Sternoclavicular septic arthritis, a late complication after surgical tracheostomy: A case report

Abstract

Septic arthritis of the sternoclavicular joint is a rare condition. The diagnosis of sternoclavicular septic arthritis as a late complication of surgical tracheostomy is extremely uncommon. A case study is presented of a man in his 70s who experienced painful swelling of the right sternoclavicular joint three months after elective surgical tracheostomy. The diagnosis was made based on clinical history and examination. The patient achieved a full recovery following antibiotic treatment and surgical drainage. This report is the second documented case of sternoclavicular septic arthritis resulting from surgical tracheostomy.

Keywords:

• Septic arthritis
• sternoclavicular joint
• suppurative arthritis
• surgical management

Introduction

Surgical tracheostomy is a surgical procedure that creates a semi-permanent or permanent connection between the trachea and the skin. It was developed by Trousseau in the nineteenth century to relieve respiratory obstruction in patients with diphtheria [1]. Complications associated with this procedure² can be classified as immediate, occurring during the surgical procedure (such as bleeding, pneumothorax, and pneumomediastinum). Infections and pressure ulcers are considered early postoperative complications, while tracheal stenosis, tracheocutaneous, tracheoinnominate and tracheoesophageal fistulas are considered late postoperative complications.

Septic arthritis of the sternoclavicular joint is a rare clinical condition, accounting for only 1% of all cases of septic arthritis [3]. It can lead to serious complications such as thoracic abscesses, osteomyelitis, mediastinitis and bacteremia [3]. Risk factors for sternoclavicular arthritis include immunosuppressant drugs, intravenous drugs, chronic kidney disease, cancer, chemotherapy, and diabetes mellitus [4]. Although cases in healthy adults have also been described [5], septic arthritis as a late complication of surgical tracheostomy is very unusual. The authors report the second case of septic arthritis of the sternoclavicular joint following surgical tracheostomy.

Patient information

A 72-year-old man presented to the emergency department (ED) with a two-week history of fever, pain, and reduced range of motion in his right upper limb. The patient had been diagnosed with squamous cell carcinoma of the hypopharynx approximately three months ago (cT3N2aM0) and was recommended for radical chemoradiotherapy. He underwent an elective surgical tracheostomy (Bjork flap technique) at the time of diagnosis due to airway risk, which was uneventful. The patient had a medical history of hypopharynx cancer and type 2 diabetes mellitus. He did not smoke, but was a social drinker and denied any intravenous or recreational drug use.

Clinical findings

Upon presentation, he had a fever and normal blood pressure. His oxygen saturation was 99% on air. During the initial examination, he exhibited a reduced range of motion in his right upper limb and a painful, red swelling in the area of the right sternoclavicular joint without fluctuation. The tracheostoma was open, with granulation tissue present at 12 h and minor serohematic drainage. There were no signs of pus or fistulization. An indirect laryngoscopy revealed an ulcerative-vegetative lesion implanted on the medial wall of the left piriform sinus, with left vocal cord paralysis.

The initial baseline blood test showed a hemoglobin level of 8.8 g/dL, normal white cell count, and raised inflammatory markers: C-reactive protein of 129 mg/dL (normal range: <0.5 mg/dL) and sedimentation rate of 103 mm/h (normal range: <15 mm/h). Blood cultures were negative.

Diagnostic assessment

A CT scan with contrast was performed on the head, neck and chest. The results showed effusion in the right sternoclavicular joint, with thickening and increased synovial uptake (Figure 1B and 1D), irregularity of the clavicular and sternal cortical bone (Figure 1A and 1C), with erosion and inflammatory changes in the soft tissues adjacent to the tracheostomy. The contrast-enhanced MRI of the head, neck, and chest revealed a suppurative collection adjacent to the tracheostomy and a fistulous path between the referred liquid collection and the sternoclavicular joint effusion, in the plane immediately above the sternal notch (Figures 2A and 2B).

Figure 1. (A) Coronal and (C) Axial contrast-enhanced CT of the head, neck and chest shows irregularity of the right clavicular and sternal cortical bone (arrows). (B) Coronal and (D) Axial contrast-enhanced CT of the head, neck and chest shows effusion in the right sternoclavicular joint, with thickening and increased synovial uptake.

Figure 2. (A) Coronal and (B) Axial T2 with fat saturation shows suppurative collection adjacent to the tracheostomy and a fistulous path (arrows) between the referred liquid collection and the sternoclavicular joint effusion, in the plane immediately above the notch sternal.

Therapeutic intervention

The patient received treatment with intravenous antibiotics (ceftriaxone 2 g id) and anti-inflammatory drugs (dexamethasone 4 mg id, cetorolac 40 mg 2id and paracetamol 1000 mg 3id). Urgent surgical debridement and drainage of intra-articular content were performed. The pus culture was positive for Prevotella buccae and Streptococcus constellatus, both sensitive to ceftriaxone. Intravenous antibiotics were continued. One week after the initial surgery, the patient’s complaints persisted and inflammatory parameters worsened (C-reactive protein of 220 mg/dL and sedimentation rate of 87 mm/h, with normal white cell count). As a result, the patient underwent a second drainage procedure to remove intra-articular content and a piecemeal resection of necrotic bone (sternal manubrium and clavicular end). Microbiologic analysis revealed a positive result for Escherichia coli, which was sensitive to amoxicillin with clavulanic acid. The patient received intravenous antibiotics (amoxicillin with clavulanic acid, 2.2 g 3 times a day) for three weeks and was discharged four weeks after admission with significant clinical improvement. The patient’s inflammatory parameters were normalized, with a C-reactive protein level of 7.9 mg/dL and a sedimentation rate of 58 mm/h. The anatomopathological study of the resected tissues was negative for malignancy.

The patient completed a six-week course of antibiotics, taking amoxicillin with clavulanic acid 875 + 125 mg twice daily by mouth.

Follow-up and outcomes

Two weeks later, he was evaluated in the outpatient clinic and was found to be symptom-free. Chemoradiotherapy for the squamous cell carcinoma of the hypopharynx began one month later.

Discussion

The authors report a case of septic arthritis of the sternoclavicular joint following surgical tracheostomy. The patient became symptom-free after a six-week course of antibiotics and two surgical interventions. The sequence of events likely began with an infection of the tracheostoma, followed by contiguous infection of the surrounding anatomy, including the right sternoclavicular joint. This is only the second reported case [6]. Septic arthritis of the sternoclavicular joint is a rare and potentially fatal infection. Septic joints that are left untreated can result in a mortality rate of up to 10% and morbidity of over 30%, with abscess formation prevalence as high as 80% [7,8].

It is extremely rare for this condition to be identified as a late complication of surgical tracheostomy. While infection is a relatively common early complication of surgical tracheostomies, it typically involves infection of the skin around the stoma rather than the adjacent joint [2]. The presentation of this condition is usually indolent or subacute [9]. The clinical features of the reported case include fever, chest pain localized to the joint, shoulder pain, reduced upper limb mobility, and local erythema [3]. Leukogram findings were consistently normal [10]. Risk factors most commonly associated with this entity are cancer and immunosuppression [11,12]. In this case, the patient had type 2 diabetes mellitus and hypopharyngeal carcinoma.

Staphylococcus aureus is responsible for up to two-thirds of cases [3], with the remaining cases caused by Pseudomonas aeruginosa (10%), Brucella melitensis (9%), Escherichia coli (5%), and Mycobacterium tuberculosis (<5%). The microorganisms identified in this case were Prevotella buccae, Streptococcus constellatus, and Escherichia coli. Prevotella buccae is a gram-negative anaerobic bacterium that is part of the oral, urogenital, and intestinal microbiota. Respiratory tract infections are commonly associated with it. Additionally, it has been linked to cases of osteomyelitis and periodontal disease [13]. Streptococcus constellatus is a gram-negative coccus that is also present in the oral, urogenital, and intestinal microbiota. It is typically associated with abscess formation in the upper half of the body and respiratory tract [14]. In contrast, Escherichia coli is a gram-negative bacillus found in the intestinal microbiota. Polymicrobial septic arthritis is a relatively rare condition that is often associated with gastrointestinal and genitourinary infections [15]. In cases where small and intermediate joints, such as the sternoclavicular joint, are affected, the condition is more likely to be polymicrobial and caused by Streptococcus, Eikenella, or anaerobic bacteria [16].

To diagnose sternoclavicular arthritis, a CT and MRI of the head, neck, and chest should be performed to determine the extent of the infection and associated bone destruction. Bone scintigraphy can aid in distinguishing between infection and degenerative changes in the joint [17].

The initial step in the therapeutic approach should be intravenous antibiotics. It is recommended to use broad-spectrum antibiotics in the beginning, followed by spectral reduction after microbiological results. The most commonly used antibiotics are cephalosporins, vancomycin, and fluoroquinolones [18]. The duration of treatment varies depending on the severity of the infection. When there is bone involvement, it is recommended to undergo four to six weeks of treatment [19].

Surgical intervention is especially relevant in cases where there is bone involvement, abscess, or a collection of periarticular fluid [20]. En bloc joint resection is the most effective procedure, although other procedures such as simple debridement and piecemeal resection of the affected tissue may also be used. Following the surgical procedure, a dressing with negative pressure should be applied, particularly in more extensive approaches, to promote the formation of granulation tissue and closure of the surgical wound. Hyperbaric oxygen therapy is an alternative treatment option [3]. Postoperative complications may include empyema, pleural effusion, abscess, mediastinitis, and sepsis [21,22]. In our case, high-dose antibiotics and two surgical procedures were used to manage the condition, resulting in complete resolution of symptoms.

Conclusion

Septic arthritis of the sternoclavicular joint is a rare condition, accounting for only 1% of all cases of septic arthritis. It is an extremely uncommon complication of surgical tracheostomy. This condition can have life-threatening complications that require aggressive medical management and surgery.

Informed consent statement

Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.

Disclosure statement

The authors report there are no competing interests to declare.