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Arthritis, Infectious Tenosynovitis, and Tendon Rupture in a Patient with Rheumatoid Arthritis and Psoriasis

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Arthritis, Infectious Tenosynovitis, and Tendon Rupture in a Patient with Rheumatoid Arthritis and Psoriasis Case in Point Arthritis, Infectious Tenosynovitis, and Tendon Rupture in a Patient With Rheumatoid Arthritis and Psoriasis Peter Vu Bui, MD; and Ifeoma Stella Izuchukwu, MD Multiple comorbidities, advanced age, tobacco use, and alcohol abuse made a proper diagnosis difficult in a patient with polyarticular septic arthritis, infectious tenosynovitis, and ruptures in the tendons of both thumbs. ompared with monoarticular of 31% to 42% compared with 4% to milleri (S. milleri). During surgery, he arthritis, polyarticular arthri- 8% for monoarticular septic arthri- was also found to have bilateral ex- tis may yield an initially nar- tis, and RA was present in 67% of the tensor pollicus longus (EPL) tendon Crower differential diagnosis PASA fatalities.1 rupture. Given the possible morbid- that focuses on systemic inflamma- Rheumatoid arthritis and its treat- ity, the authors believe this patient tory conditions, such as rheumatoid ment predispose patients to septic may be of interest to the medical arthritis (RA). Approximately 15% to arthritis. Septic arthritis in the UK community. 30% of septic arthritis is polyarticu- general population is 0.42 per 100 lar, of which about 45% is associated patient-years for patients with RA on CASE PRESENTATION with underlying RA.1,2 Regardless of antitumor necrosis factor therapy.3,4 A 69-year-old African American male the number of joints involved, septic In a retrospective study in the U.S., presented with 3 to 4 days of swell- (infectious) arthritis is a valid con- the incidence of septic arthritis was ing and pain of bilateral wrists, bi- sideration given the morbidity and 0.40 per 100 patient-years for pa- lateral hands, and the left ankle with mortality. tients with RA compared with 0.02 subjective, but resolved, fevers and In a retrospective study in the per 100 patient-years for patients chills. His medical history was sig- United Kingdom (UK) between 1982 without RA.5 nificant for seropositive erosive RA, and 1991, the morbidity and mortal- Other complications of RA in- psoriasis, hypertension, hyperlipid- ity of septic arthritis was 31.6% and clude infectious tenosynovitis and emia, alcohol abuse, chronic tobacco 11.5%, respectively, and 16% of the tendon rupture. The incidence and use, osteoporosis, and glaucoma. He study population had RA.3 A review prevalence of infectious tenosynovi- did not have diabetes, reported no of the literature by Dubost and col- tis and tendon rupture in RA are not IV drug abuse, and except for the leagues found that polyarticular sep- firmly established in the literature. immunosuppressive effects of his tic arthritis (PASA) has a mortality We present a patient with RA and medications, was not otherwise im- psoriasis who responded initially to munocompromised. acute management for RA but subse- For 2 years in the outpatient set- Dr. Bui is a resident physician in the Department of Internal Medicine at the University of New quently was diagnosed with culture- ting, the rheumatology clinic had Mexico in Albuquerque. Dr. Izuchukwu is a staff negative polyarticular arthritis and been managing the patient’s rheu- physician at the VA Greater Los Angeles Health infectious tenosynovitis associated matoid factor (RF) positive and anti- Care System in California and associate clinical professor of medicine at the David Geffen School with beta hemolytic group G Strepto- cyclic citrullinated peptide (CCP) of Medicine at UCLA. coccus (GGS), a part of Streptococcus antibody positive erosive RA with www.fedprac.com FEBRUARY 2015 • FEDERAL PRACTITIONER • 31 SEPTIC ARTHRITIS etanercept 25 mg subcutaneously The patient was started on pred- and had no growth (Table). Gastro- twice a week. The RA affected his nisone 40 mg orally once a day (for 5 enterology studies were limited to hands, wrists, shoulders, and ankles days) for empiric treatment of an RA stool cultures and did not include bilaterally but was successfully con- flare and continued on etanercept. colonoscopy. Leukocytosis began trolled. The dermatology clinic was The inpatient rheumatology service trending down. managing the patient’s psoriasis with was consulted. Further evaluation On day 8, antibiotics were tai- calcipotriene cream 0.005% twice a later that day found involvement of lored to penicillin G 4 million units week and clobetasol ointment 0.05% the proximal interphalangeal joints IV every 4 hours following growth twice a week. Psoriatic plaques were and elbows and tenderness of the of GGS from the sample of the left noted on bilateral elbows, bilateral tendons of the dorsal hand bilater- wrist. Subsequently, synovial fluid dorsal hands, and bilateral dorsal feet. ally. Over the next 2 days, the pa- (3 mL) from the left shoulder was tient remained afebrile and WBCs obtained following initiation of an- Initial Evaluation were within normal limits. Edema, tibiotic therapy and had no growth. At evaluation, the patient’s vital erythema, and tenderness of the in- Magnetic resonance imaging (MRI) signs revealed a temperature of volved joints somewhat improved, found tenosynovitis of the left ankle 36.3°C (97.3°F), pulse of 102 beats but tenderness along the tendons of and right wrist. per minute, respiratory rate of the dorsal hand worsened, which On day 9, transthoracic echocar- 16 breaths per minute, oxygen satu- concerned the managing teams for diography was performed and found ration of 99% on room air, and blood infectious tenosynovitis. no evidence of infectious endocar- pressure of 102/70 mm Hg. He was By day 4, the patient was afebrile ditis. Later that night, the patient found to have edema, tenderness, and had a leukocytosis of 12.9 k/μL was taken to surgery for incision and and erythema of the wrists bilaterally with neutrophils 86.7%, but im- drainage/debridement of bilateral and left metacarpophalangeal joints provement of erythema, pain, and wrists and left ankle, synovectomy (MCPs) and edematous right MCPs range of motion of involved joints of right wrist, and aspiration of right and left medial ankle. and no tenderness to palpation of shoulder. Findings included abscess The patient had been nonadher- tendons was noted. The inpatient in the left wrist and inflammatory sy- ent with etanercept for 5 month- orthopedic surgery service evalu- novitis and bilateral EPL tendon rup- sand restarted taking the medication ated the patient and did not find ture consistent with RA. Pus from only 2 weeks before presentation. He sufficient evidence necessitating the left ankle had few gram-positive had noticed worsening arthritis for at surgical intervention. cocci in chains with no growth, and least 1 month. His last RA flare was the specimens from both wrists grew approximately 1 year before presenta- Worsening Condition GGS. Aspirate from the left ankle tion. Additional symptoms included On day 6, arthrocentesis of the left was an opaque yellow fluid with 4 days of nausea, nonbloody and wrist was performed secondary to 14,900/mm3 WBC, 30,000/mm3 red nonbilious emesis, left lower quad- worsening of erythema and edema. blood cells (RBC), 97% neutrophils, rant pain, and diarrhea without me- The patient experienced new edema 1% macrophages, 2% lymphocytes, lena or hematochezia. of the left shoulder and leukocy- and 0% monocytes. Aspirate from Initial laboratory studies found tosis continued to trend upward the right shoulder was an opaque 3.2 k/μL white blood cells (WBCs) (15.7 k/μL on day 6). Purulent as- bloody fluid with 10,100/mm3 WBC, with a differential of 11.9% lym- pirate (1.5 mL) was obtained from 40,000/mm3 RBC, 95% neutrophils, phocytes, 4.2% monocytes, 83.3% the fluctuance and tenosynovium of 2% macrophages, 1% lymphocytes, neutrophils, 0.5% eosinophils, and the left wrist. Empiric vancomycin and 1% monocytes. On day 10, sul- 0.1% basophils; 165 k/μL platelets; 1 g IV twice daily and ceftriaxone 2 g fasalazine 500 mg twice a day was 96 mm/h erythrocyte sedimentation IV daily were started and continued initiated for RA. rate (ESR); and 45 mg/dL C-reactive for 3 days. By this point in his hos- Following surgery and contin- protein. The patient was diagnosed pital course, the patient had received ued antibiotics, the patient’s leuko- with viral gastroenteritis and RA flare 1 dose of etanercept. Prednisone and cytosis resolved, and improvement and was admitted for inpatient man- etanercept were previously discon- was seen in all joints with decreased agement secondary to limited ability tinued because of the discovered in- edema, erythema, and pain and in- to care for himself. fection. Blood cultures were drawn creased range of motion. Postop- 32 • FEDERAL PRACTITIONER • FEBRUARY 2015 www.fedprac.com SEPTIC ARTHRITIS Table. Microbiology Hospital Day Collected Sample Source of Sample Result 6 Aspirate Left wrist No growth 6 Pus (aspirate) Tenosynovium at left Group G Streptococcus wrist 6 Stool Feces No growth 7 Blood (x 2) Blood No growth 8 Aspirate Left shoulder No growth 9 Surgical specimen Superficial left wrist Group G Streptococcus 9 Pus (surgical specimen) Deep left wrist Group G Streptococcus 9 Surgical specimen Right wrist Group G Streptococcus 9 Opaque yellow aspirate Left ankle Few gram-positive cocci in (surgical specimen) chains 9 Opaque bloody aspirate Right shoulder No growth (surgical specimen) 22 Blood (x 2) Blood No growth 24 Urine Urine Candida albicans erative recovery was complicated by failed to meet the classification cri- use, extra-articular manifestations of ileus, urinary retention, and fungal teria for PsA.6,7 However, the clini- RA, positive RF, rheumatoid nodules, (Candida albicans) urinary tract infec- cal features of RA and PsA overlap. poor functional capacity, high ESR, tion, all of which resolved without Rheumatoid factor and CCP can be leukopenia, comorbidities (chronic significant complications. The inpa- positive laboratory findings in both lung disease, alcoholism, organic tient rheumatology service restarted RA and PsA.8-14 Tenosynovitis is brain disease, and diabetes), and the prednisone at a lower dose of 20 mg.
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