Henry Ford Hospital Medical Journal

Volume 22 | Number 4 Article 2

12-1974

Pseudomonas Arthritis and Osteomyelitis inHeroin Addiction: Report of Three CasesPaul M. Ross

Robert C. Nestor

Kent K. Wu

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Recommended CitationRoss, Paul M.; Nestor, Robert C.; and Wu, Kent K. (1974) "Pseudomonas Arthritis and Osteomyelitis in Heroin Addiction: Report ofThree Cases," Henry Ford Hospital Medical Journal : Vol. 22 : No. 4 , 187-194.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol22/iss4/2

Henry Ford Hosp. Med. Journal

Vol . 22, No. 4, 1974

Pseudomonas Arthritis and Osteomyelitis in Heroin Addiction

Report of Three Cases

Paul M . Ross, M D , Robert C. Nestor, DO and Kent K. W u , M D *

r S E L J D O M O N A S a r t h r i t i s w i t h o s ­

t e o m y e l i t i s has b e e n r e c o g n i z e d w i t h i n ­

c r e a s i n g f r e q u e n c y in b o t h m e d i c a l a n d

su rg i ca l pa t ien ts . " - ^ " '^ H e r o i n a d d i c t s

s e e m t o b e p a r t i c u l a r l y p r o n e t o t h e d e ­

v e l o p m e n t o f sep t i c a r t h r i t i s as a c o m p l i ­

c a t i o n o f t h e i r hab i t ' - " --"

Pseudomonas-caused sternoclavicular ar­thritis and osteomyelitis has received little at­tention in the medical literature. The authors present three cases including one case of bilateral sternoclavicular joint involvement. Prompt recognition, operative debridement, and institution of adequate chemotherapy re­sult in dramatic clinical response.

•Depar tment of Orthopaedic Surgery, Henry Ford Hospital

Address reprint requests to Dr. P.M. Ross, Henry Ford Hospi ta l , 2799 West Grand Boulevard, Detroi t , M l 48202.

At H e n r y Fo rd Ford H o s p i t a l , w e have

f o u n d P s e u d o m o n a s a e r u g i n o s a t h e

p r e v a i l i n g o f f e n d e r in sep t i c a r t h r i t i s . It

has b e e n c u l t u r e d f r o m d i sc spaces o f

t h e ce rv i ca l a n d l u m b a r s p i n e , sac ro i l i ac

j o i n t , p u b i c s y m p h y s i s , isch ia l t u b e r o ­

s i ty , r i bs , h i p j o i n t , a c r o m i o c l a v i c u l a r

j o i n t , l o w e r s t e r n u m , a n d s t e r n o c l a v i c u ­

lar j o i n t . "

Case R e p o r t s

Case 1. C. C , a 39-year-old hero in addict, was admit ted to Henry Ford Hospital on Au­gust 10,1970. Three weeks pr ior to admission, left shoulder pain had been treated by local cort isone inf i l t rat ion by his private physician w i thou t relief of symptoms. The patient was seen in the Emergency Room the day before admission compla in ing of left pleuri t ic chest pain and l imitat ion of mot ion of his left shoulder. He was diaphoret ic and had a temperature of 40°C. The wh i te b lood cell count was 15,600 per m m ' w i th a shift to the left. A sputum stain revealed gram posit ive d ip lococc i . He was diagnosed as having a left lower lobe pneumonia conf i rmed by X-ray and ampici l l in t r ihydrate chemotherapy was begun. He was admit ted the fo l lowing day because of pleurisy.

Physical examinat ion revealed a tempera­ture of 38.8°C, b lood pressure of 120/70, pulse 120 per minute , and respiration of eighteen per minute . There was non-specif ic lym-

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Figure 1a A radiolucent lesion is visualized at the medial end of the left clavicle.

«

Figure lb Microscopic section revealing acute and chronic osteomyelitis.

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P s e u d o m o n a s Arthrit is a n d Os teomye l i t i s in Hero in Add ic t ion

phadenoplasia involv ing the cervical and axil­lary nodes bilaterally. Auscultat ion of the lungs revealed rales over the left lower lobe. Examination of the heart revealed a sinus tachycardia. The liver was quest ionably pal­pable at the right costal margin. The skin over both arms and legs revealed mul t ip le scars f rom inject ions. The left shoulder revealed de l to id , supraspinatus, and infraspinatus at­rophy, and the patient was unable to ful ly ab­duct his left arm. There was tenderness over the lef t s te rnoc lav icu la r j o i n t , but no erythema or increased warmth .

Laboratory examinat ion revealed hemoglo­bin of 11.6 grams per 100 mi l l i l i ters, w i i i te b lood cell count of 8,100 per m m ' wi th a nor­mal d i f ferent ia l . Routine laboratory studies were w i th in normal l imits. The febr i le ag­glut inins revealed Salmonella typhosa 0 titer of 1:320, Salmonella paratyphi H titer of 1:640, Salmonella paratyphi A of 1:40, Sal­monel la paratyphi B of 1:80, and the Brucella abortus t i ter was negative. The hemoglob in electrophoresis revealed A type only. The serum was negative for Australian ant igen. Chest f luoroscopy produced evidence of pleural f lu id and partial collapse of the left lower lobe. A rout ine x-ray of the sternum and left clavicle was unremarkable. Lamino­

grams of the left sternoclavicular jo int per­formed five days after admission (8/15/1970) revealed a localized area of radiolucency w i thou t evidence of bone destruct ion in the medial end of the clavicle (see f igure l a ) . A lung scan was predictably posit ive for a de­creased uptake of the left lower lobe.

Dur ing the hospital ization per iod , results of b l ood , ur ine, stool cul tures, and skin tests were consistently negative, but a low-grade fever persisted. Use of antibiot ics was discon­t inued upon admission to the hospital and w i thhe ld pending diagnosis, despite the pneumonic process. On August 24, an open biopsy and resection were done of the proxi­mal left clavicle and articular disc. A gelati-nuous l ight-brown material was found sub-cort ical ly w i t h granulat ion tissue in the s t e r n o c l a v i c u l a r j o i n t . Pseudomonas aeruginosa was isolated f rom the tissue, and under microscopy revealed actue and chronic osteomyeli t is (see f igure l b ) . Because of postoperat ive clinical improvement , it was the op in ion of the infectious disease consul­tant that antibiosis should be w i thhe ld and a localized osteomyeli t is cou ld be cured by the operative procedure. The patient was dis­charged on August 31 as asymptomatic, w i th roentgenogram showing resolut ion of the

Figure 1c Roentgenogram revealing destruction of the right sternoclavicular joint. The left medial clavicle

has previously been resected.

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R o s s , Nestor a n d W u

Figure I d There is suggestion of a sequestrium of the right sternoclavicular joint. New bone formation is

noted in the left sternoclavicular joint.

pneumon ic process. He was readmit ted three months later, November 30, because of recurrent pain in the left sternoclavicular area and the onset of pain over the right sterno­clavicular jo in t . Admission tests were hemo­g lob in , 13.9 grams per 100 mi l l i l i ters; wh i te b lood cell count 6,000 per m m ' w i th 59% po lymorphonuc lear leukocytes, 37% lympho­cytes, 3% monocy tes , , and 1 % basophi l . Sedimentat ion rate was 37 mm per hour . Ag­glut inins were w i th in normal l imits. A ur ine drug screen was negative for all narcotics.

Physical examinat ion revealed a b lood pressure of 110/60, pulse of 80 per minute , tempera ture of 37.2 C, and respirat ion eighteen per minu te . Physical examinat ion showed no abnormali t ies of the ear, nose, throat, lungs, abdomen or heart. The right poster ior cervical and axillary nodes bilater­ally were palpable. There was palpable ten­derness over the manubr ium and right ster­noclavicular jo int . The patient was unable to abduct the ipsilateral arm ful ly because of the sternoclavicular pain.

On December 3, open bone biopsies of the tender right sternoclavicular jo int and man­ubr ium were per fo rmed under local anes­thesia. Blood cultures had been consistently negative, but cultures of both biopsied areas revealed Pseudomonas aeruginosa and Cen-tamycin chemotherapy was begun. A prog­ress laminogram on December 21 revealed increased destruct ion of the right sterno­clavicular jo in t (Figure 1c). When laminog­rams one mon th later (Figure I d ) , suggested a sequestrum of the right medial clavicle, it was felt that the osteomyeli t is was too dissemi­nated for surgical t reatment. The patient was discharged asymptomatic after eight weeks of

Centamycin chemotherapy. Two months after discharge he was still asymptomat ic, w i th sedimentat ion rate of 15 mi l l imeters per hour, Laminogram was suggestive of persistent os­teomyeli t is (Figure le). He was subsequently lost to fo l low-up.

Case 2. B. C , a 24-year-old male hero in ad­dict was admit ted to the Henry Ford Hospital on October 25,1972, compla in ing of pain and swel l ing of the right sternoclavicular jo in t . The year before, he had been hospital ized f rom December 2-20 for left sacroiliac os­teomyel i t is. Cultures of the urine and b lood were negative. Aspirat ion of the sacroiliac jo in t had been unreward ing, and the patient had been given empirical ly oral Dicloxaci l l in and intramuscular Centamycin. He was dis­charged asymptomatic after only two weeks of chemotherapy. He remained asymptomatic unt i l three weeks pr ior to his current admis­sion when he noted pain, swel l ing, redness, and l imitat ion of adbuct ion of his right arm.

Physical examination revealed a b lood pressure of 120/70, pulse 90 per minu te , temperature of 37.2°C, and respiratory rate of 18/per minu te . There was a Grade l l /VI sys­tol ic murmur at the left sternal border , and the second heart sound was normal ly split. No organomegaly was noted. There was bilat­eral cervical lymphadenoplasia and a 5 x 6 cm area of swel l ing and tenderness over the right sternoclavicular jo in t . He was unable to ful ly abduct his r ight arm above the hor izontal po­si t ion. Both sacroiliac joints were unremark­able.

Laboratory test results were hemoglob in of 14.3 grams per 100 mil l i l i ters, and whi te b lood cell count of 6,200 m m ' wi th 49% polymor-

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P s e u d o m o n a s Arthrit is and Os teomye l i t i s in Hero in Add ic t ion

Figure l e Persistent osteomyelitis of the right sternoclavicular joint. The left sternoclavicular joint appears to

have healed with new bone formation.

phonuclear leukocytes, 42% lymphocytes, 7% monocytes, and 2% atypical lymphocytes. Sedimentat ion rate was 40 m m per hour. Ur ine drug screen revealed the presence of c o d e i n e , m o r p h i n e , h e r o i n , and phenothiazines. Blood drug screen revealed only phenobarb i ta l . Blood cultures were negative. Chest roentgeonogram was nega­tive and rout ine f i lms of the right sterno­clavicular jo int were unremarkable.

Pseudomonas ant i toxin levels were ele­vated to a d i lu t ion greater than 4,096 and the organism was cul tured f rom an aspirate of the right sternoclavicular jo int . Intramuscular chemotherapy w i th tobramycin was ini t iated. Two days after admission, the patient under­went an incision and debr idement w i th resec­t ion of the proximal clavicle of the right ster­noclavicular jo in t , wh ich was packed open . Seropurulent drainage and granulat ion tissue was retrieved f rom the jo int , and subsequent cultures were posit ive for Pseudomonas aeruginosa.

The postoperat ive course was compl icated by low-grade fever and tachycardia. Chest roentgenograms, taken 12 days postopera­t ively, revealed a poor ly def ined density over

the right upper lobe. Radiographs conf i rmed an extrapleural retroclavicular mass (Figure 2). This apparent soft tissue swel l ing resolved uneventful ly . The patient was discharged asymptomatic after six weeks of Tobramycin therapy, his w o u n d having closed w i thou t in­c ident .

When seen three weeks later, he had no tenderness, l imitat ion of mo t ion , or drainage f rom the operative site. Sedimentat ion rate was 12 mm per hour . He was subsequently lost to fo l l ow-up .

Case 3. A. C , a 21-year-old male hero in ad­dic t , was admit ted to Henry Ford Hospital on January 30, 1974, w i th pain over the right ster­noclavicular area. Three months previously he had been admit ted to another hospital compla in ing of nuchal , r ight supraclavicular and bilateral shoulder pain. He had been treated for a viral pneumonia pr ior to that admission, but no antibiot ics were adminis­tered. He was diagnosed as having os­teomyel i t is of the right sternoclavicular jo in t , but he left the hospital before an open biopsy could be pe r fo rmed . He was seen in the or­thopaedic cl inic on December 27, where laminograms revealed f indings compat ib le

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Figure 2 Lateral radiograph of the sternum indicating a retroclavicular mass.

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P s e u d o m o n a s Arthritis and Osteomye l i t i s in Hero in Addic t ion

Figure 3 Laminogram of case 3 consistent with osteomyelitis of the right sternoclavicular joint.

wi th osteomyelit is of the right sternoclavicu­lar jo int , (Figure 3). This f ind ing was con­f i rmed by bone scan.

Physical examination revealed a b lood pressure of 128/84, pulse 88 per minute , temperature of 36.8°C and respiratory rate 20 per minute . Examination of the ear, nose, throat, lungs, heart, and abdomen were nega­tive. Needle marks were in evidence over both upper extremit ies. No cervical lym­phadenopathy was appreciated. A l though there was mi ld tenderness over the right ster­noclavicular jo in t , the patient was able to ful ly abduct his arm.

Laboratory examinat ion revealed hemoglo­bin of 15.6 grams per 100 mil l i l i ters, sedimen­tat ion rate of 6 mil l imeters per hour, wh i te b lood cell count 5,800 per m m ' w i th 55% polymorphonuclear leukocytes, 32% lympho­cytes, 3% atypical lymphocytes, 3% mono­cytes, and 6% eosinophi ls, and 1 % basophi l . Routine laboratory studies were wi th in nor­mal l imits. A chest roentgenogram was nor­mal. All b lood cultures were negative. On February 4, the f i f th day of hospital izat ion, the patient underwent resection of the medial end of the right clavicle. No evidence of acute inf lammat ion was seen by microscopic ex­aminat ion, but Pseudomonas aeruginosa was isolated f rom the specimen and consequent ly Gentamicin chemotherapy was ini t iated.

The w o u n d healed uneventfu l ly , and the patient was discharged asymptomatic after six

weeks of Gentamicin therapy. Routine views of the clavicle obta ined two weeks after dis­charge disclosed uneventful healing of the re­sected right sternoclavicular jo int . Sedimenta­t ion rate at that t ime was 10 mm per hour. The patient was subsequently lost to fo l l owup .

D i s c u s s i o n

In r e v i e w i n g l i t e r a t u r e in t h e Engl ish

l a n g u a g e , w e w e r e ab le t o d o c u m e n t

less t h a n 50 cases o f P s e u d o m o n a s ar­

t h r i t i s a n d o s t e o m y e l i t i s , a n d o n l y 10

cases i n v o l v i n g t h e s t e r n o c l a v i c u l a r

j o i n t . T o t h e best o f o u r k n o w l e d g e ,

n o r e p o r t o f P s e u d o m o n a s s t e r n o ­

c lav i cu la r o s t e o m y e l i t i s has a p p e a r e d in

t h e o r t h o p a e d i c l i t e r a t u r e . C e r t a i n l y , at

t h e H e n r y Fo rd H o s p i t a l , P s e u d o m o n a s

is t h e p r e v a l e n t o r g a n i s m in t h e inc reas­

i n g n u m b e r s o f p y a r t h r o s e s d i a g n o s e d in

h e r o i n a d d i c t s .

T h e r e are severa l p o s s i b l e e x p l a n a ­

t i o n s . First o f a l l , P s e u d o m o n a s is p res ­

e n t in t h e s t o o l o f 10% o f t h e n o r m a l

p o p u l a t i o n . ' I n d e e d , t h i s o r g a n i s m can

o f t e n be c u l t u r e d f r o m t a p w a t e r , w h i c h

is o t h e r w i s e q u i t e f r e e f r o m m i c r o o r ­

g a n i s m s . It has b e e n p o s t u l a t e d t h a t a d ­

d i c t s h a p h a z a r d l y " s t e r i l i z e " d i r t y n e e ­

d les by r u n n i n g h o t tap w a t e r o v e r t h e m .

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They may then innoculate themselves wi th the organism. We may further speculate that the availability of ant ibi­otics " o n the street" leads many addicts to use them in inadequate doses for the numerous abscesses they incur. Cer­ta in ly , the metabo l ic versat i l i ty of Pseudomonas makes it an opportunist ic organism requir ing little nutr i t ion and able to resist most antibiot ics. All three patients were long term addicts and two had a history of either previous or con­comitant pneumonia. This combinat ion has been reported.

The empirical use of antibiotics should be discouraged, as evident in patients 1 and 2. It may contr ibute directly to Pseudomonas superinfect ion. Screening laboratory tests generally are not diag­nostic. The whi te b lood cell count and sedimentation rate may be elevated in acute cases, but can be modi f ied by in­judicious use of antibiotics and chronic-ity. However a check of Pseudomonas antitoxin levels may be extremely help­fu l . The yield of positive b lood cultures generally is not high. All our cases were

negative. Kaftan recently described a modi f ied roentgenographic view which el iminates d istor t ion of the sterno­clavicular jo int and which might prove useful in the diagnosis of early os­teomyel i t is . On occasion aspirat ion might be f ru i t fu l , but open biopsy should be used in chronic cases to cul­ture the organism f rom the granulation tissue. Interestingly, in all our patients, pain was prompt ly alleviated postopera­tively. Centamycin is the drug of choice in Pseudomonas infections. We use a dosage of 3 mg/kg for six weeks, closely fo l lowed wi th serial audiograms and b lood creatinine determinat ions. No ad­verse affects were encountered. In one case, we used an experimental drug, Tobramycin, wi th good results.

Summary

Pseudomonas sternoclavicular os­teomyelit is is not dif f icult to diagnose providing one has a high index of suspi­c ion. Open debr idement is advised for culture of organism and may relieve pain.

R e f e r e n c e s

1. Schroeder SA, Catino D, Tolla P and Finland M : Chronic Pseudomonas os­teomyel i t is . / Bone j o i n t Surg 52-A: 1611-7, 1970

2. Waldevogal FA, Medof f C and Swartz M N : Osteomyel i t is : A review of clinical features, therapeut ica l considerat ions and unusual aspects, (first of three parts). New Eng / Med, 282: 198-206, 1970

3. Waldevogal FA, Medof f G and Swartz M N : Osteomyel i t is : A review of clinical features, therapeut ica l considerat ions and unusual aspects, ( third of three parts). New £ng ] Med , 282: 316-22, 1970

4. Gold in RH, Chow AW, Edwards JE and Guze LB: Sternoarticular septic arthrit is in hero in users. New Eng j M e d 289:616-8, 1973

5. Gricco M H : Pseudomonas arthrit is and osteomyel i t is. J Bone Joint Surg 54-A: 1693-1704, 1972

6. Salahuddin N l , Madhavan T, Fisher EJ, Cox F, Q u i n n EL and Eyler W R : Pseudomonas osteomyel i t is, radiologic features. Radiology 109: 41-7, 1973

7. Schre iberSN: Extremity compl icat ions of heroin addic t ion, y Sone Joint Surg 54-A: 1578-9, 1972

8. Tindel JR and Crowder JG: Septic arthrit is due to Pseudomonas aeruginosa. JAMA, 218: 559-61, 1971

9. Kaufer H, Spengler D M , Noyes FR and Louis DS: Or thopaedic implicat ions of the drug subcul ture.y Trauma 14:853-66, 1974

10. Kattan KR: Mod i f ied view for use in roentgeno-examinat ion of the sterno­clavicular jo ints. Radiology 108:8, 1973

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