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Consult Dilemma:
a case of divergent opinions
Alev Wilk
Primary Care Conference
4/18/07
Conflict of Interests
None
Objectives
Patient case
Teaching points in septic arthritis
Teaching points in consult management
Patient Case
47 y.o. obese man with IDDM who was
admitted with a one week history of
progressive right shoulder pain & diffuse
myalgias
No recent trauma, pulmonary, CV, GI, GU
problems. He denied F/C/S, HA, chest
pain, sob, n/v.
Medications included insulin 70/30
20Units bid and prn vicodin
Patient Case
He worked as a welder; nonsmoker; light
drinker; no IV drug use; monogamous
Exam findings: Tenderness & swelling in
the right shoulder & knee, systolic heart
murmur, 1st toe abrasion.
Labs: Leukocytosis, elevated esr/crp. TEE
negative; HIV negative; A1C is 7.2.
Patient Case
First 24 hours:
– Rheumatology consult: diagnostic and
therapeutic taps; continue joint surveillance
– Blood & joint fluid cultures grew gram
positive cocci in clusters
– ID consult: antibiotic management
– Orthopedic consult: arthroscopic irrigation and
debridement of the right shoulder.
Patient Case
One week
– He improves on IV antibiotics but continues
with debilitating right shoulder pain and right
knee pain.
– Rheumatology: deferred the shoulder to ortho
but continued serial right knee taps.
– Orthopedics: no further intervention or
imaging. Tell Rheum to stop tapping the knee.
Septic arthritis
Medical exam
– Very tender though less swollen shoulder and
knee (extension to adjacent tissues)
– Afebrile, normal WBC but esr is high.
Medical management*
– Antimicrobial combination therapy
– Increase bactericidal activity and prevent
development of resistance
– Continue IV nafcillin and rifampin
*N Engl J Med 1998;339:520-532
Septic Arthritis
Staphylococcus aureus infections*
– Produces proteolytic enzymes that destroy
tissue & facilitate spread of infection
– Metastatic infection: spread to bones, joints,
kidney and lung which become potential foci
for recurrent infections
– Clinical experience: extension from extra- to
intra-articular regions and osteomyelitis**
*N Engl J Med 1998;339:520-532
**J Bone Joint Surg Am 2006; 88(8): 1802-6
Septic Arthritis
 Risk factors*:
– Age > 80
– Diabetes: 10-20% of patients are colonized with
S.Aureus (highest in diabetics)
– RA
– Prosthesis
– Recent joint surgery
– Skin infection
– HIV infection
*JAMA, April 4, 2007; 297(13); 1478
Septic Arthritis
Repeat imaging revealed enlarging fluid
collections in the shoulder, thigh as well as
A-C osteomyelitis
Orthopedic intervention with surgical
drainage, acromioplasty.
Reconsulted ID, same antibiotics with a
time extension
Septic Arthritis: take-home points
Staph aureus can present as a metastatic
infection that is progressive & persistent
Risk factors are numerous in adults
Joint surveillance with exam & imaging
Consult Dilemma: take-home points
We direct the consultants, they do not
direct us
We are specialists with the wide-angle lens
and the telephoto lens
We are specialists in managing behavioral
and physical medicine