Spontaneous knee hemarthrosis associated with enoxaparin treatment in a post covid 19 patient

Purpose: To report a case of a 66-year- old Filipino male who developed spontaneous knee hemarthrosis following enoxaparin prophylaxis. Method(s): Case report Result: Case: We report a case of a 66-year- old Filipino male who developed spontaneous hemarthrosis of the left knee following enoxaparin use as venous thromboembolism prophylaxis. Pertinent in the medical history was the diagnosis of chronic kidney disease and chronic respiratory failure as sequelae of COVID 19 infection. During the course of admission, the patient developed acute pain and swelling of the left knee. He was bedridden and no prior traumatic events were noted. Coagulation parameters were within normal range. Arthrocentesis revealed viscous hemorrhagic synovial fluid (25 ml) with fluid analysis showing predominance of red blood cells (Red blood cells: 680,000/muL, White blood cells: 7200/muL) with no crystals seen on polarizing microscopy. Microbial culture was negative. Intravenous methylprednisolone was given and enoxaparin was continued. One day post arthrocentesis, there was improvement of pain and joint function. Joint swelling resolved. Patient had no recurrence of joint pain and swelling. Ethical consideration: Informed consent for both written and photographic content was secured and patient confidentiality was observed. Conclusion(s): Our patient is an elderly with chronic kidney disease who recently recovered from COVID 19 infection. He received prophylactic dose of enoxaparin at 40 mg every 24 hours subcutaneously. No other drugs that can affect hemostasis were given. The patient's bleeding parameters were within normal during admission and at the onset of hemarthrosis. We hypothesize that elderly patients with chronic kidney disease receiving low dose enoxaparin may present with spontaneous hemarthrosis even in the absence of trauma. Whether the association between history of recent COVID-19 infection and hemarthrosis is co incidental or causal remains to be elucidated. Prompt aspiration can provide early diagnosis and facilitate proper treatment. (Figure Presented).

Impact of a Cadaver Lab and Video Content-Based Curriculum on Emergency Physician and Advanced Practice Provider Performance Confidence and Clinical Utilization of Ultrasound-Guided Knee and Ankle Arthrocentesis

Study Objectives: The diagnosis of septic arthritis cannot be ruled out without performing an arthrocentesis. Delay in diagnosis leads to potentially irreversible joint damage and patient mortality. It is essential for emergency physicians (EPs) and advanced practice providers (APPs) to perform this procedure. Ultrasound guidance during arthrocentesis has been shown to reduce procedural pain scores and improve first-pass success rates compared to a landmark-guided approach. However, many providers trained when ultrasound was not readily available and feel uncomfortable recognizing a joint effusion on ultrasound. The study objective was to assess the impact of a hands-on cadaver lab arthrocentesis training on emergency medicine provider confidence in performing knee and ankle ultrasound-guided arthrocentesis and subsequent utilization in clinical practice. Method(s): EPs and APPs from a large academic, quaternary-care hospital prospectively enrolled in a 2-hour cadaver lab ultrasound-guided arthrocentesis training intervention. Didactic video content was created and distributed prior to cadaver lab training. The cadaver knee and ankle joint capsules were pre-injected with saline to create realistic effusions. Participant confidence performing and interpreting US-guided arthrocentesis was assessed pre- and post-cadaver lab via electronic survey based on a 0-10 scale (0=not confident at all, 10=extremely confident). Ultrasound-guided knee and ankle arthrocentesis utilization in clinical practice was compared before and after the cadaver lab which was held on October 4, 2021. The pre- intervention comparison time frame was January 1, 2019-December 31, 2019 to avoid changes in ED visits and practice associated with the COVID-19 pandemic. The post-intervention comparison time frame was October 5, 2021 through April 4, 2022. Median confidence scores with interquartile ranges (IQR) and monthly rates of ultrasound-guided arthrocentesis were calculated and presented with 95% confidence intervals. Result(s): A total of 28 emergency providers participated in the ultrasound-guided arthrocentesis cadaver lab (17 EPs, 10 APPs, 1 unknown) and 28 (100%) completed both pre- and post-intervention surveys. Sixty-one percent (17/28) of participants had greater than 5 years of post-training clinical practice. The median (IQR) confidence rating was 7.5 (IQR 5.0-9.0) pre-intervention and 8.0 (IQR 6.0-9.8) post-intervention (p=.153) for performance of ultrasound-guided knee arthrocentesis and was 2.5 (IQR 1.0-4.3) pre-intervention and 7.0 (IQR 6.0-8.8) post-intervention (p<.001) for performance of ultrasound-guided ankle arthrocentesis. Ultrasound-guided knee arthrocentesis utilization increased from a monthly average of 2.3 (95% CI 1.5-3.3) pre-intervention to 6.3 (95% CI 4.5-8.6) post-intervention, rate ratio 2.74 (95% CI 1.64 - 4.63), p<.001. Ultrasound-guided ankle arthrocentesis utilization increased from a monthly average of 0.8 (95% CI 0.4-1.5) pre-intervention to 2.5 (95% CI 1.4-4.1) post-intervention, rate ratio 3.02 (95% CI 1.27 - 7.53), p=.009. Conclusion(s): Our data demonstrate that a cadaver-based educational intervention increased EP and APP confidence in performing ultrasound-guided ankle arthrocentesis and increased ultrasound-guided ankle and knee arthrocentesis utilization in clinical practice. Further studies are needed to determine if this resulted in a meaningful reduction in time to diagnosis and ED length of stay. No, authors do not have interests to disclose Copyright © 2022

Septic arthritis caused by Brucella melitensis - An orthopedic chal-lenge (11194)

Introduction The zoonotic infection with Brucella melitensis can be acquired by inges-tion of unpasteurized goat's or sheep's milk. The infection is common in Eastern Mediterranean countries (EMC), but rare in western Europe (6 cases in Switzerland, 2021). When evaluating patients with symptoms of septic arthritis, brucellosis is not the foremost differential diagnosis. How-ever, with the increasing population of people from EMC in western Eu-rope, the incidence may be rising. We present a patient who was initially suspected to suffer from Long-COVID-Syndrome (LCS), which underscores the relevance of this case in a pandemic situation. Methods/Results A 58-year-old male patient was admitted to the emergency department with a painful right knee effusion after a minor trauma. Additionally, he suffered from fatigue, subfebrile temperatures, back pain and myalgias for more than two months. He was suspected to suffer from LCS after a mild COVID-19 three months earlier. The culture of the arthrocentesis (14.400 cells/mul with 61% polynuclear cells) unexpectedly turned positive for B. melitensis. The patient declared that he had been drinking three liters of unpasteurized goat's milk to cure the presumptive LCS. To ensure staff safety, arthroscopic lavage was postponed until brucella-active antibiotics had been administered for at least 24 hours. Surgery was performed under strict infection control measures to avoid generating aerosols. According to Duke, one major (continuous bacteremia over 14 days) and 2 minor criteria (fever, most probably septic embolic gonarthritis) were fulfilled. Therefore, possible endocarditis had to be assumed although transesophageal echocardiography was normal. Antibiotic treatment was escalated to a quadruple regimen (intravenous gentamicin for three weeks;as well as oral doxycycline, trimethoprim/sulfomethoxazole and rifampin for at least 3 months). The clinical recovery - still under treatment - is protracted with slowly improving knee pain and normalizing signs of inflammation. Conclusion Although B. melitensis is a rare pathogen in Switzerland, orthopedic sur-geons, rheumatologists and infectious disease specialists need to be aware of diseases with low incidence and non-specific symptoms espe-cially in times of a global pandemia. A high index of suspicion is needed in patients related to EMC. When brucellosis is confirmed, strict infection control measures to protect staff involved in aerosol generating proce-dures must be adopted.

Case report: post-Covid-19 arthritis and peri arthritis

We present the case of a 63 years old male patient known for type 2 diabetes and sleep apnoea. He was admitted as inpatient for a nontraumatic severe and disabling left hip pain. The pain started progressively one month ago. The medical history was otherwise irrelevant, with no general symptoms nor other symptoms suggestive of an inflammatory disease. To mention a history of an asymptomatic SARS-COV2 infection, diagnosed by a naso-pharyngial PCR, approximately 10 days before the onset of the pain. On physical examination, the patient was afebrile. The palpation of the inguinal region was tender on palpation with marked limitation of the hip range of motion. The spine and other peripheral joints were painless without inflammatory sign. Moreover, there was no skin lesion nor inguinal lymph nods enlargement. Due to the importance of pain with marked functional limitation, the patient is hospitalized for investigations and pain-management. On blood sample there was a mild increase of inflammatory markers (CRP 25mg/l, VS 20mm/h) with normal cell count. Standard X-rays of the pelvis and hip were normal. The MRI of the hip showed a mild coxo-femoral arthritis with marked inflammation of the surrounding musculature. An arthrocentesis was performed and 2ml of serous fluid was aspirated. There were no crystals. The cellularity could not be tested due to small amounts of fluid. The synovial culture showed a polymicrobious growth compatible with contamination. In summary, we were facing a patient with an acute and very painful hip monoarthritis. There was no history of gastrointestinal or urinary tract infection, the search for C. trachomatis and N. gonorrhoea in urines was negative. An extensive serologic testing (HIV, HBV, HCV, HBV, HCV, HIV, Lyme, Syphilis, Coxiella, Bartonella, Brucella & Quantiferon) and the search for T. whipplei were negative as well. There was no HLA-B27 and rheumatoid factor, ACPA, ANA, ANCA and specific antibodies related to polymyositis were negative. The chest-abdomen-pelvis scan showed no sign of neoplasia. To rule out a vasculitis we proceeded to a PET-CT, which showed no sign of vasculitis or myositis. Considering the timing of the onset of the symptoms and the absence of any other diagnosis, the patient was diagnosed with reactive arthritis caused by SARS-COV2. The patient was treated with Diclofenac 150 mg/day and opioids. The clinical evaluation one month after discharge showed a spontaneous significant improvement.

KNEE ARTHRITIS by PARACOCCIDIOIDES BRASILIENSIS in A LONG-STANDING RHEUMATOID ARTHRITIS PATIENT

Background: Arthritis by Paracoccidioides brasiliensis is a remarkably unusual etiology of infectious joint disease. While osseous lesions can be present in systemic disease, intra-articular-restricted disease without typical lung or lymph node involvement is mostly anecdotal1,2. Objectives: We hereby describe a case of this fungal arthritis in a patient with rheumatoid arthritis (RA) without signifcant immunosuppression. Methods: Patient records review. Written informed consent was obtained. Results: A 65-year-old female Brazilian patient with a 35-year history of seropositive RA complained of a painful knee edema for the last three weeks. Skin surrounding the joint was erythematous, warm, and tender to the touch, which initially raised the suspicion of cellulitis. She had already received a 10-day course of amoxicillin-clavulanate, with no improvement. C-reactive protein was 17.8 mg/L, rest of blood chemistry panel was within reference range. Point-of-care ultrasound revealed joint effusion, and a diagnostic arthrocentesis was performed. Synovial fluid was slightly turbid, with 10,100 cells per mm3, of which 80% were lymphocytes. Cultures for bacteria and mycobacteria yielded negative results, but culture for fungi detected growth of P. brasiliensis. The patient had been solely on prednisone 5 mg once daily for the last year, given that, due to covid-19 pandemics, she lost regular follow-up and abandoned treatment with immunosuppressants. Aside from mild RA-related interstitial lung disease, she had no other comorbidity. She denied local trauma to the knee, which made hematogenous dissemination of the fungi the most probable source. Comprehensive work-up to search for organic involvement of paracoccid-ioidomycosis, including chest computed tomography and transthoracic echocardiogram, did not evidence any visceral compromise. Voricona-zole 200mg t.i.d. was started, with good response. Three months after the beginning of the azole, tofacitinib was started for moderate RA disease activity, which also responded satisfactorily. Repeat arthrocentesis and synovial biopsy were performed eight months after the start of antifun-gal treatment, the former being normal (770 cells per mm3, negative cultures), and the later only demonstrating non-specific chronic synovitis with fibrosis. Conclusion: We reported an exceedingly rare presentation of P. brasiliensis infection with exclusive joint involvement.

From Other Journals

The article highlights that balanced multielectrolyte solution (BMES) has been touted as superior to 0.9% saline because of concerns about iatrogenic acute kidney injury and hyperchloraemic metabolic acidosis. It also discusses that patients who have suffered out- of-hospital cardiac arrest frequently have cardiogenic shock.

Global vision and clinical reasoning in complexity: An endangered competency in Internal Medicine in the CoViD era. Case series in an Internal Medicine unit CoViD-free

Background: During SARS-CoV-2 pandemic management of internist patient is even more complex: hospital acquired infection, resources devolved to CoViD-19, round visit with PPE, minor interrelation, post-CoViD patients. Presentation of the case series: 1. A 75-year old man had dysphagia, fever, low back pain, shoulder pain. Anamnesis: CoViD pneumonia (P/F143, TTS18/20), goiter, bladder neoplasm, T2DM. CT showed pneumomediastinum, pneumotorax, iliopsoas haematoma. He underwent broad spectrum antibiotic, arthrocentesis, culture tests. We concluded for pneumomediastinum due to CoViD-19 pneumonia, MSSA sepsis, septic arthritis, dysphagia due to goiter and pneumomediastinum, UTI. He is transferred to OSCO (surgery delayed) - 2. A 72-year old woman presented respiratory failure, fever, bacterial pneumonia. Anamnesis: stroke at age 50, APS diagnosis, AOCP, kidney failure. We performed antibiotics. Near to discharge, she had profuse haematemesis due to acute esophageal necrosis. She underwent PPI infusion and tests for risk factors and triggers (as APS or neoplasm). - 3. A 45-year old man had severe sepsis and intestinal obstruction. Anamnesis: paraplegia, previous intestinal obstruction. He underwent antibiotics, rehydration, NGT. Colonoscopy and gastrografin enema ruled out stenosis, but occlusion persisted. After collegial discussion surgical approach was proposed, but the patient had unfavorable outcome due to CoViD-19 infection. Discussion: These cases share high level of complexity: need of subintensive care, difficult management of patients' need. Clinical judgment, assessment of EBM priorities are essentials, underestimated skills.