50 something male was admitted 3 weeks ago for a septic right knee and subsequent endocarditis – MSSA. His knee has no problems, but he needs 6 weeks of IV antibiotics. Social work has worked on finding an intermediate care facility, and they find one! But we get called during rounds because the patient has a fever of 102 (afebrile for 2 weeks.)
Discharge is delayed, and a fever workup begins. The next morning on rounds he has tender hot joints – left elbow and right ankle. He is in obvious pain.
What do you do? What diagnosis do you suspect? Do you start treatment?
We have a clear answer – and a controversy coming.
More tomorrow …
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Well, sadly, I begin questioning compliance and dirty IV access. However, the differential for migrating polyarthritis including rheumatic fever, gonococcal arthritis, Lyme Dz, HIV, Henoch-Schonlein purpura, Hepatitis B/C, and Sarcoidosis. Fever of unknown origin also includes TB and neoplasms.
HPE, admitted 3 wk prior with septic R knee and endocarditis. Febrile 1 week following admission, afebrile 2 weeks, currently febrile again at 102.
I’m assuming that since it was MSSA, the antibiotic used was dicloxacillin. My first thought is to perform and arthrocentesis and do a susceptibility study while changing treatment to IV clindamycin and metronidazole. I would also do sputum studies, detailed medical history and social history. Also, test Hepatitis and C. diff status.
Pseudogout (Calcium Pyrophosphate Deposition Disease) is definitely a possibility. CPDD can present as a febrile oligoarticular disease, given this patient’s recent hospitalization and coexisting medical conditions he is at risk for crystal disease. I would check his synovial fluid and look for intracellular crystals and would try to rule out hematogenic spread of his MSSA.
Common things being common, I would like to know why he got endocarditis in the first place. The fact that it took three weeks to find a rehab joint suggests the guy has no insurance. Perhaps he has no insurance because he is spending all his money on meth.
Check a drug screen on him. Maybe he’s shooting up in his room.
Herx?
Common things being common, gout would be top of the list, but fever of 102 shouldn’t have preceded the onset of synovitis. Inappropriate drug choice, dose or inadequate joint drainage could lead to recurrence but wouldn’t happen on your watch I’m sure and should have recurred in the same joint as well. Antibiotic related drug fever followed by a reactive type arthritis or beginning of a serum sickness. Serum sickness is usually polyarticular though. Therefore, a new infection as suggested by HH seems likely but I’ll give the patient the benefit of doubt and blame a line-associated MRSA infection. Still, don’t see much room for controversy there.
Joint tap to R/O crystal, if neg, broader spectrum until gram/cultures back.