Consult Dilemma: a case of divergent opinions

1. Consult Dilemma:a case of divergent opinions Alev Wilk Primary Care Conference 4/18/07

2. Conflict of Interests • None

3. Objectives • Patient case • Teaching points in septic arthritis • Teaching points in consult management

4. Patient Case • 47 y.o. obese man with IDDM who was admitted with a one week history of progressive right shoulder pain & diffuse myalgias • No recent trauma, pulmonary, CV, GI, GU problems. He denied F/C/S, HA, chest pain, sob, n/v. • Medications included insulin 70/30 20Units bid and prn vicodin

5. Patient Case • He worked as a welder; nonsmoker; light drinker; no IV drug use; monogamous • Exam findings: Tenderness & swelling in the right shoulder & knee, systolic heart murmur, 1st toe abrasion. • Labs: Leukocytosis, elevated esr/crp. TEE negative; HIV negative; A1C is 7.2.

6. Patient Case • First 24 hours: • Rheumatology consult: diagnostic and therapeutic taps; continue joint surveillance • Blood & joint fluid cultures grew gram positive cocci in clusters • ID consult: antibiotic management • Orthopedic consult: arthroscopic irrigation and debridement of the right shoulder.

7. Patient Case • One week • He improves on IV antibiotics but continues with debilitating right shoulder pain and right knee pain. • Rheumatology: deferred the shoulder to ortho but continued serial right knee taps. • Orthopedics: no further intervention or imaging. Tell Rheum to stop tapping the knee.

8. Septic arthritis • Medical exam • Very tender though less swollen shoulder and knee (extension to adjacent tissues) • Afebrile, normal WBC but esr is high. • Medical management* • Antimicrobial combination therapy • Increase bactericidal activity and prevent development of resistance • Continue IV nafcillin and rifampin *N Engl J Med 1998;339:520-532

9. Septic Arthritis • Staphylococcus aureus infections* • Produces proteolytic enzymes that destroy tissue & facilitate spread of infection • Metastatic infection: spread to bones, joints, kidney and lung which become potential foci for recurrent infections • Clinical experience: extension from extra- to intra-articular regions and osteomyelitis** *N Engl J Med 1998;339:520-532 **J Bone Joint Surg Am 2006; 88(8): 1802-6

10. Septic Arthritis • Risk factors*: • Age > 80 • Diabetes: 10-20% of patients are colonized with S.Aureus (highest in diabetics) • RA • Prosthesis • Recent joint surgery • Skin infection • HIV infection *JAMA, April 4, 2007; 297(13); 1478

11. Septic Arthritis • Repeat imaging revealed enlarging fluid collections in the shoulder, thigh as well as A-C osteomyelitis • Orthopedic intervention with surgical drainage, acromioplasty. • Reconsulted ID, same antibiotics with a time extension

12. Septic Arthritis: take-home points • Staph aureus can present as a metastatic infection that is progressive & persistent • Risk factors are numerous in adults • Joint surveillance with exam & imaging

13. Consult Dilemma: take-home points • We direct the consultants, they do not direct us • We are specialists with the wide-angle lens and the telephoto lens • We are specialists in managing behavioral and physical medicine