Enterobacter cloacae infection of the shoulder in a 52-year-old woman without apparent predisposing risk factor: a case report and literature review.

BACKGROUND: Enterobacter cloacae (E. cloacae) is one of the commensal flora in the human intestinal tract and a prevalent nosocomial pathogen, which rarely causes infectious osteoarthritis in immunocompetent patients without recent trauma or surgery. Here, we report the first case of septic monoarthritis of the shoulder caused by E. cloacae in an immunocompetent patient. CASE PRESENTATION: A 52-year-old female with a 6-year history of right shoulder pain was referred to our emergency department due to fever, acute severe shoulder pain, and swelling. Blood test showed elevated inflammatory markers. The patient denied any recent invasive surgical procedure and trauma. She was misdiagnosed with a frozen shoulder, and the anti-inflammatory painkiller celecoxib for symptomatic treatment was ineffective. Magnetic resonance imaging (MRI) showed a shoulder joint abscess and supraspinatus tendon tear. The joint aspirate culture showed E. cloacae. After late diagnosis, she was treated with levofloxacin and underwent surgical debridement and irrigation. Her follow-up data revealed that she did not suffer from shoulder swelling and severe pain. CONCLUSION: This is a rare case of E. cloacae infected arthritis of the shoulder in an immunocompetent patient with a rotator cuff tear, indicating that even if the symptoms and age of the patients match the characteristics of frozen shoulder, the possibility of septic arthritis should be considered in the presence of fever and increasing inflammatory markers. The cases of our literature review suggest that the patients subjected to invasive procedure may develop a subsequent E. cloacae osteoarticular infection, regardless of being asymptomatic after the procedure.

Tuberculosis of acromioclavicular joint: a case report.

BACKGROUND: Osteoarticular tuberculosis is a great masquerader presenting in varied forms and in atypical locations, and it is prone to misdiagnosis and missed diagnosis. Isolated acromioclavicular joint tuberculosis has been reported rarely. CASE PRESENTATION: A 19-year-old man presented with a chronic, mild pain, non-healing ulcer in right shoulder. Imaging of the shoulder revealed destruction of the acromioclavicular joint and histopathology confirmed the diagnosis of acromioclavicular tuberculosis. The patient underwent debridement, synovectomy and drainage of the abscess and recovered well with antitubercular therapy postoperatively. CONCLUSIONS: Awareness of this uncommon presentation of osteoarticular tuberculosis may assist in earlier diagnosis. Especially, in endemic countries, osteoarticular tuberculosis should be considered as a differential diagnosis in all atypical presentations to avoid residual problems.

Infective Endocarditis Presenting as Right Shoulder Pain: A Case Report.

Although cases of referred shoulder pain due to ischemic heart disease have been well documented, to our knowledge no reports on infective endocarditis accompanied by referred right shoulder pain have been published. A 43-year-old Japanese man presented with severe right shoulder pain and a body temperature of 38°C.Blood tests showed inflammation and liver dysfunction, although magnetic resonance imaging did not indicate septic shoulder arthritis. However, contrast-enhanced computed tomography showed renal, splenic, and hepatic infarctions. Moreover, a labile vegetation was detected on an echocardiogram. The patient was diagnosed with infective endocarditis and antibiotics were administered intravenously. Infective endocarditis is a serious condition that can result in complications if it is not diagnosed and treated at an early stage. Therefore, in cases with referred shoulder pain, physicians should carefully consider the presence of internal diseases that may cause this condition, as in the present case.

Infection Prevention in Shoulder Surgery.

The microbiome of the shoulder demonstrates distinctive differences to other orthopaedic surgical sites. Recent studies have demonstrated that the most common organisms found in deep shoulder infections are coagulase-negative staph lococcal species and Propionibacterium acnes . Many studies support diligent hand washing, decreasing operative time, routine glove changing, minimizing operating room traffic, and covering instruments as means for decreasing the risk of deep infection. On the other hand, hair clipping and the use of adhesive drapes may have little effect on decreasing the incidence of deep infection. Although generally considered the most efficacious skin preparation solution, chlorhexidine gluconate has minimal effect on eradication of P. acnes from the surgical site; however, the addition of preoperative topical applications of benzoyl peroxide to standard surgical preparation has shown promise in decreasing the rate of P . acnes culture positivity. Additionally, the use of local antibiotic formulations seems to be an effective means of preventing deep infection.

[A boy with a cough and shoulder pain]. / Een hoestende jongen met schouderpijn.

A 15-year-old boy reported to the Accident and Emergency Department with excessive coughing, shortness of breath and pain in the area of his left shoulder blade. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured from his sputum. The boy was otherwise healthy, and had no immune deficiency or underlying anatomic abnormality. He probably contracted the MRSA infection at the international school he attends.

Injection-induced low-grade infection of the shoulder joint: preliminary results.

BACKGROUND: Purulent arthritis of the shoulder has been widely reported. Low-grade post-operative infections of the shoulder have also been observed. Low-grade infections of the shoulder without prior surgery have not been reported in the literature. The purpose of this study is to present our experience of seven patients with low-grade infections of the shoulder without a history of prior surgery. METHODS: We retrospectively reviewed seven patients, mean age of 45 years that originally presented with diffuse shoulder pain, with or without stiffness. None had prior surgery but all had prior injections, average 5.6, into the shoulder. All patients were treated with various arthroscopic procedures. All had harvesting of four tissue probes identifying low-grade infection. Pre/post-operative pain score, pre/post-operative range of motion, intraoperative findings, post-operative Constant score, Subjective Shoulder Value and pre/post operative radiographs were analyzed. Post-operative antibiotic therapy was recorded. RESULTS: All patients showed synovitis without pus or any other sign of infection. Propionibacterium acnes were identified in five, coagulase-negative Staphylococcus in two, and Staphylococcus saccharolyticus in one shoulder. One patient had a mixed infection (Propionibacterium acnes and coagulase-negative Staphylococcus). Therapy consisted of oral antibiotics for 1-6 months. Four patients had a satisfactory and three an unsatisfactory outcome. CONCLUSIONS: Diffuse shoulder pain with or without stiffness in patients without prior surgical history can be caused by low-grade infection. Treatment using oral antibiotics has unpredictable outcomes. Further studies are necessary to analyze this pathology. LEVEL OF EVIDENCE: Level IV, retrospective case series, treatment study.

Propionibacterium acnes infection as an occult cause of postoperative shoulder pain: a case series.

BACKGROUND: Infections after shoulder surgery are potentially devastating complications. Propionibacterium acnes is recognized as a causal agent in shoulder infections. The clinical presentation is usually insidious and nonspecific, but a P. acnes infection could be an occult cause of postoperative shoulder pain. QUESTIONS/PURPOSES: What are the clinical and microbiologic characteristics of a postsurgical P. acnes shoulder infection and how should it be addressed? PATIENTS AND METHODS: Ten patients with an average age of 57 years presented with P. acnes postsurgical shoulder infection. Clinical infection signs and surgical history were assessed and joint aspirates and tissue biopsy specimens were obtained. Diagnosis was confirmed by microbiologic cultures. RESULTS: At the time of confirmation of the diagnosis, clinical signs of infection were absent. C-reactive protein and erythrocyte sedimentation rates were inconsistently elevated. Cultures took a mean 7 days to confirm organism growth. The average time from surgery to diagnosis of infection was 1.8 years (range, 0.07-8.0 years). All patients underwent irrigation and débridement and were treated with antibiotics for 6 weeks. CONCLUSIONS: P. acnes shoulder infections should be considered as a cause for persistent, unexplained shoulder pain. Shoulder aspirations and tissue samples should be obtained. Surgical débridement and intravenous antibiotics are necessary treatment modalities. LEVEL OF EVIDENCE: Level IV, Prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Septic arthritis of the acromioclavicular joint.

The acromioclavicular joint is rarely the site of septic arthritis. We conducted a retrospective review at our rheumatology department, which identified five cases within the last 6 years. All five patients were males, and their mean age was 63 years. Risk factors were consistently identified and included intravenous substance abuse, prior joint disease, a recent history of intraarticular injections, and a remote history of surgery. Joint aspiration was performed in all five patients and provided the organism in two patients. Blood cultures recovered Staphylococcus aureus in three patients, a coagulase-negative Staphylococcus in one patient, and no organism in one patient. Ultrasonography and/or magnetic resonance imaging established the early diagnosis in four patients and ruled out concomitant involvement of the glenohumeral joint. Only about 20 cases of septic arthritis of the acromioclavicular joint have been reported to date. This rare infection must be diagnosed rapidly to prevent joint destruction. The treatment is that usually recommended for septic arthritis.

Pitfalls in the diagnosis of infection around the shoulder joint--report of three cases.

Infection around the shoulder joint is rare. Clinical suspicion and diagnostic imaging are required for accurate diagnosis. We present three cases that emphasise particular diagnostic challenges when dealing with infection around the shoulder joint. Discussion includes the role of ultrasound as a screening tool and the importance of magnetic resonance imaging (MRI) in the accurate diagnosis and localisation of infections around the shoulder.

Bilateral glenohumeral septic arthritis secondary to retroperitoneal abscess.

Glenohumeral septic arthritis is rare and usually a result of Staphylococcus aureus infection. Gram-negative septic arthritis is on the increase and is usually associated with intraabdominal pathology. We present a case of bilateral E. Coli glenohumeral septic arthritis associated with retroperitoneal abscess and discuss pitfalls in diagnosis and management.

Osteomyelitis--a case report.

BACKGROUND: Methicillin resistant Staphylococcus aureus (MRSA) infection has classically been associated with institutional health care settings such as hospitals and nursing homes. OBJECTIVE: This article presents a case of community acquired MRSA infection resulting in severe osteomyelitis of the humerus, followed by a brief discussion and literature review. DISCUSSION: Over the past few years, more community acquired cases of MRSA have occurred. Methicillin resistant S. aureus usually infects skin and soft tissue. Occasionally, a life threatening infection occurs involving the blood, lungs, heart and bone.

Parsonage-Turner syndrome revealing Lyme borreliosis.

Parsonage-Turner syndrome, also known as acute brachial neuritis or neuralgic amyotrophy, can be caused by various infectious agents. We report on four patients who experienced Parsonage-Turner syndrome as the first manifestation of Lyme disease. The clinical picture was typical, with acute shoulder pain followed rapidly by weakness and wasting of the shoulder girdle muscles. Electrophysiological testing showed denervation. A single patient reported erythema chronicum migrans after a tick bite. Examination of the cerebrospinal fluid showed lymphocytosis and protein elevation in 3 patients. Serological tests for Lyme disease were positive in the serum in all 4 patients and in the cerebrospinal fluid in 2 patients. Antibiotic therapy ensured a favorable outcome in all 4 cases. Two patients achieved a full recovery within 6 months. Parsonage-Turner syndrome should be added to the list of manifestations of neuroborreliosis. Serological tests for Lyme disease should be performed routinely in patients with Parsonage-Turner syndrome.

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