Case of Sternoclavİcular Joİnt Arthrİtİs Confused Wİth Catheter-Related Tunnel İnfectİon

Case of Sternoclavİcular Joİnt Arthrİtİs Confused Wİth Catheter-Related Tunnel İnfectİon | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case of Sternoclavİcular Joİnt Arthrİtİs Confused Wİth Catheter-Related Tunnel İnfectİon Nazmiye serap Biçer, Tuğba Yılmaz, Sümeyra Koyuncu, Özgür Karabıyık, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5569611/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Sternoclavicular joint arthritis is a rare but challenging condition that can lead to serious complications, particularly in patients with underlying health conditions. Delayed diagnosis may result in life-threatening complications, including osteomyelitis, mediastinitis, and sepsis. We present the case of an 85-year-old female patient with a history of hypertension, diabetes, congestive heart failure, and end-stage renal disease, undergoing hemodialysis through a jugular venous catheter. She was admitted with fever and fatigue, initially diagnosed as catheter-related infection. Despite broad-spectrum antibiotic therapy, her inflammatory markers remained elevated, prompting further investigation. Imaging revealed findings consistent with sternoclavicular joint arthritis. Given her limited response to antibiotics, intravenous corticosteroid therapy was introduced, leading to significant clinical improvement. This case highlights the importance of considering rare complications, such as sternoclavicular joint inflammatory arthritis, in patients undergoing hemodialysis with central venous catheters, especially when symptoms do not respond to standard infection management. Early recognition and targeted treatment are essential to avoid severe morbidity in this vulnerable population. sternoclavicular joint arthritis inflammatory arthritis central venous catheter hemodialysis Figures Figure 1 Figure 2 BACKGROUND Sternoclavicular joint arthritis is a rare clinical condition with challenges in diagnosis, treatment, and management. It can lead to severe complications and high morbidity. In advanced cases, surgical intervention is often necessary, as conservative treatments are typically ineffective. Delays in diagnosis can result in potentially fatal conditions, such as osteomyelitis, mediastinitis, and sepsis ( 1 ). Sternoclavicular joint arthritis may develop in the context of rheumatic diseases like rheumatoid arthritis, systemic lupus erythematosus, and osteoarthritis, or be associated with trauma or severe infections. Differentiating inflammatory arthritis from infectious arthritis can be facilitated by assessing features such as capsular distension, extracapsular fluid accumulation, periarticular muscle edema, the extent of bone erosions on imaging, patient age, and C-Reactive Protein (CRP) and erythrocyte sedimentation rate (ESR) levels ( 2 ). The lack of significant joint effusion in sternoclavicular joint arthritis can delay diagnosis. Here, we present a rare case of an 85-year-old patient undergoing hemodialysis via a central jugular venous catheter who was hospitalized with a preliminary diagnosis of catheter infection. During the evaluation of secondary causes due to unresponsiveness to antibiotic therapy, sternoclavicular joint arthritis was identified. CASE REPORT An 85-year-old female patient presented to our clinic with complaints of fever and weakness persisting for two days. Her medical history included essential hypertension, diabetes mellitus, congestive heart failure, and stage 5 chronic kidney disease, requiring hemodialysis via a right internal jugular venous catheter three times a week for the past three years. During anamnesis, she reported intermittent fever at home and after dialysis sessions. Physical examination revealed redness, swelling, and tenderness along the right jugular venous catheter tract, with notable edema and pain over the sternoclavicular joint (Image 1). Blood pressure was measured at 90/60 mmHg, heart rate was 110 bpm, and body temperature was 39.5°C. Laboratory findings included a CRP level of 89 mg/dL, ESR of 112 mm/hour, procalcitonin of 16 ng/mL, leukocyte count of 12,700/mm³, serum creatinine of 5.14 mg/dL, BUN of 59.7 mg/dL, and Pro-BNP level of 15,600 pg/mL. Peripheral and catheter blood cultures were obtained, and broad-spectrum empirical antibiotic therapy was initiated with intravenous piperacillin/tazobactam (3 × 2.25 g) and vancomycin (1 × 0.5 g). Clinical improvement was observed; however, acute-phase reactant levels did not significantly decline. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from both peripheral and catheter blood cultures, prompting continued antibiotic therapy. Ultrasound imaging around the catheter tunnel, performed on the third day of antibiotic treatment, did not reveal signs of a tunnel infection but demonstrated findings consistent with sternoclavicular joint arthritis. Computed tomography of the neck and thorax was performed for further evaluation (Fig. 1 and Fig. 2 ). An attempt to aspirate synovial fluid from the affected joint was unsuccessful. Given radiologic features suggestive of inflammatory arthritis, the patient was initiated on intravenous methylprednisolone at 1 mg/kg. By the second day of corticosteroid therapy, swelling and redness had markedly reduced, and by the fourth day, they had resolved completely. Tests for human leukocyte antigen B27 (HLA-B27), rheumatoid factor (RF), and anti-citrullinated peptide antibodies (Anti-CCP) were negative, ruling out autoimmune etiologies. Additionally, Brucella agglutination testing was negative, excluding brucellosis as a potential cause. Given the patient's history of multiple catheter-related thrombosis, a decision was made to preserve the current catheter rather than replace it immediately, as catheter exchange posed a significant thromboembolic risk. The patient remained on intravenous antibiotics during corticosteroid initiation, ensuring infection control prior to addressing the inflammatory component. She did not receive NSAIDs due to concerns regarding renal impairment. After corticosteroid treatment, the patient's CRP and ESR levels decreased significantly, and her clinical status improved. She was discharged in a stable condition once inflammatory markers returned to near-normal levels. The case highlights the diagnostic challenge of differentiating infectious vs. inflammatory arthritis in hemodialysis patients with catheter-related bloodstream infections. While infectious arthritis was suspected, the rapid response to corticosteroids suggested an inflammatory component rather than persistent infection. Literature on catheter-related MSSA bacteremia leading to sternoclavicular arthritis is limited, but similar cases have been reported, supporting the hypothesis that catheter infections may trigger reactive inflammatory arthritis. The careful timing of corticosteroid initiation in septic patients remains controversial, as steroids may exacerbate infection if administered prematurely. In this case, the delayed introduction of steroids until bacteremia had been controlled likely contributed to the positive clinical outcome. This case underscores the complexity of managing catheter-associated infections in patients at high risk for thrombosis and highlights the need for multidisciplinary decision-making when balancing thrombosis risk, infection control, and inflammatory complications in long-term hemodialysis patients. DISCUSSION In hemodialysis patients, the presence of uremia and an impaired immune system increases susceptibility to infections compared to the general population ( 9 ). Although an arteriovenous fistula is the preferred method for vascular access, central venous catheters are frequently used in cases requiring emergency dialysis access. However, catheter-related complications—including infections, thrombosis, hematomas, and bleeding—pose significant morbidity risks and may negatively impact dialysis efficacy ( 3 ). Jugular venous catheterization is rarely associated with septic or inflammatory arthritis of the sternoclavicular joint, but when present, distinguishing between inflammatory and septic arthritis remains a diagnostic challenge. Sternoclavicular septic arthritis is commonly linked to infected central venous catheters, with Staphylococcus aureus being the most frequently isolated pathogen ( 4 ). Other contributing factors include intravenous drug use, diabetes mellitus, trauma, and underlying infections ( 7 ). Advanced imaging studies, including computed tomography (CT) and magnetic resonance imaging (MRI), are essential for confirming sternoclavicular joint arthritis and differentiating between infectious and inflammatory etiologies ( 2 ). If imaging reveals extensive bone destruction, phlegmon formation, chest wall abscess, mediastinitis, or pleural spread, surgical resection of the joint becomes necessary ( 5 ). However, in cases where joint involvement is limited, medical therapy alone may suffice, with specific antibiotic treatment continuing for at least four weeks based on culture results ( 6 ). In our case, several clinical findings—including markedly elevated CRP and procalcitonin levels, fever on admission, and an infected venous catheter—initially suggested septic arthritis ( 10 ). However, the slow response to antibiotic therapy and dramatic improvement following corticosteroid administration indicated an inflammatory component rather than persistent infection ( 11 ). While local steroid injections are commonly reported for inflammatory sternoclavicular arthritis, our patient responded well to systemic intravenous corticosteroid therapy, with no complications or relapses observed during follow-up ( 8 ). Recent studies highlight the prevalence and management of catheter-related bloodstream infections (CRBSI) in hemodialysis patients. A study from Ghana reported a CRBSI prevalence of 34.2%, with Coagulase-negative Staphylococci and Acinetobacter baumannii identified as the primary pathogens ( 6 ). Similarly, a retrospective cohort study in the Philippines found a CRBSI incidence rate of 6.72 episodes per 1000 catheter days, with multidrug-resistant organisms (MDROs) comprising nearly half of the isolates ( 7 ). Additionally, immune system dysfunction and chronic inflammation play a significant role in the pathogenesis of inflammatory arthritis in hemodialysis patients ( 9 ). A study analyzing biological DMARD therapy in rheumatoid arthritis patients undergoing hemodialysis found that IL-6 inhibitors had the highest drug retention rate and the lowest treatment discontinuation due to inefficacy ( 10 ). Another case report demonstrated the successful use of Tocilizumab in a rheumatoid arthritis patient on long-term hemodialysis, suggesting potential management strategies for inflammatory arthritis in ESRD patients ( 11 ). This case emphasizes the importance of recognizing inflammatory sternoclavicular arthritis as a rare complication in hemodialysis patients with catheter-related infections. Although corticosteroid therapy was beneficial for our patient, steroid administration during active infection must be carefully considered, and close monitoring is required to prevent exacerbation of sepsis. CONCLUSION Catheter-related infections, bleeding, and thrombosis are common complications in hemodialysis patients. Although rare complications such as inflammatory sternoclavicular arthritis are often overlooked, failure to recognize them can lead to increased morbidity and mortality. Therefore, patients presenting with erythema and swelling along the catheter tunnel tract should be carefully evaluated for possible inflammatory arthritis. Treatment should be individualized, incorporating infection control measures, imaging studies, and—in select cases—corticosteroid therapy when an inflammatory etiology is suspected. Declarations Ethics approval and consent to participate Not applicable for this case report. Consent for publication Patient provided written informed consent for the publication of this case report. Competing interests The authors declare no competing interests. Funding This report was not supported by any funding. Author Contribution NSB: Wrote the manuscript and served as a contributing author; IK, TY and OK: Experimental guidance; SK: Contributed to design of the study. All authors contributed to manuscript revision, read, and approved the submitted version. Acknowledgement We would like to express our gratitude to all authors who contributed to this case. Data availability No datasets were generated or analysed during the current study. References Gupta, M. N., Sturrock, R. D., & Field, M. (2001). A prospective 2‐year study of 75 patients with adult‐onset septic arthritis. Rheumatology , 40 (1), 24-30. Kang, B. S., Shim, H. S., Kwon, W. J., Lim, S., Park, G. M., Lee, T. Y., & Bang, M. (2019). MRI findings for unilateral sternoclavicular arthritis: differentiation between infectious arthritis and spondyloarthritis. Skeletal Radiology , 48 , 259-266. Alfano, G., Morisi, N., Giovanella, S., Frisina, M., Amurri, A., Tei, L., ... & Donati, G. (2024). Risk of infections related to endovascular catheters and cardiac implantable devices in hemodialysis patients. The Journal of Vascular Access , 11297298241240502. Ross, J. J., & Shamsuddin, H. (2004). Sternoclavicular septic arthritis: A review of 180 cases. The Journal of Thoracic and Cardiovascular Surgery , 83 (3), 139-148. Burkhart, H. M., Deschamps, C., Allen, M. S., Nichols III, F. C., Miller, D. L., & Pairolero, P. C. (2003). Surgical management of sternoclavicular joint infections. The Journal of Thoracic and Cardiovascular Surgery , 125 (4), 945-949. Opoku-Asare, B., Boima, V., Ganu, V. J., et al. (2023). Catheter-Related Bloodstream Infections among patients on maintenance haemodialysis: a cross-sectional study at a tertiary hospital in Ghana. BMC Infectious Diseases, 23, 664. Pasilan, R. M., Tomacruz-Amante, I. D., & Dimacali, C. T. (2024). The epidemiology and microbiology of central venous catheter-related bloodstream infections among hemodialysis patients in the Philippines: a retrospective cohort study. BMC Nephrology, 25, 331. Bhojaraja, M. V., Prabhu, R. A., Nagaraju, S. P., et al. (2023). Hemodialysis catheter-related bloodstream infections: a single-center experience. J Nephropharmacol, 12(2), e10475. Campo, S., Lacquaniti, A., Trombetta, D., et al. (2022). Immune System Dysfunction and Inflammation in Hemodialysis Patients: Two Sides of the Same Coin. J Clin Med, 11(13), 3759. Yoshimura, Y., Yamanouchi, M., Mizuno, H., et al. (2024). Efficacy and safety of first-line biological DMARDs in rheumatoid arthritis patients with chronic kidney disease. Ann Rheum Dis, 83(10), 1278. Kiliç, P., Ikiç, L., Mayer, M., et al. (2023). Safe and Efficient Use of Tocilizumab in Rheumatoid Arthritis Patient on Maintenance Hemodialysis: A Case Report. Medicina, 59(9), 1517. Khoo, C. Y., & Chia, C. M. L. (2024). A challenging case of severe bilateral septic arthritis with osteomyelitis of the sternoclavicular joint in a patient with end-stage renal disease. Interdisciplinary CardioVascular and Thoracic Surgery, 38(5), ivae080. Şaş, S., Kaplan, H., Şenköy, E., & Cengiz, G. (2022). A significant joint involvement in spondyloarthritis: Sternoclavicular arthritis. J PMR Sci, 25(2), 269-272. Sternoclavicular Joint Arthritis with Acute Kidney Injury. (2013). Renal Failure, 35(2), 305-307. Image 1 Image 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files documant1.docx image.jpg Image 1. Clinical photograph showing redness and swelling at the sternoclavicular joint, corresponding with localized inflammation. These findings, combined with imaging data, aid in differentiating between septic and inflammatory arthritis. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5569611","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":445911829,"identity":"c563fdf0-4558-4fce-9609-f1edbaca31c0","order_by":0,"name":"Nazmiye serap Biçer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYLACxgYJBgb2BiDLwIIULTwHQFokiNYCJCQSQEwitMi39z78XLjDQt585vOrG34USDDwt3cn4NVicOa4sfTMMxKGc27nlN3sATpM4szZDfi1SKQxSPO2SSRISOek3eABajGQyMWvRX7+M+bfYC2SZ9Ju/iFGC8MNNjaILRLsx24TZYvBmTQ2a5BfZvDksN2WMZDgIegX+fZjzLcLd9TJS7Aff3bzzR8bOf72XgIOAwJmCMVjACYJKkfSwv6AKNWjYBSMglEw8gAAZS9A2uv1EMoAAAAASUVORK5CYII=","orcid":"","institution":"Kayseri State Hospital","correspondingAuthor":true,"prefix":"","firstName":"Nazmiye","middleName":"serap","lastName":"Biçer","suffix":""},{"id":445911830,"identity":"2bc90b5e-660b-422c-bb81-9fe546476368","order_by":1,"name":"Tuğba Yılmaz","email":"","orcid":"","institution":"Erciyes University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tuğba","middleName":"","lastName":"Yılmaz","suffix":""},{"id":445911831,"identity":"bb16fdc7-29c9-4aee-9541-82387a6f0d7e","order_by":2,"name":"Sümeyra Koyuncu","email":"","orcid":"","institution":"Kayseri State Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sümeyra","middleName":"","lastName":"Koyuncu","suffix":""},{"id":445911832,"identity":"0213ef53-25fb-419b-9e1c-06fa8d70574e","order_by":3,"name":"Özgür Karabıyık","email":"","orcid":"","institution":"Erciyes University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Özgür","middleName":"","lastName":"Karabıyık","suffix":""},{"id":445911833,"identity":"35161f97-d314-42e4-a174-ebc1c40c7011","order_by":4,"name":"İsmail Koçyiğit","email":"","orcid":"","institution":"Erciyes University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"İsmail","middleName":"","lastName":"Koçyiğit","suffix":""}],"badges":[],"createdAt":"2024-12-03 07:08:44","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5569611/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5569611/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81542632,"identity":"1aafafd3-e563-4466-bb85-a48b2179d18a","added_by":"auto","created_at":"2025-04-28 11:21:44","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":89188,"visible":true,"origin":"","legend":"\u003cp\u003eTomographic images of sternoclavicular joint arthritis, demonstrating inflammatory changes and structural abnormalities in sagittal, coronal, and axial sections. The coronal section highlights joint space narrowing, while the axial view reveals periarticular soft tissue edema consistent with an inflammatory process.\u003c/p\u003e","description":"","filename":"figure1...jpg","url":"https://assets-eu.researchsquare.com/files/rs-5569611/v1/1bd3c2e01685f717a604d45a.jpg"},{"id":81540984,"identity":"5c643371-3d3a-4107-8a26-09dbea7d59ba","added_by":"auto","created_at":"2025-04-28 11:13:44","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45841,"visible":true,"origin":"","legend":"\u003cp\u003eThree-dimensional reconstruction of the sternoclavicular joint and central venous catheter, providing a detailed anatomical perspective. The image illustrates the spatial relationship between the infected catheter and adjacent structures, supporting the hypothesis of hematogenous spread leading to sternoclavicular joint involvement.\u003c/p\u003e","description":"","filename":"figure2...jpg","url":"https://assets-eu.researchsquare.com/files/rs-5569611/v1/bae57465f00e9da3ce107a5e.jpg"},{"id":86749126,"identity":"e9f41550-c9a6-4499-9276-a5b62ca50354","added_by":"auto","created_at":"2025-07-15 08:17:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":477583,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5569611/v1/b6fdd25d-2fa2-42ba-85c9-c4469a8ce164.pdf"},{"id":81540980,"identity":"7c41f5da-6c6b-4719-be54-266eac78b0b1","added_by":"auto","created_at":"2025-04-28 11:13:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13541,"visible":true,"origin":"","legend":"","description":"","filename":"documant1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5569611/v1/530173078cc01aa28f1fee12.docx"},{"id":81540985,"identity":"60cd5cdd-a72c-417d-b9c8-f9d2901fd273","added_by":"auto","created_at":"2025-04-28 11:13:44","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":102603,"visible":true,"origin":"","legend":"\u003cp\u003eImage 1. Clinical photograph showing redness and swelling at the sternoclavicular joint, corresponding with localized inflammation. These findings, combined with imaging data, aid in differentiating between septic and inflammatory arthritis.\u003c/p\u003e","description":"","filename":"image.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5569611/v1/37cdf4b545544862bd3c6250.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eCase of Sternoclavİcular Joİnt Arthrİtİs Confused Wİth Catheter-Related Tunnel İnfectİon\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eSternoclavicular joint arthritis is a rare clinical condition with challenges in diagnosis, treatment, and management. It can lead to severe complications and high morbidity. In advanced cases, surgical intervention is often necessary, as conservative treatments are typically ineffective. Delays in diagnosis can result in potentially fatal conditions, such as osteomyelitis, mediastinitis, and sepsis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Sternoclavicular joint arthritis may develop in the context of rheumatic diseases like rheumatoid arthritis, systemic lupus erythematosus, and osteoarthritis, or be associated with trauma or severe infections. Differentiating inflammatory arthritis from infectious arthritis can be facilitated by assessing features such as capsular distension, extracapsular fluid accumulation, periarticular muscle edema, the extent of bone erosions on imaging, patient age, and C-Reactive Protein (CRP) and erythrocyte sedimentation rate (ESR) levels (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The lack of significant joint effusion in sternoclavicular joint arthritis can delay diagnosis. Here, we present a rare case of an 85-year-old patient undergoing hemodialysis via a central jugular venous catheter who was hospitalized with a preliminary diagnosis of catheter infection. During the evaluation of secondary causes due to unresponsiveness to antibiotic therapy, sternoclavicular joint arthritis was identified.\u003c/p\u003e"},{"header":"CASE REPORT","content":"\u003cp\u003eAn 85-year-old female patient presented to our clinic with complaints of fever and weakness persisting for two days. Her medical history included essential hypertension, diabetes mellitus, congestive heart failure, and stage 5 chronic kidney disease, requiring hemodialysis via a right internal jugular venous catheter three times a week for the past three years. During anamnesis, she reported intermittent fever at home and after dialysis sessions. Physical examination revealed redness, swelling, and tenderness along the right jugular venous catheter tract, with notable edema and pain over the sternoclavicular joint (Image 1). Blood pressure was measured at 90/60 mmHg, heart rate was 110 bpm, and body temperature was 39.5\u0026deg;C.\u003c/p\u003e \u003cp\u003eLaboratory findings included a CRP level of 89 mg/dL, ESR of 112 mm/hour, procalcitonin of 16 ng/mL, leukocyte count of 12,700/mm\u0026sup3;, serum creatinine of 5.14 mg/dL, BUN of 59.7 mg/dL, and Pro-BNP level of 15,600 pg/mL. Peripheral and catheter blood cultures were obtained, and broad-spectrum empirical antibiotic therapy was initiated with intravenous piperacillin/tazobactam (3 \u0026times; 2.25 g) and vancomycin (1 \u0026times; 0.5 g). Clinical improvement was observed; however, acute-phase reactant levels did not significantly decline. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from both peripheral and catheter blood cultures, prompting continued antibiotic therapy.\u003c/p\u003e \u003cp\u003eUltrasound imaging around the catheter tunnel, performed on the third day of antibiotic treatment, did not reveal signs of a tunnel infection but demonstrated findings consistent with sternoclavicular joint arthritis. Computed tomography of the neck and thorax was performed for further evaluation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). An attempt to aspirate synovial fluid from the affected joint was unsuccessful. Given radiologic features suggestive of inflammatory arthritis, the patient was initiated on intravenous methylprednisolone at 1 mg/kg. By the second day of corticosteroid therapy, swelling and redness had markedly reduced, and by the fourth day, they had resolved completely. Tests for human leukocyte antigen B27 (HLA-B27), rheumatoid factor (RF), and anti-citrullinated peptide antibodies (Anti-CCP) were negative, ruling out autoimmune etiologies. Additionally, Brucella agglutination testing was negative, excluding brucellosis as a potential cause.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGiven the patient's history of multiple catheter-related thrombosis, a decision was made to preserve the current catheter rather than replace it immediately, as catheter exchange posed a significant thromboembolic risk. The patient remained on intravenous antibiotics during corticosteroid initiation, ensuring infection control prior to addressing the inflammatory component. She did not receive NSAIDs due to concerns regarding renal impairment.\u003c/p\u003e \u003cp\u003eAfter corticosteroid treatment, the patient's CRP and ESR levels decreased significantly, and her clinical status improved. She was discharged in a stable condition once inflammatory markers returned to near-normal levels. The case highlights the diagnostic challenge of differentiating infectious vs. inflammatory arthritis in hemodialysis patients with catheter-related bloodstream infections. While infectious arthritis was suspected, the rapid response to corticosteroids suggested an inflammatory component rather than persistent infection.\u003c/p\u003e \u003cp\u003eLiterature on catheter-related MSSA bacteremia leading to sternoclavicular arthritis is limited, but similar cases have been reported, supporting the hypothesis that catheter infections may trigger reactive inflammatory arthritis. The careful timing of corticosteroid initiation in septic patients remains controversial, as steroids may exacerbate infection if administered prematurely. In this case, the delayed introduction of steroids until bacteremia had been controlled likely contributed to the positive clinical outcome.\u003c/p\u003e \u003cp\u003eThis case underscores the complexity of managing catheter-associated infections in patients at high risk for thrombosis and highlights the need for multidisciplinary decision-making when balancing thrombosis risk, infection control, and inflammatory complications in long-term hemodialysis patients.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn hemodialysis patients, the presence of uremia and an impaired immune system increases susceptibility to infections compared to the general population (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Although an arteriovenous fistula is the preferred method for vascular access, central venous catheters are frequently used in cases requiring emergency dialysis access. However, catheter-related complications\u0026mdash;including infections, thrombosis, hematomas, and bleeding\u0026mdash;pose significant morbidity risks and may negatively impact dialysis efficacy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eJugular venous catheterization is rarely associated with septic or inflammatory arthritis of the sternoclavicular joint, but when present, distinguishing between inflammatory and septic arthritis remains a diagnostic challenge. Sternoclavicular septic arthritis is commonly linked to infected central venous catheters, with Staphylococcus aureus being the most frequently isolated pathogen (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Other contributing factors include intravenous drug use, diabetes mellitus, trauma, and underlying infections (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdvanced imaging studies, including computed tomography (CT) and magnetic resonance imaging (MRI), are essential for confirming sternoclavicular joint arthritis and differentiating between infectious and inflammatory etiologies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). If imaging reveals extensive bone destruction, phlegmon formation, chest wall abscess, mediastinitis, or pleural spread, surgical resection of the joint becomes necessary (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, in cases where joint involvement is limited, medical therapy alone may suffice, with specific antibiotic treatment continuing for at least four weeks based on culture results (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our case, several clinical findings\u0026mdash;including markedly elevated CRP and procalcitonin levels, fever on admission, and an infected venous catheter\u0026mdash;initially suggested septic arthritis (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, the slow response to antibiotic therapy and dramatic improvement following corticosteroid administration indicated an inflammatory component rather than persistent infection (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). While local steroid injections are commonly reported for inflammatory sternoclavicular arthritis, our patient responded well to systemic intravenous corticosteroid therapy, with no complications or relapses observed during follow-up (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent studies highlight the prevalence and management of catheter-related bloodstream infections (CRBSI) in hemodialysis patients. A study from Ghana reported a CRBSI prevalence of 34.2%, with Coagulase-negative Staphylococci and Acinetobacter baumannii identified as the primary pathogens (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Similarly, a retrospective cohort study in the Philippines found a CRBSI incidence rate of 6.72 episodes per 1000 catheter days, with multidrug-resistant organisms (MDROs) comprising nearly half of the isolates (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, immune system dysfunction and chronic inflammation play a significant role in the pathogenesis of inflammatory arthritis in hemodialysis patients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A study analyzing biological DMARD therapy in rheumatoid arthritis patients undergoing hemodialysis found that IL-6 inhibitors had the highest drug retention rate and the lowest treatment discontinuation due to inefficacy (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Another case report demonstrated the successful use of Tocilizumab in a rheumatoid arthritis patient on long-term hemodialysis, suggesting potential management strategies for inflammatory arthritis in ESRD patients (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis case emphasizes the importance of recognizing inflammatory sternoclavicular arthritis as a rare complication in hemodialysis patients with catheter-related infections. Although corticosteroid therapy was beneficial for our patient, steroid administration during active infection must be carefully considered, and close monitoring is required to prevent exacerbation of sepsis.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eCatheter-related infections, bleeding, and thrombosis are common complications in hemodialysis patients. Although rare complications such as inflammatory sternoclavicular arthritis are often overlooked, failure to recognize them can lead to increased morbidity and mortality. Therefore, patients presenting with erythema and swelling along the catheter tunnel tract should be carefully evaluated for possible inflammatory arthritis. Treatment should be individualized, incorporating infection control measures, imaging studies, and\u0026mdash;in select cases\u0026mdash;corticosteroid therapy when an inflammatory etiology is suspected.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eNot applicable for this case report.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Patient provided written informed consent for the publication of this case report.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis report was not supported by any funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNSB: Wrote the manuscript and served as a contributing author; IK, TY and OK: Experimental guidance; SK: Contributed to design of the study. All authors contributed to manuscript revision, read, and approved the submitted version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to express our gratitude to all authors who contributed to this case.\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e \u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGupta, M. N., Sturrock, R. D., \u0026amp; Field, M. (2001). A prospective 2‐year study of 75 patients with adult‐onset septic arthritis. \u003cem\u003eRheumatology\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(1), 24-30.\u003c/li\u003e\n\u003cli\u003eKang, B. S., Shim, H. S., Kwon, W. J., Lim, S., Park, G. M., Lee, T. Y., \u0026amp; Bang, M. (2019). MRI findings for unilateral sternoclavicular arthritis: differentiation between infectious arthritis and spondyloarthritis. \u003cem\u003eSkeletal Radiology\u003c/em\u003e, \u003cem\u003e48\u003c/em\u003e, 259-266.\u003c/li\u003e\n\u003cli\u003eAlfano, G., Morisi, N., Giovanella, S., Frisina, M., Amurri, A., Tei, L., ... \u0026amp; Donati, G. (2024). Risk of infections related to endovascular catheters and cardiac implantable devices in hemodialysis patients. \u003cem\u003eThe Journal of Vascular Access\u003c/em\u003e, 11297298241240502.\u003c/li\u003e\n\u003cli\u003eRoss, J. J., \u0026amp; Shamsuddin, H. (2004). Sternoclavicular septic arthritis: A review of 180 cases. \u003cem\u003eThe Journal of Thoracic and Cardiovascular Surgery\u003c/em\u003e, \u003cem\u003e83\u003c/em\u003e(3), 139-148. \u003c/li\u003e\n\u003cli\u003eBurkhart, H. M., Deschamps, C., Allen, M. S., Nichols III, F. C., Miller, D. L., \u0026amp; Pairolero, P. C. (2003). Surgical management of sternoclavicular joint infections. \u003cem\u003eThe Journal of Thoracic and Cardiovascular Surgery\u003c/em\u003e, \u003cem\u003e125\u003c/em\u003e(4), 945-949.\u003c/li\u003e\n\u003cli\u003eOpoku-Asare, B., Boima, V., Ganu, V. J., et al. (2023). Catheter-Related Bloodstream Infections among patients on maintenance haemodialysis: a cross-sectional study at a tertiary hospital in Ghana. BMC Infectious Diseases, 23, 664.\u003c/li\u003e\n\u003cli\u003ePasilan, R. M., Tomacruz-Amante, I. D., \u0026amp; Dimacali, C. T. (2024). The epidemiology and microbiology of central venous catheter-related bloodstream infections among hemodialysis patients in the Philippines: a retrospective cohort study. BMC Nephrology, 25, 331.\u003c/li\u003e\n\u003cli\u003eBhojaraja, M. V., Prabhu, R. A., Nagaraju, S. P., et al. (2023). Hemodialysis catheter-related bloodstream infections: a single-center experience. J Nephropharmacol, 12(2), e10475.\u003c/li\u003e\n\u003cli\u003eCampo, S., Lacquaniti, A., Trombetta, D., et al. (2022). Immune System Dysfunction and Inflammation in Hemodialysis Patients: Two Sides of the Same Coin. J Clin Med, 11(13), 3759.\u003c/li\u003e\n\u003cli\u003eYoshimura, Y., Yamanouchi, M., Mizuno, H., et al. (2024). Efficacy and safety of first-line biological DMARDs in rheumatoid arthritis patients with chronic kidney disease. Ann Rheum Dis, 83(10), 1278.\u003c/li\u003e\n\u003cli\u003eKili\u0026ccedil;, P., Iki\u0026ccedil;, L., Mayer, M., et al. (2023). Safe and Efficient Use of Tocilizumab in Rheumatoid Arthritis Patient on Maintenance Hemodialysis: A Case Report. Medicina, 59(9), 1517.\u003c/li\u003e\n\u003cli\u003eKhoo, C. Y., \u0026amp; Chia, C. M. L. (2024). A challenging case of severe bilateral septic arthritis with osteomyelitis of the sternoclavicular joint in a patient with end-stage renal disease. Interdisciplinary CardioVascular and Thoracic Surgery, 38(5), ivae080.\u003c/li\u003e\n\u003cli\u003eŞaş, S., Kaplan, H., Şenk\u0026ouml;y, E., \u0026amp; Cengiz, G. (2022). A significant joint involvement in spondyloarthritis: Sternoclavicular arthritis. J PMR Sci, 25(2), 269-272.\u003c/li\u003e\n\u003cli\u003eSternoclavicular Joint Arthritis with Acute Kidney Injury. (2013). Renal Failure, 35(2), 305-307.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Image 1","content":"\u003cp\u003eImage 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"sternoclavicular joint arthritis, inflammatory arthritis, central venous catheter, hemodialysis","lastPublishedDoi":"10.21203/rs.3.rs-5569611/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5569611/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSternoclavicular joint arthritis is a rare but challenging condition that can lead to serious complications, particularly in patients with underlying health conditions. Delayed diagnosis may result in life-threatening complications, including osteomyelitis, mediastinitis, and sepsis. We present the case of an 85-year-old female patient with a history of hypertension, diabetes, congestive heart failure, and end-stage renal disease, undergoing hemodialysis through a jugular venous catheter. She was admitted with fever and fatigue, initially diagnosed as catheter-related infection. Despite broad-spectrum antibiotic therapy, her inflammatory markers remained elevated, prompting further investigation. Imaging revealed findings consistent with sternoclavicular joint arthritis. Given her limited response to antibiotics, intravenous corticosteroid therapy was introduced, leading to significant clinical improvement. This case highlights the importance of considering rare complications, such as sternoclavicular joint inflammatory arthritis, in patients undergoing hemodialysis with central venous catheters, especially when symptoms do not respond to standard infection management. Early recognition and targeted treatment are essential to avoid severe morbidity in this vulnerable population.\u003c/p\u003e","manuscriptTitle":"Case of Sternoclavİcular Joİnt Arthrİtİs Confused Wİth Catheter-Related Tunnel İnfectİon","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-28 11:13:39","doi":"10.21203/rs.3.rs-5569611/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5001bf04-b6a9-4871-b46a-b6eb07ad2e21","owner":[],"postedDate":"April 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-15T08:08:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-28 11:13:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5569611","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5569611","identity":"rs-5569611","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}