CCS Interactive Case 22

Question 1

40 y/o M, no PMHx, presents to the office w/fever and chills for 2 days, swollen, painful L knee since last night

Walks with a limp, fever of 102.3F, no trauma to the joint. HDS.

Family hx of RA, no family hx of gout

DDx?

Answer 1

Fever + monoarticular joint pain - septic arthritis, gout, pseudogout, RA, Reiter’s syndrome, Lyme disease

Question 2

Exam?

Answer 2

Focused - skin, joints, extremities, heart, lungs

Question 3

Erythematous tender, sweollen left knee, limited ROM, exam otherwise normal

Next step?

Answer 3

Admit to the hospital

Question 4

Orders upon admission?

Answer 4

Joint aspiration - fluid sent for cell count and diff, gram stain, culture and sensitivity, microscopy to evaluate for crystals

BMP, CBC, ESR, blood cultures, radiograph

Question 5

Synovial fluid - WBC count of 120,000 w/85% neutrophils, lower glucose, decreased viscosity, absence of crystals, GP cocci in clusters - Dx?

Answer 5

Septic arthritis

S. aureus

Question 6

Rx?

Answer 6

IV ABX early - broad-spectrum coverage w/3rd generation cephalosporin +/- vancomycin immediately after joint aspiration and while awaiting gram stain results.

This patient also needs arthroscopy due to inadequate joint aspiration

Question 7

Initial ABX therapy of non-gonococcal bacterial arthritis?

Answer 7

Broad-spectrum coverage while awaiting gram stain - IV 3rd generation cephalosporin (ceftriaxone, ceftazidime, cefotaxime) + IV vancomycin

Question 8

Adjust ABX w/gram stain results - gram-positive cocci?

Answer 8

MRSA - IV Vanc x 4-6 weeks

MSSA - IV nafcillin or IV cefazolin for 2 weeks + 2-4 more weeks oral ABX

Question 9

Adjust ABX w/gram stain results - gram-negative bacilli?

Answer 9

IV 3rd generation cephalosporin (ceftriaxone x 14 days), then 14 days PO ABX

Question 10

Sequence?

Answer 10

Focused exam
Admit to ward
Order: CBC, BMP, ESR, PT/INR, PTT, blood cultures, knee x-ray, synovial fluid - gram stain, cell count, glucose, crystals, culture and sensitivity, fluid viscosity (all stat)
Note thick purulent fluid that is difficult to aspirate
Order - NPO, IV access, NSS 0.9% IV continuous, morphine IV x1, Tylenol, PO, continuous, ceftriaxone IV, continuous, vancomycin, IV, continuous
Consult ortho surgery stat (arthroscopy)
Clock: advance to obtain consult recs and GS resutls -GP cocci in clusters
Cancel IV cetriaxone
Arthroscopy stat
Advance clock
Cancel NPO, order normal diet
Advance clock to reevaluate in 6-12 hours
Case ends
Final orders: counsel patient
Dx: septic arthritis of the L knee