Comments on: A patient care puzzle

By: 3+speckled

3+speckled — Tue, 24 Feb 2009 03:38:36 +0000

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.

By: CHenry

CHenry — Tue, 24 Feb 2009 02:11:17 +0000

Herx?

By: The Happy Hospitalist

The Happy Hospitalist — Mon, 23 Feb 2009 21:09:55 +0000

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.

By: Mehmet Karaca

Mehmet Karaca — Mon, 23 Feb 2009 17:34:22 +0000

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.

By: Jared

Jared — Mon, 23 Feb 2009 16:59:13 +0000

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.