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  • Teleconference Case Maharat Nakhon Ratchasima Hospital

    Extern Khosit Pinmai Code 5502180 Faculty of Medicine, Ramathibodi Hospital,

    Mahidol University

  • Patient History




    Chief complaint

    7 ..

  • Present Illness

    9 PTA

    8 PTA CT

    7 PTA .. admit ATB ceftriazone 2g IV OD x 6 days, ceftriazone 2g IV q 12 hr x 2 days Clindamycin 600 mg IV q 8 hr x 1 day

    refer .

  • Personal History

    DM HT TB

  • Family History


  • Systemic Review



    HEENT: Head:

    Eye: 1


    Nose & Sinus:

    Mount & Oral cavity:


  • Systemic Review (cont.)











  • Physical Examination

    Vital Signs: T 38.2C, P 102 bpm, RR 20/min, BP 125/76 mmHg

    Wt 40 kg, Ht 155 cm BMI= 16.65 kg/m2

    GA: Thai female, Age 39 year olds, Looking well, Active, Cooperative

    Skin: Ulceration wound at

    Lt lateral foot, mild tender

    Eyes: no pale conjunctiva, anicteric sclerae, Pupil round and equal diameter 3 mm. Rt = Lt , RTL Both eyes

    Ear: Normal hearing, No abnormal looking, Ear canals are normal looking, No discharge, Tympanic membranes intact

    Nose: Symmetrical, No septal deviation, No visible blockage, No inflammation in the nostrils

  • Physical Examination (cont.)

    Oral cavity: no oral ulcer, No dental caries or gingivitis, Tongue not deviated, Pharynx not injected, Tonsils not enlarged, not injected

    Neck: Trachea in midline, Thyroid gland not enlarged, Jugular veins not engorged, Cervical LN not palpable

    Chest: Symmetrical chest wall, Normal breathing movement, Expansion full, Rt =Lt, Normal breath sound, no adventitious sound

    CVS: No cyanosis, No clubbing fingers, No heave or thrill, Peripheral pulses are equal, No carotid bruit, Normal S1 S2, no murmur

    Abdomen: No distension, no dilated veins, Normal movement, No scar, Bowel sounds normal, Soft, not tender, no mass, Liver and spleen cant be palpated, No guarding, No rebound tenderness, No liver stigmata, Fluid thrill negative, Shifting dullness negative

  • Physical Examination (cont.)


    No pitting edema, no petechiae, no rash

    Mild erythema Warmth Marked tenderness Mild swelling Limit ROM at Right shoulder due to pain (Joint immobility) (Passive & Active)

  • Physical Examination (cont.)

  • Physical Examination (cont.)

    Neurological: Fully conscious, Good orientation to time, place, person

    Speech: normal

    Cranial nerves: normal

    Motor: grade V all extremities

    Sensory: grossly intact

    DTR: 2+ all

    Stiffness of neck: negative

  • Problem lists

    Acute fever

    Right shoulder pain



    Blurred vision of both eyes

    R/O Septic embolic phenomenon


  • Differential diagnosis

    Infectious arthritis (Septic arthritis)

    Inflammatory arthritis

    Crystal-induced arthritis

    Systemic infection (Bacterial

    endocarditis, HIV infection)







    E C


    F B




  • Complete blood count (CBC)

    Hb 11.7 g/dL

    Hct 35.2 %

    MCV 89.8 fl

    MCH 29.8 pg

    MCHC 33.2 g/dL

    RDW 13.4

    WBC 7800 cell/mm3 N 58

    L 30

    E 2

    Plt count 430,000 cell/mm3

  • Rt shoulder AP, transcapular

  • Joint fluid examination

    Color: Yellow

    Transparence: Cloudy

    Specific gravity: 1.020

    pH: 9.0

    RBC: 2000 cell/mm3

    WBC: 28,960 cell/mm3

    Neutrophil: 95%

    Lymphocyte: 4%

    Monocyte: 1%

    Crystal: Not found

  • Electrolytes, BUN, Cr

    BUN 5.2 mg/dL

    Cr 0.45 mg/dL

    Uric acid 2.1 mg/dL

    Phosphorus 3.4 mg/dL

    eGFR 127 ml/min/1.73m2

    Na 137 mmol/L

    K 3.9 mmol/L

    Cl 98.2 mmol/L

    CO2 26.3 mmol/L

    Anion gap 16.6

  • ESR, CRP

    ESR 82 mg/L

    CRP 66.9 mg/L

  • CXR

  • Synovial fluid (Microscopic exam)

    Moderate WBC

    Many RBC

    Organism: Not seen

    Synovial fluid (Aerobic Culture) No bacterial growth after 48 hr

  • Hemoculture after 48 hr

    H/C 1

    Organism: Staphylococcus aureus

    Susceptible: Oxacillin Co-Trimoxazole Erythromycin

    Clindamycin Tetracycline Fosfomycin

    H/C 2:

    Organism: Gram positive cocci in cluster

  • Anti HIV

    Anti HIV (ELISA) Neg

  • Plan of Managment

    Cefazolin 1 g IV q 6 hr

    Paracetamol (500) 1 tab po prn q 4-6 hr

  • Operative Note

    Open arthrotomy Right shoulder

    Serosanguinous fluid 2 ml, no pus,

    no cartilage destruction

  • Additive treatment


    Isometric exercise Prevent muscle atrophy

    ROM exercise Prevent joint stiffness


    Fever & Pain relief

    Dehydration: fluid hydration

  • Post-operative progression

    POD0: (38.5C)

    POD1: (38.7C), Drain 20 ml, H/C: NG

    Joint fluid: not seen org., mod.WBC

    POD2: ps=2 (37.8C), Drain 20 ml,

    H/C: S. aureus, J/C: NG

    POD3: ps=4 , Drain 0 ml

    POD4: ps=3 , Drain 0 ml


    POD6: ps=5

    POD7: ps=5

    ESR 100, CRP= 34.8


  • Post-operative progression

    POD8: ps=2 1 peak (37.9C)

    POD9: ps=3



    POD12: (ROM active 30)

    POD13: (ROM active 30, passive 120)

    POD14: (ROM active 45, passive 120) , ESR 64, CRP= 7.93

    POST OP 2nd WK

  • L/O/G/O

    Septic Arthritis

  • General

    known as infectious arthritis, may represent a direct invasion of joint space by various microorganisms, most commonly caused by bacteria.

    key consideration in adults presenting with acute monoarticular arthritis.

    becoming increasingly common among people who are immunosuppressed and elderly persons.

    Of people with septic arthritis, 45% are older than 65 years; these groups are more likely to have various comorbid disease states.

    Septic arthritis due to bacterial infections is commonly classified as either gonococcal or nongonococcal.

  • Pathogenesis

    Because of the lack of a limiting basement plate in synovial tissues, the most common route of entry into the joint is hematogenous spread during bacteremia.

    Pathogens may also enter through direct inoculation (e.g., arthrocentesis, arthroscopy, trauma) or contiguous spread from local infections (e.g., osteomyelitis, septic bursitis, abscess).

    Once in the joint, microorganisms are deposited in the synovial membrane, causing an acute inflammatory response.

    Inflammatory mediators and pressure from large effusions lead to the destruction of joint cartilage and bone loss.

  • L/O/G/O

    Approach to Septic arthritis



    The physical examination should determine if the site of inflammation is intraarticular or periarticular, such as a bursa or skin.

    Intraarticular pathology results in severe limitation of active and passive range of motion, and the joint is often held in the position of maximal intraarticular space.

    Conversely, pain from periarticular pathology occurs only during active range of motion, and swelling will be more localized.


    Serum markers, such as white blood cell (WBC) count, ESR and C-reactive protein levels, are often used to determine the presence of infection or inflammatory response.

    Patients with confirmed septic arthritis have been found to have normal ESR and C-reactive protein levels.

    When elevated, these markers may be used to monitor therapeutic response.


    In synovial fluid, a WBC count of more than 50,000/mm3 (50 109 per L) and a polymorphonuclear cell count greater than 90 percent have been directly correlated with infectious arthritis, although this overlaps with crystalline disease.


    There are no data on imaging studies that are pathognomonic for acute septic arthritis.

    Plain films establish a baseline and may detect fractures, chondrocalcinosis, or inflammatory arthritis.

    U/S is more sensitive for detecting effusions, particularly in difficult-to examine joints, such as the hip.

    MRI findings that suggest an acute intraarticular infection include the combination of bone erosions with marrow edema.

    Imaging may allow guided arthrocentesis, particularly in difficult-to-examine joints (e.g., hip, sacr