Presentation
Right shoulder pain. Admitted to ICU with shocked state.
Patient Data
CT of right shoulder with contrast demonstrates large collection of intermediate density, extending into the rotator cuff muscles. Associated widening of glenohumeral joint and subacromial space. No fractures seen.
Microbiology - Arthrocentesis
Specimen: Fine Needle Aspirate No Site specified
Gram Stain: Leukocytes 3+
Epithelials Nil
Gram pos. cocci scant
Culture: Streptococcus agalactiae (Group B) 1+
Comments: Group B streptococci are susceptible to penicillins and cephalosporins Calcium pyrophosphate crystals seen.
Microbiology - Intra-operative specimen
Specimen : Pus Right,Shoulder
Gram Stain : Leukocytes 3+
Epithelials Nil
Gram pos. cocci 1+
Culture: Streptococcus agalactiae (Group B) 1+
Group B streptococci are susceptible to penicillins and cephalosporins.
Comments: Calcium pyrophospate crystals scant
Case Discussion
Patient received ultrasound guided arthrocentesis following CT, confirming large volume purulent fluid in joint space with associated soft tissue collection. Culture grown Streptococcus agalactiae consistent with septic arthritis.
The patient subsequently underwent multiple washouts of the right shoulder. Intra-operative findings confirmed large volume purulent collection within subdeltoid space and glenohumeral joint. Further collections within muscle bellies of subscapularis, supraspinatus and infraspinatus muscles. Intra-operative specimens also grew S. agalactiae.
Patient was treated with 4-week course of antibiotics. Patient developed right shoulder subluxation secondary to manipulation and mobilization of the rotator cuffs intra-operatively. Subluxation was treated by immobilization of shoulder in sling.
Diagnosis of septic arthritis can be challenging in non-verbal and sedated patients. In these patients, high index of suspicion and imaging is often necessary. Septic arthritis requires prompt drainage and early antibiotics to avoid permanent damage to the joint and long-term sequelae.
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