Septic Arthritis of the Manubriosternal Joint
2007; Elsevier BV; Volume: 83; Issue: 3 Linguagem: Inglês
10.1016/j.athoracsur.2006.07.032
ISSN1552-6259
AutoresEdward W.K. Peng, Graham McKillop, Sai Prasad, W. S. G. Walker,
Tópico(s)Orthopedic Surgery and Rehabilitation
ResumoPyarthrosis of the manubriosternal joint is exceedingly rare. Its rarity defies an early diagnosis, and other causes of chest pain would normally be ruled out first. We describe a patient with a short history of chest pain, pyrexia, and raised inflammatory markers. A destroyed manubriosternal joint with a large abscess was found during surgical exploration. This case illustrates an unusually rapid development of septic arthritis involving a fibrocartilaginous joint in an otherwise healthy young man. Nine other cases have been described in the literature and are reviewed. Early diagnosis followed by adequate surgical drainage and antibiotic therapy led to a good outcome. Pyarthrosis of the manubriosternal joint is exceedingly rare. Its rarity defies an early diagnosis, and other causes of chest pain would normally be ruled out first. We describe a patient with a short history of chest pain, pyrexia, and raised inflammatory markers. A destroyed manubriosternal joint with a large abscess was found during surgical exploration. This case illustrates an unusually rapid development of septic arthritis involving a fibrocartilaginous joint in an otherwise healthy young man. Nine other cases have been described in the literature and are reviewed. Early diagnosis followed by adequate surgical drainage and antibiotic therapy led to a good outcome. Pyarthrosis of the manubriosternal joint is extremely rare. Sternal osteomyelitis and septic arthritis of the sternoclavicular joint are two other uncommon entities involving the sternum, but both have been reported from time to time in the literature. A literature search which includes MEDLINE and OLDMEDLINE under the keywords manubriosternal or sternomanubrial with pyarthrosis or septic arthritis revealed nine other reports of manubriosternal septic arthritis. We describe a young patient with this rare infection and present a review of the literature in order to clarify its clinical features, epidemiology, investigation, and management.A 28-year-old man was referred to the cardiothoracic unit with a mass at the manubriosternal area. He was a well-built, active rugby player representing a local club and also worked as a joiner. Before his admission, he presented 10 days earlier to the emergency department with chest pain secondary to a “strain” endured at work after heavy lifting. He received opiate analgesia and was discharged home.He was subsequently admitted with worsening central chest pain and swelling over the manubriosternal area. The symptoms were aggravated by any movement, stooping down particularly. Systems review was unremarkable, including any chest or urinary symptom. He had previously undergone two elective open distal clavicle resections, 7 months and 1 year previously, both with uneventful recovery. He was otherwise fit without significant medical history. He denied any substance abuse or risk factor for HIV infection. He was a nonsmoker, and there was no history of alcohol excess. There was no recent travel history.On admission, he had temperature 38.9°C, white cell count of 11.7 × 109/L, C-reactive protein level of more than 300 mg/L, and an erythrocyte sedimentation rate of 96 mm/h. He had a tender, fluctuant swelling over the manubriosternal joint. A chest roentgenogram (posteroanterior view) showed left lower lobe collapse. An echocardiogram, which was requested to exclude pericarditis, showed a mass impinging on the right ventricle. A computed tomography (CT) chest scan showed a 7-cm inflammatory mass centered on the manubriosternal joint with mixed fluid and gas density. The mass extended anteriorly into the subcutaneous tissue and posteriorly into anterior mediastinum but did not directly involve the heart or pericardium. The manubriosternal joint looked irregular and widened (Fig 1). There was a partial collapse of the left lower lobe with small bibasal effusions.He underwent surgical exploration and evacuation of the inflammatory collection. A transverse incision was made over the presternal area. The entire manubriosternal joint was destroyed (Fig 2). A large abscess (approximately 200 mL) was found at the presternal, peristernal, and retrosternal space through the destroyed manubriosternal joint. The abscess cavity was curetted and necrotic tissue was débrided. The wound was left open and packed with gauze roll. Further dressing changes were performed under general anesthesia and subsequently under self-administered nitrous oxide.Fig 2The appearance of the destroyed manubriosternal joint after drainage of a large abscess and débridement of the necrotic tissue (left). Subsequent well-healed wound through secondary intention at 6 months’ follow-up (right).View Large Image Figure ViewerDownload (PPT)The patient’s postoperative recovery was uneventful. He received a 2-week course of intravenous antibiotics (vancomycin converted to flucloxacillin, ciprofloxacin, and metronidazole) with a subsequent oral regimen for further 4 weeks.One blood culture sample grew diphtheroids of doubtful significance. Several cultures including pus from the joint, blood, urine, and stool failed to yield any organism. Microscopic examination of the drained abscess revealed many pus cells but no organism. Test for acid-fast bacillus was negative.He was discharged home with regular wound dressing under the care of the district nurse until 6 weeks after the initial operation. He was well and the wound had healed completely at 6 months’ follow-up (Fig 2, right).CommentEpidemiology and Clinical FeaturesSeptic arthritis of the manubriosternal joint is rare [1Glushakow A.S. Carlson D. DePalma A.F. Pyarthrosis of the manubriosternal joint.Clin Orthop Relat Res. 1976; 114: 214-215PubMed Google Scholar, 2Borgmeier P.J. Kalovidouris A.E. Septic arthritis of the sternomanubrial joint due to Pseudomonas pseudomallei.Arthritis Rheum. 1980; 23: 1057-1059Crossref PubMed Scopus (12) Google Scholar, 3Gruber B.L. Kaufman L.D. Gorevic P.D. Septic arthritis involving the manubriosternal joint.J Rheumatol. 1985; 12: 803-804PubMed Google Scholar, 4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar, 5Van Linthoudt D. De Torrente A. Humair L. Ott H. Septic manubriosternal arthritis in a patient with Reiter’s disease.Clin Rheumatol. 1987; 6: 293-295Crossref PubMed Scopus (6) Google Scholar, 6Chattopadhyay B. Jeremiah J.D. Sadler G. An unusual presentation of salmonella infection.J Infection. 1990; 20: 265-266Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 7Rubinstien E. Slavin J. Thymic abscess with bacteremia and manubriosternal pyarthrosis in a geriatric patient.Chest. 1993; 103: 962-964Crossref PubMed Scopus (12) Google Scholar, 8Kruper L.L. Low D.W. Bucky L.P. Immediate pectoralis flap closure following septic arthritis of the manubriosternal joint.Plast Reconstr Surg. 2001; 107: 997-999Crossref PubMed Scopus (3) Google Scholar, 9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar] (Table 1), and its occurrence in an otherwise healthy adult is unusual. It is more common in men (70%). The median age of presentation is 42.5 (range, 20 to 75; mean, 44.7). Predisposing factors are seen in 50% of the cases. Risk factors include intravenous drug abuse, immunosuppressive drugs, inflammatory joint disease, and primary source of infection elsewhere [3Gruber B.L. Kaufman L.D. Gorevic P.D. Septic arthritis involving the manubriosternal joint.J Rheumatol. 1985; 12: 803-804PubMed Google Scholar, 4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar, 5Van Linthoudt D. De Torrente A. Humair L. Ott H. Septic manubriosternal arthritis in a patient with Reiter’s disease.Clin Rheumatol. 1987; 6: 293-295Crossref PubMed Scopus (6) Google Scholar, 8Kruper L.L. Low D.W. Bucky L.P. Immediate pectoralis flap closure following septic arthritis of the manubriosternal joint.Plast Reconstr Surg. 2001; 107: 997-999Crossref PubMed Scopus (3) Google Scholar, 9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar].Table 1Review of Case Reports on Manubriosternal Septic ArthritisGender, AgeAssociated ConditionClinical/ Laboratory FeaturesMicrobiologyManagementGlushakow [1Glushakow A.S. Carlson D. DePalma A.F. Pyarthrosis of the manubriosternal joint.Clin Orthop Relat Res. 1976; 114: 214-215PubMed Google Scholar]M, 42NoneSternal pain, feverWCC 10 700/mm3, ESR 52 mm/hPus: Coag +ve S. aureusBlood culture negativeIV antibioticsSurgical drainageBorgmeier [2Borgmeier P.J. Kalovidouris A.E. Septic arthritis of the sternomanubrial joint due to Pseudomonas pseudomallei.Arthritis Rheum. 1980; 23: 1057-1059Crossref PubMed Scopus (12) Google Scholar]M, 49None (except travel abroad)Sternal painApyrexiaWCC 11 600/mm3, ESR 38 mm/hPus: P. pseudomalleiIV antibioticPus aspiration, spontaneous drainageGruber [3Gruber B.L. Kaufman L.D. Gorevic P.D. Septic arthritis involving the manubriosternal joint.J Rheumatol. 1985; 12: 803-804PubMed Google Scholar]M, 38SLECorticosteroid useSeptic arthritis of the kneeAnterior chest wall painApyrexiaWCC 61 000/mm3, ESR 49 mm/hPus: Coag +ve S. aureusIV antibioticsSurgical drainageLopez-Longo [4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar]M, 20Heroin userSternal pain, feverWCC 10 000/mm3, ESR 40 mm/hBlood/joint material: Coag +ve S. aureusIV antibiotic onlyVan Linthoudt [5Van Linthoudt D. De Torrente A. Humair L. Ott H. Septic manubriosternal arthritis in a patient with Reiter’s disease.Clin Rheumatol. 1987; 6: 293-295Crossref PubMed Scopus (6) Google Scholar]M, 43Reiter diseaseUpper chest pain, pyrexia, WCC 11 700/mm3, ESR 113 mm/hBlood/turbid synovial fluid: Coag +ve S. aureusIV antibiotic onlyChattopadhyay [6Chattopadhyay B. Jeremiah J.D. Sadler G. An unusual presentation of salmonella infection.J Infection. 1990; 20: 265-266Abstract Full Text PDF PubMed Scopus (4) Google Scholar]M, 55NoneSternal painPus: S. brandenburgStool C+S negativeAntibiotic onlyRubinstien [7Rubinstien E. Slavin J. Thymic abscess with bacteremia and manubriosternal pyarthrosis in a geriatric patient.Chest. 1993; 103: 962-964Crossref PubMed Scopus (12) Google Scholar]F, 75NoneSternal pain, pyrexiaWCC 15 000/mm3, ESR 121 mm/hComplicated by thymic abscessBlood/pus: Coag +ve S. aureusIV antibioticsSurgical exploration, thymus removalKruper [8Kruper L.L. Low D.W. Bucky L.P. Immediate pectoralis flap closure following septic arthritis of the manubriosternal joint.Plast Reconstr Surg. 2001; 107: 997-999Crossref PubMed Scopus (3) Google Scholar]F, 57SLE, rheumatoid arthritisCorticosteroid, azathioprine useCellulitisMiddle chest pain, low grade temperature, diffuse arthralgiaBlood/pus: Coag +ve S. aureusIV antibioticsSurgical drainage, pectoralis flap closureSinha [9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar]F, 40Psoriatic arthropathyAnterior chest wall pain, normal WCC, ESR, CRPNegative cultureIV antibioticsSurgical drainage and pectoralis flap closurePeng [this study]M, 28NoneSternal pain, feverWCC 11,700/m3, CRP >300 mg/L, ESR 86 mm/hNegative cultureIV antibioticsSurgical drainageCRP = C-reactive protein; ESR = erythrocyte sedimentation rate; IV = intravenous; P. pseudomallei = Pseudomonas pseudomallei; S. aureus = Staphylococcus aureus; S. brandenburg = Salmonella brandenburg; SLE = systemic lupus erythematosus; +ve = positive; WCC = white cell count. Open table in a new tab The clinical course can be acute (days), as seen in our case, or subacute over months [6Chattopadhyay B. Jeremiah J.D. Sadler G. An unusual presentation of salmonella infection.J Infection. 1990; 20: 265-266Abstract Full Text PDF PubMed Scopus (4) Google Scholar]. In an inadequately treated case, a clinical course of longer than 18 months has been reported [9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar]. Anterior chest wall pain as a result of suppurative involvement is a typical presentation but may be confused with other more common causes, such as costochondritis, especially in the presence of underlying systemic inflammatory joint disorder. Fever is usually present (60% of patients) but may be occasionally absent, especially with the use of steroids [2Borgmeier P.J. Kalovidouris A.E. Septic arthritis of the sternomanubrial joint due to Pseudomonas pseudomallei.Arthritis Rheum. 1980; 23: 1057-1059Crossref PubMed Scopus (12) Google Scholar].The source of this rare infection is conjectural. Both local and hematogenous spread from elsewhere has been proposed. The primary focus of bacteremic spread has included septic knee arthritis, cellulitis, and gastrointestinal infection [3Gruber B.L. Kaufman L.D. Gorevic P.D. Septic arthritis involving the manubriosternal joint.J Rheumatol. 1985; 12: 803-804PubMed Google Scholar, 6Chattopadhyay B. Jeremiah J.D. Sadler G. An unusual presentation of salmonella infection.J Infection. 1990; 20: 265-266Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 8Kruper L.L. Low D.W. Bucky L.P. Immediate pectoralis flap closure following septic arthritis of the manubriosternal joint.Plast Reconstr Surg. 2001; 107: 997-999Crossref PubMed Scopus (3) Google Scholar]. Locally deranged joint anatomy predisposes to septic arthritis hence underlying inflammatory joint disorder is a risk factor. Manubriosternal joint involvement in seronegative arthritides is well reported.Although the underlying condition in our patient leading to manubriosternal pyarthrosis remains elusive, onset of chest pain after heavy lifting and subsequent subclinical hematoma formation may have led to superimposed infection.Relevant AnatomySeptic arthritis is far more common in the synovial joint than in other types of joints. The manubriosternal joint is a secondary cartilaginous joint (symphysis) that represents a fibrocartilaginous union of the lower edge of the manubrium and the upper edge of the sternum, each covered by a hyaline cartilage. Suppurative involvement of the intervertebral discs (a symphysis) is well established. Although approximately 100 cases have been reported, involvement of the symphysis pubis is still uncommon [10Sinha S. Sinha A. Nagarajah K. et al.Septic arthritis of the pubic symphysis: review of 100 cases.Medicine (Baltimore). 2003; 82: 340-345Crossref PubMed Scopus (136) Google Scholar]. The occurrence of manubriosternal septic arthritis is exceptionally rare.Anatomically adjacent to the manubriosternal junction is the sternoclavicular joint, an atypical synovial joint. Septic arthritis involving this joint is relatively rare but far better known than the manubriosternal infection. Septic arthritis of both the sternoclavicular and manubriosternal joints seems to occur in younger age group (mean age, 45) compared with infection of other joints [11Ross J.J. Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases.Medicine (Baltimore). 2004; 83: 139-148Crossref PubMed Scopus (222) Google Scholar]. The most common risk factor is intravenous drug abuse, this being related to upper limb injection, and subclavian phlebitis, neck injection, and potential needle breech into the joint itself. Intravenous drug abuse was the predisposing factor in only one patient with manubriosternal septic arthritis.InvestigationLaboratory investigations will invariably revealed leukocytosis and the erythrocyte sedimentation rate is often more than 40 mm/h. Normal white cell count and C-reactive protein have been reported in one case [9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar]. Posteroanterior chest roentgenogram is usually unremarkable, but some may show bibasal effusion [7Rubinstien E. Slavin J. Thymic abscess with bacteremia and manubriosternal pyarthrosis in a geriatric patient.Chest. 1993; 103: 962-964Crossref PubMed Scopus (12) Google Scholar]. Lateral roentgenogram of the joint is more sensitive, and findings include substernal soft tissue swelling, periosteal elevation, erosion of the joint margin and widened joint space [1Glushakow A.S. Carlson D. DePalma A.F. Pyarthrosis of the manubriosternal joint.Clin Orthop Relat Res. 1976; 114: 214-215PubMed Google Scholar, 3Gruber B.L. Kaufman L.D. Gorevic P.D. Septic arthritis involving the manubriosternal joint.J Rheumatol. 1985; 12: 803-804PubMed Google Scholar, 4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar, 6Chattopadhyay B. Jeremiah J.D. Sadler G. An unusual presentation of salmonella infection.J Infection. 1990; 20: 265-266Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar]. In early cases, the lateral roentgenogram may be normal [5Van Linthoudt D. De Torrente A. Humair L. Ott H. Septic manubriosternal arthritis in a patient with Reiter’s disease.Clin Rheumatol. 1987; 6: 293-295Crossref PubMed Scopus (6) Google Scholar]. Early diagnosis may be achieved with radionuclide scan, which shows an increased uptake at the joint, although a false-negative finding has been reported [2Borgmeier P.J. Kalovidouris A.E. Septic arthritis of the sternomanubrial joint due to Pseudomonas pseudomallei.Arthritis Rheum. 1980; 23: 1057-1059Crossref PubMed Scopus (12) Google Scholar, 3Gruber B.L. Kaufman L.D. Gorevic P.D. Septic arthritis involving the manubriosternal joint.J Rheumatol. 1985; 12: 803-804PubMed Google Scholar, 4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar, 5Van Linthoudt D. De Torrente A. Humair L. Ott H. Septic manubriosternal arthritis in a patient with Reiter’s disease.Clin Rheumatol. 1987; 6: 293-295Crossref PubMed Scopus (6) Google Scholar]. CT scan is more likely to be positive at later stage, the findings include inflammatory fluid collection at the joint area, infiltration of soft tissue, and destroyed sternum [4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar]. Superior visualization of the soft tissues and bony planes may be obtained by magnetic resonance imaging [9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar].MicrobiologyCoagulase positive Staphylococcus aureus is implicated in 60% of the cases. Pseudomonas pseudomallei was reported in 1 patient (1/10, 10%). The risk of acquiring this unusual organism is travel to an endemic area. Salmonella brandenburg was grown from pus in 1 patient (1/10, 10%). In 2 patients (2/10, 20%), microbiologic culture failed to grow any organism. Blood culture was positive in 40% of the patients.ManagementDelayed diagnosis as a result of misdiagnosis is not uncommon. In the presence of a systemic inflammatory joint disorder, this can be confused with exacerbation of disease activity and lead to increased steroid dosage. This, in turn, aggravates the septic process. Intravenous antibiotic alone may suffice at an early stage before pus formation has occurred [4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar, 5Van Linthoudt D. De Torrente A. Humair L. Ott H. Septic manubriosternal arthritis in a patient with Reiter’s disease.Clin Rheumatol. 1987; 6: 293-295Crossref PubMed Scopus (6) Google Scholar, 6Chattopadhyay B. Jeremiah J.D. Sadler G. An unusual presentation of salmonella infection.J Infection. 1990; 20: 265-266Abstract Full Text PDF PubMed Scopus (4) Google Scholar]. Surgical drainage is required in 60% of cases. If the defect is sizeable after surgical débridement, this can be covered by pectoralis flap [8Kruper L.L. Low D.W. Bucky L.P. Immediate pectoralis flap closure following septic arthritis of the manubriosternal joint.Plast Reconstr Surg. 2001; 107: 997-999Crossref PubMed Scopus (3) Google Scholar, 9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar]. Subsequent prolonged antibiotics are necessary to prevent recurrence and sternal osteomyelitis [8Kruper L.L. Low D.W. Bucky L.P. Immediate pectoralis flap closure following septic arthritis of the manubriosternal joint.Plast Reconstr Surg. 2001; 107: 997-999Crossref PubMed Scopus (3) Google Scholar].Although a pectoralis flap is useful to cover a sizeable wound defect, as reported in few cases, this will need to be considered along with other factors such as the patient’s occupation and leisure activities. The wound in our patient was relatively localized to a small but deep wound cavity. The pectoralis major is a medial rotator and a powerful adductor of the arm. Its use for flap reconstruction may not be ideal for an active sportsman or a manual worker, with its other potential complications related to the flap itself and risk of converting a localized infection to a more widespread one. Therefore whilst the role of pectoralis muscle flap cover has been shown in two reports, we believe its use should be carefully considered within the context of each individual patient’s needs. Its role in the early stage of management needs further appraisal, especially when it is still uncertain if the infection has been fully eradicated. Pyarthrosis of the manubriosternal joint is extremely rare. Sternal osteomyelitis and septic arthritis of the sternoclavicular joint are two other uncommon entities involving the sternum, but both have been reported from time to time in the literature. A literature search which includes MEDLINE and OLDMEDLINE under the keywords manubriosternal or sternomanubrial with pyarthrosis or septic arthritis revealed nine other reports of manubriosternal septic arthritis. We describe a young patient with this rare infection and present a review of the literature in order to clarify its clinical features, epidemiology, investigation, and management. A 28-year-old man was referred to the cardiothoracic unit with a mass at the manubriosternal area. He was a well-built, active rugby player representing a local club and also worked as a joiner. Before his admission, he presented 10 days earlier to the emergency department with chest pain secondary to a “strain” endured at work after heavy lifting. He received opiate analgesia and was discharged home. He was subsequently admitted with worsening central chest pain and swelling over the manubriosternal area. The symptoms were aggravated by any movement, stooping down particularly. Systems review was unremarkable, including any chest or urinary symptom. He had previously undergone two elective open distal clavicle resections, 7 months and 1 year previously, both with uneventful recovery. He was otherwise fit without significant medical history. He denied any substance abuse or risk factor for HIV infection. He was a nonsmoker, and there was no history of alcohol excess. There was no recent travel history. On admission, he had temperature 38.9°C, white cell count of 11.7 × 109/L, C-reactive protein level of more than 300 mg/L, and an erythrocyte sedimentation rate of 96 mm/h. He had a tender, fluctuant swelling over the manubriosternal joint. A chest roentgenogram (posteroanterior view) showed left lower lobe collapse. An echocardiogram, which was requested to exclude pericarditis, showed a mass impinging on the right ventricle. A computed tomography (CT) chest scan showed a 7-cm inflammatory mass centered on the manubriosternal joint with mixed fluid and gas density. The mass extended anteriorly into the subcutaneous tissue and posteriorly into anterior mediastinum but did not directly involve the heart or pericardium. The manubriosternal joint looked irregular and widened (Fig 1). There was a partial collapse of the left lower lobe with small bibasal effusions. He underwent surgical exploration and evacuation of the inflammatory collection. A transverse incision was made over the presternal area. The entire manubriosternal joint was destroyed (Fig 2). A large abscess (approximately 200 mL) was found at the presternal, peristernal, and retrosternal space through the destroyed manubriosternal joint. The abscess cavity was curetted and necrotic tissue was débrided. The wound was left open and packed with gauze roll. Further dressing changes were performed under general anesthesia and subsequently under self-administered nitrous oxide. The patient’s postoperative recovery was uneventful. He received a 2-week course of intravenous antibiotics (vancomycin converted to flucloxacillin, ciprofloxacin, and metronidazole) with a subsequent oral regimen for further 4 weeks. One blood culture sample grew diphtheroids of doubtful significance. Several cultures including pus from the joint, blood, urine, and stool failed to yield any organism. Microscopic examination of the drained abscess revealed many pus cells but no organism. Test for acid-fast bacillus was negative. He was discharged home with regular wound dressing under the care of the district nurse until 6 weeks after the initial operation. He was well and the wound had healed completely at 6 months’ follow-up (Fig 2, right). CommentEpidemiology and Clinical FeaturesSeptic arthritis of the manubriosternal joint is rare [1Glushakow A.S. Carlson D. DePalma A.F. Pyarthrosis of the manubriosternal joint.Clin Orthop Relat Res. 1976; 114: 214-215PubMed Google Scholar, 2Borgmeier P.J. Kalovidouris A.E. Septic arthritis of the sternomanubrial joint due to Pseudomonas pseudomallei.Arthritis Rheum. 1980; 23: 1057-1059Crossref PubMed Scopus (12) Google Scholar, 3Gruber B.L. Kaufman L.D. Gorevic P.D. Septic arthritis involving the manubriosternal joint.J Rheumatol. 1985; 12: 803-804PubMed Google Scholar, 4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar, 5Van Linthoudt D. De Torrente A. Humair L. Ott H. Septic manubriosternal arthritis in a patient with Reiter’s disease.Clin Rheumatol. 1987; 6: 293-295Crossref PubMed Scopus (6) Google Scholar, 6Chattopadhyay B. Jeremiah J.D. Sadler G. An unusual presentation of salmonella infection.J Infection. 1990; 20: 265-266Abstract Full Text PDF PubMed Scopus (4) Google Scholar, 7Rubinstien E. Slavin J. Thymic abscess with bacteremia and manubriosternal pyarthrosis in a geriatric patient.Chest. 1993; 103: 962-964Crossref PubMed Scopus (12) Google Scholar, 8Kruper L.L. Low D.W. Bucky L.P. Immediate pectoralis flap closure following septic arthritis of the manubriosternal joint.Plast Reconstr Surg. 2001; 107: 997-999Crossref PubMed Scopus (3) Google Scholar, 9Sinha S. Sinha A. Nagarajah K. Oei E.L. Critchley P. McNally M.A. Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis.Clin Rheumatol. 2006; 25: 934-936Crossref PubMed Scopus (4) Google Scholar] (Table 1), and its occurrence in an otherwise healthy adult is unusual. It is more common in men (70%). The median age of presentation is 42.5 (range, 20 to 75; mean, 44.7). Predisposing factors are seen in 50% of the cases. Risk factors include intravenous drug abuse, immunosuppressive drugs, inflammatory joint disease, and primary source of infection elsewhere [3Gruber B.L. Kaufman L.D. Gorevic P.D. Septic arthritis involving the manubriosternal joint.J Rheumatol. 1985; 12: 803-804PubMed Google Scholar, 4Lopez-Longo F.J. Monteagudo I. Vaquero F.J. Martinez Moreno J.L. Carreno L. Primary septic arthritis of the manubriosternal joint in a heroin user.Clin Orthop Relat Res. 1986; 202: 230-231PubMed Google Scholar, 5Van Linthoudt D. De Torrente A. Humair L. Ott H. Septic manubriosternal arthritis in a patient with Reiter’s disease.Clin Rheumatol. 1987; 6: 293-295Crossref PubMed Scopus (6) Google Scholar, 8Kruper L.L. Low D.W. Bucky L.P. Immediate pectoralis flap closure following septic arthritis of the manubriosternal joint.Plast Reconstr Surg. 2001; 107: 997-999
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