A swollen wrist and confusion

Acute post-CVA deterioration should prompt an acute referral, says Dr Louise Warburton.

Mr Williams is a 75-year-old man who lives with his wife in a tidy semi-detached house.

He had had a small cerebrovascular accident (CVA) 12 months ago, but was normally independent. His wife asked for a visit one Wednesday morning; she had been out to a coffee morning and when she returned, had found her husband slumped and drowsy in his favourite armchair.

When I arrived, he was sweaty and clammy to the touch and sitting in his chair. He was quite unable to raise his head or look me in the eye and could not speak coherently. He was not able to tell me what was wrong. His wife assured me that he had been conscious and alert when she left him two hours earlier.

On examination, I noticed that his right wrist was red and very hot and I asked his wife about this.

Apparently Mr Williams did not suffer from gout or arthritis but had complained about a sore wrist the previous evening. His BP was normal and pulse rapid, but steady. Although he was sweaty, he did not feel particularly warm.

I wondered what had caused this acute deterioration in a normally well man.

I thought about an MI, especially as he was so clammy. But given that he seemed able to move all his limbs and was confused, another CVA was number one on my list of possible diagnoses.

He was clearly in need of medical assessment in hospital, so I arranged an acute admission. Because of the warm, painful wrist I put in the letter that I wondered if he had a septic arthritis, although I favoured a CVA.

He came out of hospital two days later. The diagnosis had been septicaemia secondary to a septic arthritis. He had been pyrexial on admission with a raised white cell count, and blood cultures had grown Staphylococcus aureus. He was treated with IV flucloxacillin and benzylpenicillin and had made a full recovery.

High fatality rate
Septic arthritis is relatively rare, but the fatality rate is about 11 per cent, and delayed diagnosis can lead to joint damage.

The British Society for Rheumatology and others have released guidelines for the management of the hot swollen joint in adults.

Septic arthritis is suggested by a short history of a hot, swollen and tender joint with restriction of movement. Fever can be absent.

The guidelines suggest aspiration of joint fluid, Gram staining and culture. Warfarin therapy does not contraindicate aspiration. However, neither the absence of organisms nor negative culture rules out septic arthritis. Blood cultures should also be taken. The white cell count, ESR and CRP should be checked.

IV antibiotics should be continued for two weeks or until improvement occurs, followed by oral antibiotics for four weeks. The choice of antibiotic depends on the suspected pathogen (see guidelines).

If cloudy joint fluid is aspirated from a joint then the fluid should be sent for culture. Steroids should not be injected into the joint until culture is known to be negative.

Septic arthritis is more likely in the elderly and immunosuppressed patients, who may be taking steroids for other reasons. These can mask the presentation.

Although septic arthritis is not common it should be in the list of differential diagnoses when assessing a toxic patient.

Dr Warburton is a GP in Ironbridge, Shropshire Lessons learnt from this case

  • Septic arthritis has a high case-fatality rate.
  • Patients with a hot, swollen joint, with restriction of movement, of recent onset, should be considered to have septic arthritis until proven otherwise.
  • When assessing a toxic patient, always consider septic arthritis.
  • Laboratory test results are needed before initiating antibiotics.

Reference

Coakley G, Mathews C, Field M et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology 2006: 45; 1,039-41.

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