Figure 1). The patient required additional surgical procedures at our hospital, including a left sternoclavicular joint resection and drain placement. Operative wound cultures grew out methicillin-sensitive Staphylococcus aureus. She remained afebrile throughout her hospital course, with a normal erythrocyte sedimentation rate and only 1 day of mild leukocytosis 3 days after admission (14.45 k/uL). The patient was sent home on intravenous
oxacillin. The patient did have subsequent visits to our ED for pain control, but otherwise her postoperative course was unremarkable. DISCUSSION Infection of the sternoclavicular joint was first described by Vogelius in 1896 in a patient with pneumococcal pneumonia (10). This infection comprises both septic arthritis and osteomyelitis, and there is no clear distinction between the two because more than half of patients have both septic arthritis and osteomyelitis (5). Since its discovery, reports of this infection remain rare and mainly occur in patients with underlying illness or risk factors such as intravenous drug use and immunodeficiency syndrome (3,5). The true pathophysiology remains to be determined; however, bacteremia secondary to trauma or surgical procedures is a likely possibility (1,5,10,11). Significantly, up to 62% of patients with sternoclavicular joint infections have bacteremia, as opposed to 27% of patients with other types of septic arthritis. Thus, this supports the theory of hematogenous spread (5,12). Currently, the most common etiologic agent causing sternoclavicular joint infections is Staphylococcus aureus (9). The average age of presentation is 45 years, and unlike septic arthritis of most other joints, it tends to be insidious in onset, as symptoms may take up to 2 months to develop (5,9,13). Most patients have swelling and tenderness over the joint, as well as fever, chills, or night sweats (3,9,14). However, systemic symptoms may be absent in the elderly and immunosuppressed patients, and given the tissue expanse around the joint, effusions may not be noticeable on initial physical examination, as in our patient (5,13,14). The chest pain of sternoclavicular joint arthritis can also simulate pain from cardiac or pulmonary origins such as myocardial
Unusual Chest Pain
infarction or pulmonary embolism (13). Given these factors, the diagnosis can be challenging. If a sternoclavicular joint infection is suspected, workup including inflammatory markers and imaging should be obtained. Of note, whereas inflammatory markers are typically elevated in previously healthy patients, they may be normal in immunosuppressed patients (13,14). Although magnetic resonance imaging and bone scintigraphy are useful diagnostic tools, plain films and CT are likely the first to be obtained in the ED (15). Plain films may show soft tissue swelling and periosteal thickening, but these findings may take up to 21 days after the onset of infection (16). Additionally, plain films are less sensitive than CT, and CT will typically show abnormalities much earlier than conventional radiographs (15,17,18). Similar to our patient’s CT findings, CT in general shows sclerosis or bony erosions, gas formation, or soft tissue swelling (17). Our patient presented only 1 week after the onset of symptoms, and plain films were negative. Because CT can detect the infection earlier than plain films, it is certainly possible that the diagnosis could have been made sooner on initial visit. However, a CT scan was not considered prudent on the initial visit given the patient’s lack of risk factors and other concerning findings on history and physical examination. Definitive diagnosis of sternoclavicular joint infections is made by aspiration or open biopsy and culture of the joint fluid (3). Patients should be treated with the appropriate antibiotics, based on culture results. Although some patients do not require surgery, most cases require irrigation and drainage in the operating room (3,5,9). If treated early, most patients have good outcomes. Occasionally, complications such as mediastinitis, superior vena cava syndrome, or septic shock may occur (1,3,5,9). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? The potential for progressive, severe complications makes diagnosing sternoclavicular joint infection all the more important for emergency physicians. Our patient was young and healthy, had no history of intravenous drug use, was without fever or systemic symptoms, and had minimal physical findings. If concerning patients initially have normal examination and ED work-up,
3
they should be counseled on return precautions. The condition may also mimic more common conditions such as pulmonary embolism, acute coronary syndrome, pericarditis, and costochondritis, and thus, the diagnosis may be easily missed (13). Given the potential for devastating outcomes such as sepsis, and the need for invasive procedures, sternoclavicular joint infections should remain a part of any emergency physician’s differential diagnosis in patients with chest pain, especially in those with chest pain of musculoskeletal etiology. REFERENCES 1. Randell PA, Somers L. Case of the month: ‘‘bugs are eating my soul’’—sternal abscess, osteomyelitis and mediastinitis complicating a closed sternal fracture. Emerg Med J 2006;23:736–9. 2. Smith JW, Chalupa P, Hasan MS. Infectious arthritis: clinical features, laboratory findings and treatment. Clin Microbiol Infect 2006;12:309–14. 3. Higginbotham TO, Kuhn JE. Atraumatic disorders of the sternoclavicular joint. J Am Acad Orthop Surg 2005;13:138–45. 4. Song HK, Guy TS, Kaiser LR, et al. Current presentation and optimal surgical management of sternoclavicular joint infections. Ann Thorac Surg 2002;73:427–31. 5. Ross JJ, Shamsuddin H. Stenoclavicular septic arthritis: review of 180 cases. Medicine 2004;83:139–48. 6. Lindsey RW, Leach JA. Sternoclavicular osteomyelitis and pyoarthrosis as a complication of subclavian vein catheterization: a case report and review of the literature. Orthopedics 1984;7:1017–22. 7. Summers SA, Gupta RK, Clutterbuck EJ, Laing C, Cooke GS. Haemodialysis catheter-associated infection: common pathogens in unusual places. Nephrol Dial Transplant 2005;20:2287–8. 8. Rose JK, Roberts D, Simmons M. What’s eating your wishbone? Sternoclavicular septic arthritis with osteomyelitis. West J Emerg Med 2012;13:497–8. 9. Bar-Natan M, Salai M, Sidi Y, et al. Stenoclavicular infectious arthritis in previously healthy adults. Semin Arthritis Rheum 2002;32:189–95. 10. Taylor LJ, Belham GJ. Monoarticular septic arthritis of the sternoclavicular joint. Arch Emerg Med 1985;2:177–8. 11. Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004;364:369–79. 12. Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in a single UK health district 1982– 1991. Ann Rheum Dis 1999;58:214–9. 13. Yood RA, Goldenberg DL. Stenoclavicular joint arthritis. Arthritis Rheum 1980;23:232–9. 14. Robinson CM, Jenkens PJ, Markham PE, et al. Disorders of the sternoclavicular joint. J Bone Joint Surg Br 2008;90:685–96. 15. Schauwecker DS, Braunstein EM, Wheat LJ. Diagnostic imaging of osteomyelitis. Infect Dis Clin North Am 1990;4:441–63. 16. Bonakdar-pour A, Gaines VD. The radiology of osteomyelitis. Orthop Clin North Am 1983;14:21–37. 17. Tecce PM, Fishman EK. Spiral CT with multiplanar reconstruction in the diagnosis of sternoclavicular osteomyelitis. Skeletal Radiol 1995;24:275–81. 18. Malcius D, Jonkus M, Kuprionis G, et al. The accuracy of different imaging techniques in diagnosis of acute hematogenous osteomyelitis. Medicina 2009;45:624–31.
http://dx.doi.org/10.1016/j.jemermed.2015.05.006
Clinical Communications: Adults AN UNUSUAL CAUSE OF CHEST PAIN IN A YOUNG HEALTHY FEMALE Jennifer J. Robertson, MD, MSED Emergency Services Institute, The Cleveland Clinic, Cleveland, Ohio Reprint Address: Jennifer J. Robertson, MD, MSED, Emergency Services Institute, The Cleveland Clinic, Mail Code E19, 9500 Euclid Ave., Cleveland, OH 44195
, Abstract—Background: Infection of the sternoclavicular joint is an uncommon disease that is usually seen in patients with underlying risk factors such as prior trauma, intravenous drug use, or diabetes mellitus. The true pathophysiology remains unknown, but underlying bacteremia has been found in a number of cases. Without proper diagnosis and treatment, severe complications such as mediastinitis, sepsis, or death can occur. Case Report: This is a case of spontaneous stenoclavicular septic arthritis in an otherwise healthy female. The patient’s lack of risk factors and minimal examination findings highlight the unusual nature of the case, as well as the challenges it presents in making an early diagnosis. Why Should an Emergency Physician Be Aware of this Condition?: Emergency physicians should consider sternoclavicular joint infections in patients who present to the emergency department with chest pain, even in patients without risk factors. They should especially consider the diagnosis in patients with suspected musculoskeletal etiologies or in those with return visits for chest pain. Although most patients do well with treatment, the infection can be life threatening without appropriate interventions. Ó 2015 Elsevier Inc.
liver and kidney disease, and rheumatologic diseases (1–8). Although this infection, in otherwise healthy individuals, has been documented in the literature, it is quite rare (5,9). In fact, in the healthy population, sternoclavicular joint infections have been estimated to comprise only 0.5% of all bone and joint infections (9). Due to the rarity of this condition, sternoclavicular osteomyelitis is not something that emergency physicians first consider in healthy patients with chest pain. This case report is unusual due to its spontaneous occurrence in a young healthy female without any known risk factors or initial abnormal examination findings. This is the first reported case of sternoclavicular joint infection in the emergency medicine literature in a patient with no predisposing conditions. CASE REPORT A 28-year-old woman presented to our Emergency Department (ED) after going to several other EDs with the chief complaint of left-sided chest pain of 10 days duration. She had no significant past medical history. The patient denied trauma, fever, or intravenous drug use. The chest pain was nonradiating, constant, but worsened with arm movement. On physical examination, the patient’s vital signs were a temperature of 36.8 C, a blood pressure of 135/98 mm Hg, a pulse of 68 beats/min, and respirations of 18 breaths/min. The patient had tenderness along her left chest wall and clavicle without evidence of swelling, warmth,
, Keywords—unusual chest pain; sternoclavicular joint; osteomyelitis
INTRODUCTION Infection of the sternoclavicular joint is uncommon and is typically seen in patients with risk factors such as prior trauma, intravenous drug use, diabetes mellitus, central vein catheterization, human immunodeficiency virus,
RECEIVED: 26 February 2015; FINAL SUBMISSION RECEIVED: 18 April 2015; ACCEPTED: 14 May 2015 1
2
J. J. Robertson
Figure 1. Computed tomography of the chest with contrast shows (A) soft tissue inflammation of the sternoclavicular joint, (B) osseous destruction of the left manubrium, and (C) a sclerotic appearance of the superior sternum.
erythema, or masses of the chest wall, clavicle, or left shoulder. Her electrocardiogram showed normal sinus rhythm, and her chest and sternoclavicular joint roentgenograms showed no acute abnormalities. Her white blood cell count was 8.49 k/uL. The patient’s symptoms and evaluation were not consistent with acute coronary syndrome, aortic dissection, pulmonary embolism, or pneumonia. The tenderness along her left chest wall suggested a musculoskeletal etiology of her pain. Given that the patient had no history of intravenous drug use or immunodeficiency syndrome, and she presented with a normal white blood cell count, a normal temperature, and no warmth, swelling, or masses of the chest wall or left shoulder joint on physical examination, we had a low suspicion for an infectious etiology of her chest pain. The patient was discharged with the diagnosis of chest pain, likely musculoskeletal in nature, with the recommendation for close follow-up and to return immediately if symptoms worsened or changed. Two weeks later, the patient presented again to our ED with persistent symptoms. She had been diagnosed with left sternoclavicular osteomyelitis after receiving a computed tomography (CT) scan at an outside hospital. She also had undergone surgical incision and drainage at the outside hospital, but was complaining of persistent symptoms. CT of the chest during the second visit to our ED showed soft tissue inflammation of the sternoclavicular joint, osseous destruction of the left manubrium, and a sclerotic appearance of the superior sternum (Figure 1). The patient required additional surgical procedures at our hospital, including a left sternoclavicular joint resection and drain placement. Operative wound cultures grew out methicillin-sensitive Staphylococcus aureus. She remained afebrile throughout her hospital course, with a normal erythrocyte sedimentation rate and only 1 day of mild leukocytosis 3 days after admission (14.45 k/uL). The patient was sent home on intravenous
oxacillin. The patient did have subsequent visits to our ED for pain control, but otherwise her postoperative course was unremarkable. DISCUSSION Infection of the sternoclavicular joint was first described by Vogelius in 1896 in a patient with pneumococcal pneumonia (10). This infection comprises both septic arthritis and osteomyelitis, and there is no clear distinction between the two because more than half of patients have both septic arthritis and osteomyelitis (5). Since its discovery, reports of this infection remain rare and mainly occur in patients with underlying illness or risk factors such as intravenous drug use and immunodeficiency syndrome (3,5). The true pathophysiology remains to be determined; however, bacteremia secondary to trauma or surgical procedures is a likely possibility (1,5,10,11). Significantly, up to 62% of patients with sternoclavicular joint infections have bacteremia, as opposed to 27% of patients with other types of septic arthritis. Thus, this supports the theory of hematogenous spread (5,12). Currently, the most common etiologic agent causing sternoclavicular joint infections is Staphylococcus aureus (9). The average age of presentation is 45 years, and unlike septic arthritis of most other joints, it tends to be insidious in onset, as symptoms may take up to 2 months to develop (5,9,13). Most patients have swelling and tenderness over the joint, as well as fever, chills, or night sweats (3,9,14). However, systemic symptoms may be absent in the elderly and immunosuppressed patients, and given the tissue expanse around the joint, effusions may not be noticeable on initial physical examination, as in our patient (5,13,14). The chest pain of sternoclavicular joint arthritis can also simulate pain from cardiac or pulmonary origins such as myocardial
Unusual Chest Pain
infarction or pulmonary embolism (13). Given these factors, the diagnosis can be challenging. If a sternoclavicular joint infection is suspected, workup including inflammatory markers and imaging should be obtained. Of note, whereas inflammatory markers are typically elevated in previously healthy patients, they may be normal in immunosuppressed patients (13,14). Although magnetic resonance imaging and bone scintigraphy are useful diagnostic tools, plain films and CT are likely the first to be obtained in the ED (15). Plain films may show soft tissue swelling and periosteal thickening, but these findings may take up to 21 days after the onset of infection (16). Additionally, plain films are less sensitive than CT, and CT will typically show abnormalities much earlier than conventional radiographs (15,17,18). Similar to our patient’s CT findings, CT in general shows sclerosis or bony erosions, gas formation, or soft tissue swelling (17). Our patient presented only 1 week after the onset of symptoms, and plain films were negative. Because CT can detect the infection earlier than plain films, it is certainly possible that the diagnosis could have been made sooner on initial visit. However, a CT scan was not considered prudent on the initial visit given the patient’s lack of risk factors and other concerning findings on history and physical examination. Definitive diagnosis of sternoclavicular joint infections is made by aspiration or open biopsy and culture of the joint fluid (3). Patients should be treated with the appropriate antibiotics, based on culture results. Although some patients do not require surgery, most cases require irrigation and drainage in the operating room (3,5,9). If treated early, most patients have good outcomes. Occasionally, complications such as mediastinitis, superior vena cava syndrome, or septic shock may occur (1,3,5,9). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? The potential for progressive, severe complications makes diagnosing sternoclavicular joint infection all the more important for emergency physicians. Our patient was young and healthy, had no history of intravenous drug use, was without fever or systemic symptoms, and had minimal physical findings. If concerning patients initially have normal examination and ED work-up,
3
they should be counseled on return precautions. The condition may also mimic more common conditions such as pulmonary embolism, acute coronary syndrome, pericarditis, and costochondritis, and thus, the diagnosis may be easily missed (13). Given the potential for devastating outcomes such as sepsis, and the need for invasive procedures, sternoclavicular joint infections should remain a part of any emergency physician’s differential diagnosis in patients with chest pain, especially in those with chest pain of musculoskeletal etiology. REFERENCES 1. Randell PA, Somers L. Case of the month: ‘‘bugs are eating my soul’’—sternal abscess, osteomyelitis and mediastinitis complicating a closed sternal fracture. Emerg Med J 2006;23:736–9. 2. Smith JW, Chalupa P, Hasan MS. Infectious arthritis: clinical features, laboratory findings and treatment. Clin Microbiol Infect 2006;12:309–14. 3. Higginbotham TO, Kuhn JE. Atraumatic disorders of the sternoclavicular joint. J Am Acad Orthop Surg 2005;13:138–45. 4. Song HK, Guy TS, Kaiser LR, et al. Current presentation and optimal surgical management of sternoclavicular joint infections. Ann Thorac Surg 2002;73:427–31. 5. Ross JJ, Shamsuddin H. Stenoclavicular septic arthritis: review of 180 cases. Medicine 2004;83:139–48. 6. Lindsey RW, Leach JA. Sternoclavicular osteomyelitis and pyoarthrosis as a complication of subclavian vein catheterization: a case report and review of the literature. Orthopedics 1984;7:1017–22. 7. Summers SA, Gupta RK, Clutterbuck EJ, Laing C, Cooke GS. Haemodialysis catheter-associated infection: common pathogens in unusual places. Nephrol Dial Transplant 2005;20:2287–8. 8. Rose JK, Roberts D, Simmons M. What’s eating your wishbone? Sternoclavicular septic arthritis with osteomyelitis. West J Emerg Med 2012;13:497–8. 9. Bar-Natan M, Salai M, Sidi Y, et al. Stenoclavicular infectious arthritis in previously healthy adults. Semin Arthritis Rheum 2002;32:189–95. 10. Taylor LJ, Belham GJ. Monoarticular septic arthritis of the sternoclavicular joint. Arch Emerg Med 1985;2:177–8. 11. Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004;364:369–79. 12. Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in a single UK health district 1982– 1991. Ann Rheum Dis 1999;58:214–9. 13. Yood RA, Goldenberg DL. Stenoclavicular joint arthritis. Arthritis Rheum 1980;23:232–9. 14. Robinson CM, Jenkens PJ, Markham PE, et al. Disorders of the sternoclavicular joint. J Bone Joint Surg Br 2008;90:685–96. 15. Schauwecker DS, Braunstein EM, Wheat LJ. Diagnostic imaging of osteomyelitis. Infect Dis Clin North Am 1990;4:441–63. 16. Bonakdar-pour A, Gaines VD. The radiology of osteomyelitis. Orthop Clin North Am 1983;14:21–37. 17. Tecce PM, Fishman EK. Spiral CT with multiplanar reconstruction in the diagnosis of sternoclavicular osteomyelitis. Skeletal Radiol 1995;24:275–81. 18. Malcius D, Jonkus M, Kuprionis G, et al. The accuracy of different imaging techniques in diagnosis of acute hematogenous osteomyelitis. Medicina 2009;45:624–31.
