Download Sternoclavicular Joint Infection and Mediastinitis Originally Attributed

■ Case Report
Sternoclavicular Joint Infection and
Mediastinitis Originally Attributed to
Concomitant Rotator Cuff Pathology
JAMES A. BROWNE*; STEVEN J. KRAVET, MD†; ANDREW J. COSGAREA, MD‡
ternoclavicular septic joint
arthritis is a relatively rare
infection.1 Clinical recognition may be hampered by minor
signs and symptoms and the tendency of sternoclavicular joint pain to
be referred to the shoulder.1,2 In
advanced cases, sternoclavicular
joint sepsis can progress to descending mediastinitis. Prompt recognition and treatment is critical given
the potentially life-threatening consequences of this infection.
This article presents an elderly
woman with a neck and retrosternal
abscess secondary to a septic sternoclavicular joint. Her symptoms
were originally attributed to a torn rotator
cuff. This article demonstrates the varied
presentation of sternoclavicular joint
pathology in the evaluation of shoulder
pain and presents one scenario in which
misdiagnosis could have had fatal consequences.
S
CASE REPORT
A 67-year-old woman presented with left
shoulder pain, with symptom onset 5 days
prior to presentation. The pain was initially
responsive to rest, heat, and non-steroidal antiinflammatory medications, but progressed to
constant, throbbing pain. The pain radiated
into the left arm and jaw. No history of shoulder trauma was reported, however the patient
1108
Figure 1: MRI showing full-thickness tear of the
supraspinatous tendon (arrow).
recalled carrying heavy groceries with her left
arm on the day prior to symptom onset.
Medical history was significant for diabetes
mellitus, end-stage renal disease, mild degenerative cervical spine disease, and depression.
Physical examination revealed an obese,
afebrile patient with normal vital signs. The
left shoulder and sternoclavicular joint were
nonerythematous without increased warmth
or palpable masses. Diffuse tenderness to palpation was noted throughout the left shoulder,
supraclavicular area, neck, and arm. The
patient refused to actively move the left upper
extremity. Passive shoulder motion was
decreased in all directions, and
marked weakness with resisted
external rotation and abduction
was noted. Hawkins and Neer
impingement maneuvers could not
be adequately assessed secondary
to discomfort. Sensory and vascular examinations were normal.
Significant laboratory studies
were white blood cell count 16,100
cells/mm3, and erythrocyte sedimentation rate 136 mm/h. A tuberculosis skin test was negative. A
chest radiograph and urinalysis did
not reveal the source of infection.
Plain radiographs of the left
1
shoulder and clavicle were unremarkable. Magnetic resonance imaging (MRI)
of the cervical spine revealed only degenerative changes. A shoulder MRI revealed degenerative changes of the acromioclavicular joint
and a complete tear of the supraspinatous tendon without retraction (Figure 1). Fluid accumulation was noted in the subacromial and
subdeltoid bursae and biceps tendon sheath.
The patient was admitted to the general
From the *Johns Hopkins School of Medicine;
the †Division of General Internal Medicine, The
Johns Hopkins Bayview Medical Center; and the
‡Department of Orthopedic Surgery, The Johns
Hopkins University, Baltimore, Md.
Reprint requests: Andrew J. Cosgarea, MD,
Johns Hopkins Sports Medicine, 10753 Falls Rd,
Ste 215, Lutherville, MD 21093.
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STERNOCLAVICULAR JOINT INFECTION | BROWNE ET AL
2A
2B
Figure 2: MRI showing soft-tissue swelling around the left clavicular head (arrow) (A). Further caudally, an abcess was revealed (arrow) medial to the left jugular
vein and lateral to the left thyroid lobe (B).
medicine service for treatment of renal failure.
By the third day after admission, a subtle softtissue prominence became apparent over the
length of the left clavicle and into the left
supraclavicular fossa. Subsequent ultrasound
revealed a hypovascular intramuscular softtissue mass in the left neck. Non-contrast
computed tomography (CT) revealed a
2.0⫻2.7-cm soft-tissue mass within the left
strap muscles of the neck, which extended
inferiorly to involve the sternoclavicular joint
and the periosteum of the clavicle. An
enlarged 2.0⫻2.4-cm lymph node was also
noted on the left side of the neck. Magnetic
resonance imaging revealed left sternoclavicular joint involvement as well as several ribs
and a fluid collection that descended posterior
to the sternum to the pulmonary artery (Figure
2). Fine needle fluid aspiration collection
yielded purulent material with no atypical
cells. An incision and drainage of the same
abscess liberated 4 cc of frank pus and was
accompanied by moderate symptomatic relief.
Biopsy and blood cultures were positive for
methicillin-sensitive Staphylococcus aureus. A
6-week course of intravenous oxacillin was
started. The patients’ symptoms had significantly reduced 2 months after completing the course
of antibiotics, although some weakness in the
left arm with overhead activities was noted.
OCTOBER 2004 | Volume 27 • Number 10
DISCUSSION
Sternoclavicular joint infection is
uncommon and accounts for ⬍10% of
cases of septic arthritis.1,3,4 Predisposing
factors include intravenous drug use,
rheumatoid arthritis, liver disease, alcohol
abuse, diabetes mellitus, renal failure,
malignancy, steroid therapy, or infection
at another site.1,5 Direct spread from a
subclavian central venous catheter has
Sternoclavicular joint
infection is uncommon
and accounts for ⬍10% of
cases of septic arthritis.
also been documented,5 and reports exist
of infection in previously healthy hosts.3,6
Staphylococcus aureus appears to be
the most common pathogen, although
infections have been caused by numerous organisms1 including tuberculosis.7
Sternoclavicular joint infection leads to
abscess formation in as many as 20% of
patients.8 Few signs or symptoms are
often present to suggest mediastinal
spread,9 but mediastinitis can be
fatal,4,5,10 with septic shock as a major
cause of death.10
As this case demonstrates, sternoclavicular joint septic arthritis can be a difficult clinical problem. Septic sternoclavicular joint does not have a uniform presentation and can initially be mistaken for a
glenohumeral process. Pain due to sternoclavicular joint disease may be insidious
in onset and referred to various ipsilateral
anatomical locations, including the shoulder, neck, jaw, or elbow,2 and can easily
be confused with intrinsic shoulder or cervical spine pathologies. The pattern of
pain has also been reported to mimic
myocardial ischemia and lung disease.1,11
Swelling and erythema over the sternoclavicular joint may be absent,12 and fever
and leukocytosis are not always present.
In a patient with renal disease, an isolated
elevated erythrocyte sedimentation rate is
also not specific, as 20% of patients with
end-stage renal disease will have extreme
elevations to ⬎100 mm/h.13
The pathogenesis of sternoclavicular
joint septic arthritis may be variable.
Direct injury, bacteremia, and direct
spread from the subclavian vein have all
1109
■ Case Report
been postulated as potential mechanisms
for initial seeding.14 Wohlgethan et al8
speculated that the dense fibrous joint
capsule is not easily ruptured and spreading is through lymphatic dissemination.
However, Chen et al5 believed that infection spread through a ruptured capsule;
superior capsular rupture would lead to
erythema, swelling, and a neck abscess,
whereas inferior rupture would lead to
retrosternal spread indicated only by
vague anterior chest pain. However, this
case demonstrates both neck and retrosternal involvement with lymphadenopathy and no erythema on examination.
The treatment of sternoclavicular
infection is controversial. Most early
cases appear to respond well to conservative measures; however, development of
osteomyelitis or the formation of a retrosternal abscess are generally considered
indications for surgery.12 Successful
resection of the manubrium and medial
clavicle with wound healing by secondary
intent have been documented.5 Aggressive
en bloc resection of the joint and surrounding bony and infected soft tissues
with muscle flap coverage of the defect
also appears to be well-tolerated with
remarkably little disability.12,15,16 In this
case, initial aggressive surgical treatment
was contraindicated given the patient’s
comorbidities, and the patient responded
favorably to medical therapy.
To our knowledge, no other report
1110
exists in the literature of a patient with a
concomitant rotator cuff tear and sternoclavicular infection. Although no causative
or etiological connection exists between
the two pathologies, this case demonstrates
Septic sternoclavicular
joint does not have a
uniform presentation and
can initially be mistaken
for a glenohumeral
process.
that concurrent intrinsic shoulder disease
may delay the diagnosis of a serious sternoclavicular joint infection.
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