Diagnosis and Management of Subacute Sternoclavicular Osteomyelitis and Septic Arthritis Secondary to Escherichia coli Infection

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It is commonly caused by Staphylococcus aureus, and infrequently by other bacteria. Only cases of E. coli osteomyelitis have been reported in the literature. Patients with risk factors such as Diabetes, smoking history, and intravenous drug use are particularly susceptible. When infection seeds the joint space, septic arthritis can occur concurrently. Acute and subacute presentations of SCJ osteomyelitis and septic arthritis have been documented, with treatment modalities ranging from conservative treatment to surgical management. We describe a patient with an interesting case of SCJ Osteomyelitis with concurrent Septic Arthritis secondary to trauma to the area from a fall. We detail the patient’s presentation, hospital admission and course of treatment. We delve into her pre-existing conditions and comorbidities and outline the many challenges we faced in managing the patient from onset of presentation into recovery. We also perform a literature review of previously reported cases of SCJ Osteomyelitis. We determine that less than 350 cases have been identified and described in the literature, and we outline examples of some of these while comparing and contrasting pertinent aspects of some of these cases with our patient’s presentation and hospital course. SCJ Osteomyelitis and Septic Arthritis is a rare condition that warrants prompt identification and management to prevent destruction of bone and joint, bacteremia and sepsis, or other debilitating complications. A multidisciplinary approach must be therefore undertaken in caring for patients with existing comorbidities and/or risk factors. This includes expeditious testing and identification of causative organisms, administration of appropriate antibiotics and antipyretics as needed, and swift determination of patients' need for surgery to curtail the spread of infection and restore bone and joint health. Sternoclavicular Osteomyelitis Septic Arthritis E. coli Debridement Cardiothoracic Behavioral health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction The sternoclavicular joint (SCJ) is a small, non weight bearing synovial joint. Although septic arthritis and osteomyelitis occur in joints and bones, they are rarely reported in the SCJ. Causes can be insidious or traumatic, and causative agents are usually bacterial, particularly Staphylococcus aureus ( 10 ). Common symptoms include pain at the site and fevers. Patients with various comorbidities are susceptible, especially those with diabetes mellitus. Immunocompromised individuals such as intravenous drug users are also particularly susceptible. If left untreated, it can cause damage and dysfunction to the involved joint, leading to mortality from septic shock. Infections of the SCJ by other bacteria are even less common, and in these cases presentation is variable. We present a particularly interesting case of subacute sternoclavicular septic arthritis and osteomyelitis in a patient complicated by Diabetes Mellitus and a long history of behavioral and psychiatric comorbidities. Case Report Patient History A 36 year-old female patient was admitted to the behavioral unit via the emergency department for suicidal thoughts and ideations. The patient had a past medical history of Anxiety, Bipolar I Disorder, Depression, Diabetes Mellitus, high cholesterol, hypertension, polycystic ovarian syndrome (PCOS), Schizophrenia, and previous suicide attempts and ideations. Medications included Amantadine, 100 mg, oral, BID; Amlodipine, 5 mg, oral, Daily, Atorvastatin, 40 mg, oral, Nightly, Ciprofloxacin, 500 mg, oral, q12h SCH, Enoxaparin, 40 mg, subcutaneous, q24h, Insulin Aspart, 1-15 Units, subcutaneous, Insulin detemir, 10 Units, subcutaneous, q AM, Levetiracetam, 500 mg, oral, BID, Magnesium oxide, 400 mg, oral, BID, and Risperidone, 3 mg, oral, Nightly. Surgical history included cyst removal and wound debridement. She was a current smoker, and did not drink alcohol or use illicit drugs. The patient stated she was asleep two weeks prior and had rolled and fallen off her bed, striking her chest during the fall. In the subsequent days she developed a mildly tender right bump on her right chest, which had slowly begun to increase in size. She endorsed shortness of breath, chest pain, abdominal pain, headaches and dysuria, and denied fevers, agitation and confusion. Physical Exam On physical exam, the patient was afebrile and other vital signs were stable. A prominent swelling was noted on the right upper chest, mainly around the manubrium and sternum. The area was not obviously fluctuant, but was mildly tender to palpation. The rest of her exam was wholly unremarkable. Laboratory Studies Lab tests were drawn on the patient including a Complete Blood Count (CBC), Comprehensive Metabolic panel (CMP), Medical Blood Alcohol, Rapid Drug Screen and Blood Culture. Her white blood cell count was within normal limits, and her other CBC results were unremarkable. On CMP her blood glucose was elevated, and she had a mild hypokalemia and hypoalbuminemia. All other tests were within normal limits. Diagnostic Imaging A chest X-Ray was performed (Figure I), which showed no acute fracture or evidence of other recent trauma. A follow-up Chest CT was also performed (Figure II), which showed an ill-defined soft tissue swelling and deep and superficial subcutaneous edema in the right paramedian upper chest. This was centered at the right clavicular head, proximal first rib, and the manubrium. There was edema and thickening of the pectoralis muscle. The associated bones were fragmented with ill-defined erosion, and there was mild superior mediastinal node enlargement. Differentials included unusual presentation of localized severe trauma, septic joint with destructive osteomyelitis and associated deep and superficial cellulitis, and sarcoma/tumor. A needle biopsy of the manubrium, clavicle and 1st costomanubrial joint was performed under CT-guided IR. This was sent for culture, and infectious disease was consulted for antibiotic management. The patient was started on Zosyn 4.5 g IV q.8 hours and vancomycin 1.75 g IV q.12 hours. The patient was referred to the Cardiothoracic surgery for open drainage of sternoclavicular abscess with widespread debridement of soft tissue and bone. Hospital Course and Management Operative Procedure With informed consent, the patient was taken to the operating room where after adequate endotracheal intubation and anesthesia she was positioned, prepped and draped in the usual fashion. Next a curvilinear incision was made over the right clavicle down onto the upper sternum and manubrial area. This was carried deep until the manubrium was encountered. As the soft tissues were divided with electrocautery over the clavicle and abscess cavity was entered that had a proximally 20 ml of cloudy fluid. This was cultured. Soft tissue was then removed from the manubrial area as well as the anterior surface of the clavicle which was inflamed. A rongeur was then used to remove bony tissue in the manubrium until healthy bleeding bone was encountered. Soft tissues were debrided in the walls of the abscess cavity. The head of the clavicle which was totally separated from the manubrium was then removed with bites from a rongeur until healthy bleeding bone was encountered. These bony fragments were sent for Surgical Pathology. More phlegmacious soft tissue was removed with electrocautery until normal bleeding fatty tissue was also encountered. Adequate hemostasis was obtained. The cavity was then packed with 0.25% Dakin solution and a sterile dressing applied. Following surgery, the patient’s postoperative wound looked as shown in the images below (Figures III-V): Figure III: Wound 02/05/24 Incision Sternum Anterior;Upper Figure IV: Wound 02/05/24 Incision Sternum Anterior;Upper. Areas of necrosis encountered and debrided during procedure Figure V: Necrotic process infiltrating sternum, manubrium, and clavicle. Biopsy Results The sternal biopsy results read as follows: “Right Proximal Clavicle needle biopsy: Fragments of benign bone and cartilage with features of acute Osteomyelitis and severe inflammation surrounding soft tissue.” Blood and aspirate culture results were also positive for ESBL Escherichia coli with sensitivities shown in the table below (Table I). No other organisms were identified. Table 1: Antibiotic susceptibilities Antibiotics From Liquid media Escherischia coli (MIC) Sensitivities Ampicillin >=32 ug/ml Resistant Ampicillin + Sulbactam 8 ug/ml Susceptible Cefazolin >=64 ug/ml Resistant Cefepime - Resistant Ceftriaxone (Non-csf) 32 ug/ml Resistant Ciprofloxacin <0.25 ug/ml Susceptible Gentamicin <=1 ug/ml Susceptible Imipenem <=0.25 ug/ml Susceptible Levofloxacin 1 ug/ml Susceptible Piperacillin + Tazobactam <=4 ug/ml Susceptible Tobramycin =320 ug/ml Resistant The patient was diagnosed with Sternoclavicular Septic arthritis/osteomyelitis with ESBL E. coli on culture. Given the patient’s susceptibilities, her antibiotics were updated. Vancomycin and Zosyn were discontinued and Meropenem was initiated. On post op day 2, a wound VAC was placed to assist with the wound healing. Wound care management and discharge The patient remained in the hospital for an additional eight days following the procedure. Her white blood cell count was within normal limits, and she remained afebrile for the duration of her admission. The patient was a behavioral health admission and had little to no support to assist with her wound care and postoperative healing. Furthermore, she resided in an area with very limited outpatient wound VAC management options. As such a decision was made to keep her for a week to jump start her wound healing process, and for her to return to the outpatient wound care center 2 days following her discharge to monitor her wound VAC. She was discharged in the care of her godmother, who was her only current support system. The patient was seen by the wound care team at the appointed time 48 hours later, at which time the postsurgical was noted to be appropriate appearing, with no obvious exposed bone and no foul odor, as seen in the image below: Post Op day 10, wound edges looking healthy and healing appropriately. No obvious signs of infection or necrosis noted Hospital readmission Eight days after her outpatient follow-up, the patient presented to the ER with concerns of postoperative pain. She was postop day 18, and initially had an appointment to see wound care. She stated she was feeling unwell and as such decided to come to the ED to get her pain checked. She denied taking any home medications for pain. Additionally she endorsed suicidal thoughts and ideations, depressed mood, poor energy levels, and long periods of tiredness despite sleeping 10-12 hours a day. The patient stated she had a lot of stressors in her life including not having a stable living situation, not having many living family members or robust support system, and having to deal with the wound VAC with her recent osteomyelitis/abscess. She denied tobacco, alcohol, recreational drug use. During this ED presentation her wound looked as shown in the image below: Sternal incision site wound, it post op day 18. No evidence of erythema or infection After discussion with her prior treatment team, it was decided that she may not have the capacity to care for herself, her other chronic conditions and her surgical wound outside of the hospital. The decision was made to readmit her into the hospital. Her blood cultures were negative. She was evaluated by CV surgery and no interventions were recommended. She was started on ciprofloxacin 500 mg b.i.d. In addition to her regular medications. At the time of the writing of this paper, the patient had been in the hospital for 3 days. Her wound was healing nicely, with the wound VAC draining serosanguineous fluid. The patient remained afebrile, white blood cell count within normal limits, and no obvious signs of infection. At this time, the wound looked as seen in the picture below: Sternal incision site wound, it post op day 21. Wound healing appropriately, healthy pink tissue, no obvious signs of infection Her treatment team, particularly case management, continued to work on areas of placement given the patient’s housing instability and family issues. In the meantime the patient continued to receive inpatient treatment. At the time of the writing of this paper the patient was still admitted. Discussion This case describes a patient with a subacute, infectious, destructive process, secondary to previous trauma. In this case, the patient was diagnosed with septic arthritis and osteomyelitis of the sternoclavicular joint secondary to E. coli. While Septic arthritis and osteomyelitis can occur simultaneously, their pathophysiologies are slightly different. Septic arthritis is defined by an invasion of a joint space by microorganisms, particularly bacteria ( 1 ). This can occur by direct inoculation, contiguous spread from an infected site, or almost commonly via hematogenous spread. Osteomyelitis on the other hand, involves infection of bone that can occur due to hematogenous seeding or direct Extension. Sternoclavicular joint osteomyelitis is a rare disease, with less than 250 cases reported in the past 50 years ( 2 ). Septic arthritis of the sternoclavicular joint is a rare but serious disease with an incidence of 5.7 cases per 100,000 person years ( 9 ). Osteomyelitis can be acute, subacute or chronic. Acute osteomyelitis typically presents within 2 weeks of disease onset. Symptoms include local changes such as warmth, edema and erythema, with possible constitutional symptoms including fever, malaise, and lethargy. In subacute osteomyelitis, symptoms typically present within 2 weeks of disease onset, usually with mild or minimal pain, and little to no constitutional symptoms. Patients can also have concurrent septic arthritis if the joint capsule is involved ( 11 ). We performed a literature review of SCJ osteomyelitis and septic arthritis. A concise report of our results is listed in Table II below. Table 2: SCJ Osteomyelitis/Septic Arthritis literature review Criteria Findings/results Pubmed Search keywords : ● “Sternoclavicular osteomyelitis”: 164 hits ● “Rib osteomyelitis”: 295 hits ● “Sternoclavicular Septic Arthritis”: 302 hits ● “Sternoclavicular septic arthritis and osteomyelitis”: 63 hits ● “Sternoclavicular Osteomyelitis and “E. coli”: 6 hits ● Filtered by Case Reports only: 105 hits Most common Causative Agent : ● Staphylococcus aureus Other Causative Agents : ● Streptococcus agalactiae ● Streptococcus pneumoniae ● Escherichia coli ● Cutibacterium acnes ● Salmonella typhi ● Mycobacterium kansasii ● Moraxella nonliquefaciens ● Coxiella burnetii ● Aggregatibacter aphrophilus ● Mycobacteria ● Fungi ● Parasites ● Viruses Methods of infection : ● Hematogenous spread/seeding (most common) ● Direct inoculation/extension ● Contiguous spread from infected site Risk Factors : ● Diabetes mellitus ● Intravenous drug use, ● Trauma ● Central line associated bloodstream infections (CLABSI) ● Immunodeficiency ● Male sex ● Older age (50+) and Pediatric patients (neonates − 12yrs Common Signs and Symptoms : ● Fever ● Pain (chest, shoulder, generalized) ● In Subacute presentation, patients can be asymptomatic Mean duration of symptoms prior to presentation : ● 14 days Preferred Imaging Methods : ● Computed Tomography (CT) ● Magnetic Resonance Imaging (MRI) Treatment Modalities : ● Conservative (Antibiotics, fluids, antipyretics) ● Surgical (Drainage, Debridement, Washout) Most patients require surgical management. Complications : ● Bacteremia and sepsis ● Chest wall abscess ● Mediastinitis ● Phlegmon We searched PubMed with keywords “Sternoclavicular osteomyelitis,” which returned 164 hits. A search using the more generalized terms “Rib osteomyelitis” generated 295 articles. A narrowed search for “Sternoclavicular Osteomyelitis and “E. coli” returned 6 hits. We then searched PubMed using the terms “Sternoclavicular Septic Arthritis.” This returned 302 articles. “Sternoclavicular Osteomyelitis and Septic Arthritis” returned 63 articles. A filtered search for case reports only generated 105 articles. Per our review, the most common cause of osteomyelitis and septic arthritis is a bacterial infection secondary to Staphylococcus aureus ( 10 ) ( 15 ). Less common causes include Streptococcus agalactiae ( 18 ), Streptococcus pneumoniae ( 12 ), Escherichia coli ( 13 ), Cutibacterium acnes ( 3 ), Salmonella typhi ( 4 ), Mycobacterium kansasii ( 5 ), Moraxella nonliquefaciens ( 6 ), Coxiella burnetii ( 7 ), and rat bite fever ( 8 ). The top three risk factors for SCJ osteomyelitis/Septic Arthritis included Diabetes mellitus, Intravenous drug use and trauma ( 15 ). Central line associated bloodstream infections (CLABSI), distant site infections ( 16 ) and various forms of immunodeficiency ( 17 ) were also implicated. Of the case reports reviewed, 60% involved male patients. CT and MRI were the primary modalities for identification of the destructive and inflammatory processes of the involved bones and surrounding tissue. Joint fluid aspiration was used to detect the presence of causative organisms when septic arthritis was suspected. Treatment modalities included conservative therapy with IV fluids, antipyretics and anti-inflammatory medications. If these failed, surgical intervention was required, which included debridement of bone and washout of the septic joint. In our review 43.8% of cases required surgical intervention. In a review of 180 cases of SCJ septic arthritis performed by Ross and Shamsuddin in 2004 ( 16 ), the mean age of infected patients was 45, with 73% of cases being male patients. 77% had risk factors including Diabetes mellitus, trauma, IV drug use, and central line infection. However 23% presented with no prior risk factors. In 49% of the cases the causative agent was determined to be Staphylococcus aureus. In this review, CT and MRI were recommended to assess for complications and ongoing infectious processes. Surgical interventions recommended where indicated included surgical resection with empiric antibiotic coverage until the specific causative agents were identified. Our review of the literature closely aligns with this, and as such we support the recommendations for prompt identification and treatment when SCJ osteomyelitis/Septic arthritis is suspected to avoid complete destruction of bone and joint, and curtail possibly life-threatening complications. In the case of our patient, there were several risk factors that made her vulnerable to SCJ osteomyelitis and septic arthritis. The patient had a past medical history of Type II Diabetes, and had a recent history of trauma to the area. However, there are a number of reasons why we believe this was a uniquely interesting case. Firstly, as mentioned above in the introduction, the most common presentation of acute SCJ osteomyelitis/septic arthritis is fever and pain at the site. Our patient presented with no pain, and some mild discomfort, allowing for the diagnosis of her condition as subacute. Secondly, E. coli , the causative agent of the condition in this case, has been associated with SCJ Osteomyelitis and/or Septic Arthritis in only a handful of presentations. From our review of the PubMed database, few pertinent cases of the condition with this pathogen are reported. Luu et al. ( 13 ) describe a case of a patient with SCJ osteomyelitis in an immunocompetent patient with no prior history of trauma to the area, but with a concurrent urinary tract infection (UTI) and signs of prostatic abscess confirmed with imaging. When E. coli was cultured from both the abscess and the SCJ, it was concluded that the patient’s SCJ osteomyelitis had resulted from hematogenous spread of the bacteria to that area. In the case presented by Elshikh et al. ( 19 ), the patient presented with an acute case of SCJ osteomyelitis compounded by pleural involvement and subcutaneous emphysema diagnosed via CT scan. Our patient had a primary SCJ infection with no evidence of hematogenous seeding. We believe our case is the first reported of a primary subacute SCJ infection secondary to E. coli. Thirdly, our patient had a long behavioral health history to include suicidal attempts and ideations. Her family living situation was unstable, and prior to this visit and procedure she was constantly admitted and readmitted to the hospital and placed in temporary housing assignments. Her recovery was further complicated by the fact that wound vac care was limited in her home location. As such the patient remained in the hospital until suitable accommodations were arranged for her post-op care. Conclusion This case describes a patient who developed subacute SCJ osteomyelitis and septic arthritis secondary to a E. coli after a fall. The patient was treated with antibiotics initially, and after failure of medical treatment, a debridement and washout procedure was performed at the site of infection. The patient remained in hospital for a period of twenty one days, after which she was discharged with the expectation of a full recovery. Our patient case delves into the critical process of caring for patients needing surgical treatment, and the even more challenging issue of deciding how to navigate patients with medical, behavioral and socioeconomic limitations. The patient received care and treatment from a dedicated team of specialists including internists, cardiothoracic surgeons, infectious disease specialists and behavioral health case managers. This allowed for her to have excellent care for her current and previous medical conditions, and to remain close to prompt post-operative care until she was medically ready for discharge. Declarations Patient Consent Statement Written, informed consent was obtained from the patient for the publication of their case. Author Contribution VN wrote the main manuscript text and prepared the tables and figures. WH provided editing and subject matter expertise. Both authors reviewed and approved the final manuscript prior to submission References Brusch JL. Septic Arthritis. Medscape [serial online] 2014. Mar, [cited 2015 Sep 20]. Available from: http://emedicine.medscape.com/article/236299-overview. [Ref list] Khan K, Wozniak SE, Mehrabi E, Giannone AL, Dave M. Sternoclavicular osteomyelitis in an immunosuppressed patient: a case report and review of the literature. The American Journal of Case Reports. 2015;16:908. Yaphe S, Bahcheli K. Cutibacterium acnes sternoclavicular joint osteomyelitis in an otherwise healthy 55-year-old man. BMJ Case Rep . 2021;14(7):e241778. Published 2021 Jul 19. doi:10.1136/bcr-2021-241778 Princess I, Theckumparampil NPJ, Dorairajan SK. Salmonella Typhi sternoclavicular abscess with osteomyelitis-a rare case report. Indian J Thorac Cardiovasc Surg . 2024;40(2):250-253. doi:10.1007/s12055-023-01648-8 Bhatt K, Banavathi K. 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Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis, 56 (1997), pp. 470-475 Chiang C, Huang YC, Chang JM, Chen KH. Septic sternoclavicular arthritis, osteomyelitis and mediastinitis. Journal of Acute Medicine. 2016 Jun 1;6(2):46-8. Dobaria DG, Cohen HL. Osteomyelitis Imaging. 2023 Aug 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 37603633. Murthy R, Petrescu D, Salit IE. Osteomyelitis with a twist: Streptococcus pneumoniae causing sternoclavicular septic arthritis. Can J Infect Dis Med Microbiol . 2015;26(5):251-252. doi:10.1155/2015/426704 Luu T, Reid G, Lavery B. Escherichia coli associated hematogenous sternoclavicular joint osteomyelitis: A rare condition with a rare causative pathogen. IDCases . 2022;27:e01381. Published 2022 Jan 6. doi:10.1016/j.idcr.2022.e01381 Corey SA, Agger WA, Saterbak AT. 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Medicine (Baltimore) . 1998;77(2):122-139. doi:10.1097/00005792-199803000-00004 Elshikh A, Gowda N, Glass L, Maximos RB. Emphysematous osteomyelitis of the clavicle: a pleural process?. BMJ Case Rep . 2020;13(7):e235764. Published 2020 Jul 28. doi:10.1136/bcr-2020-235764 Additional Declarations No competing interests reported. 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-4237927","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":289489677,"identity":"9833f826-b9e9-4880-afbe-c5572222d946","order_by":0,"name":"Veronica Epah NKIE","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApElEQVRIiWNgGAWjYDACHsYGBoYKGId4LWdI0wLEjG2kaDHnOdz4mHeenTy/2AHGB2/bCOtgsOxtbDbm3ZZsOHN2ArPhXGK0GJxnbJOcuY05weB2Aps0L5Fa2n/OnFMP0sL+mzgtZxvbGD42HAbbwkycljMHmyU+HDsO9Etis+Scc0RpSX/4IaGmWp5fOvnghzdlRGhBAqA4HQWjYBSMglFAHQAAcHw1D02XdyIAAAAASUVORK5CYII=","orcid":"","institution":"Alabama College of Osteopathic Medicine","correspondingAuthor":true,"prefix":"","firstName":"Veronica","middleName":"Epah","lastName":"NKIE","suffix":""},{"id":289489678,"identity":"f780923f-ac3c-428f-8438-6a30a2fa69df","order_by":1,"name":"William David Hewitt","email":"","orcid":"","institution":"Southeast Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"William","middleName":"David","lastName":"Hewitt","suffix":""}],"badges":[],"createdAt":"2024-04-08 17:11:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4237927/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4237927/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55175581,"identity":"680dbf8c-a953-4d01-b648-663ed7de7388","added_by":"auto","created_at":"2024-04-23 16:14:10","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56047,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/6e385e4a40ad04183cf0908b.jpg"},{"id":55174716,"identity":"3336cdd1-0a09-42a8-9e54-704b54c0d437","added_by":"auto","created_at":"2024-04-23 16:06:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":63100,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/53199a2b85188072c5b20569.jpg"},{"id":55175580,"identity":"26ab9186-e3ea-4aeb-b468-77cf644e61aa","added_by":"auto","created_at":"2024-04-23 16:14:10","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":118220,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eWound 02/05/24 Incision Sternum Anterior;Upper\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/1a9b754ef7252df6562f37d6.jpg"},{"id":55175582,"identity":"faf08141-5272-400f-855b-4f22a30d6de5","added_by":"auto","created_at":"2024-04-23 16:14:11","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":81048,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eWound 02/05/24 Incision Sternum Anterior;Upper. Areas of necrosis encountered and debrided during procedure\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/b004cdf3874b8d4a3597eee5.jpg"},{"id":55174709,"identity":"3b724552-6c35-4af9-b4ad-3f583b7329fc","added_by":"auto","created_at":"2024-04-23 16:06:10","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":117655,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eNecrotic process infiltrating sternum, manubrium, and clavicle.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/98c05c9915984477bc9a16f2.jpg"},{"id":55175585,"identity":"572b537a-6ab0-4f5b-a26b-1293aa4bd12c","added_by":"auto","created_at":"2024-04-23 16:14:11","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":123829,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePost Op day 10, wound edges looking healthy and healing appropriately. No obvious signs of infection or necrosis noted\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/e6dad8cb222746413d238f91.jpg"},{"id":55174713,"identity":"cad36d4c-975b-42d5-9ec5-3b16e23dd05f","added_by":"auto","created_at":"2024-04-23 16:06:10","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":112157,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSternal incision site wound, it post op day 18. No evidence of erythema or infection\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/dea096a7d74f47e49c5e58d9.jpg"},{"id":55174714,"identity":"51ea9950-2c3d-448f-b0a3-32d4a95cdaa5","added_by":"auto","created_at":"2024-04-23 16:06:10","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":143462,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSternal incision site wound, it post op day 21. Wound healing appropriately, healthy pink tissue, no obvious signs of infection\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/9d4041e15a073b97c9a8c018.jpg"},{"id":67611852,"identity":"95089ea9-4c45-4b85-abb9-7295aa41c51f","added_by":"auto","created_at":"2024-10-28 05:55:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1578350,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4237927/v1/9cd2cd5f-08ff-49f8-a115-1807be163271.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnosis and Management of Subacute Sternoclavicular Osteomyelitis and Septic Arthritis Secondary to Escherichia coli Infection","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe sternoclavicular joint (SCJ) is a small, non weight bearing synovial joint. Although septic arthritis and osteomyelitis occur in joints and bones, they are rarely reported in the SCJ. Causes can be insidious or traumatic, and causative agents are usually bacterial, particularly Staphylococcus aureus (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Common symptoms include pain at the site and fevers. Patients with various comorbidities are susceptible, especially those with diabetes mellitus. Immunocompromised individuals such as intravenous drug users are also particularly susceptible. If left untreated, it can cause damage and dysfunction to the involved joint, leading to mortality from septic shock.\u003c/p\u003e \u003cp\u003eInfections of the SCJ by other bacteria are even less common, and in these cases presentation is variable. We present a particularly interesting case of subacute sternoclavicular septic arthritis and osteomyelitis in a patient complicated by Diabetes Mellitus and a long history of behavioral and psychiatric comorbidities.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003ePatient History\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 36 year-old female patient was admitted to the behavioral unit via the emergency department for suicidal thoughts and ideations. The patient had a past medical history of Anxiety, Bipolar I Disorder, Depression, Diabetes Mellitus, high cholesterol, hypertension, polycystic ovarian syndrome (PCOS), Schizophrenia, and previous suicide attempts and ideations. \u0026nbsp;Medications included Amantadine, 100 mg, oral, BID; Amlodipine, 5 mg, oral, Daily, Atorvastatin, 40 mg, oral, Nightly, Ciprofloxacin, 500 mg, oral, q12h SCH, Enoxaparin, 40 mg, subcutaneous, q24h, Insulin Aspart, 1-15 Units, subcutaneous, Insulin detemir, 10 Units, subcutaneous, q AM, Levetiracetam, 500 mg, oral, BID, Magnesium oxide, 400 mg, oral, BID, and Risperidone, 3 mg, oral, Nightly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSurgical history included cyst removal and wound debridement. She was a current smoker, and did not drink alcohol or use illicit drugs. The patient stated she was asleep two weeks prior and had rolled and fallen off her bed, striking her chest during the fall. In the subsequent days she developed a mildly tender right bump on her right chest, which had slowly begun to increase in size. She endorsed shortness of breath, chest pain, abdominal pain, headaches and dysuria, and denied fevers, agitation and confusion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003ePhysical Exam\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn physical exam, the patient was afebrile and other vital signs were stable. A prominent swelling was noted on the right upper chest, mainly around the manubrium and sternum. The area was not obviously fluctuant, but was mildly tender to palpation. The rest of her exam was wholly unremarkable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eLaboratory Studies\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLab tests were drawn on the patient including a Complete Blood Count (CBC), Comprehensive Metabolic panel (CMP), Medical Blood Alcohol, Rapid Drug Screen and Blood Culture. Her white blood cell count was within normal limits, and her other CBC results were unremarkable. On CMP her blood glucose was elevated, and she had a mild hypokalemia and hypoalbuminemia. All other tests were within normal limits.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eDiagnostic Imaging\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA chest X-Ray was performed (Figure I), which showed no acute fracture or evidence of other recent trauma. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA follow-up Chest CT was also \u0026nbsp;performed (Figure II), which showed an ill-defined soft tissue swelling and deep and superficial subcutaneous edema in the right paramedian upper chest. This was centered at the right clavicular head, proximal first rib, and the manubrium. There was edema and thickening of the pectoralis muscle. The associated bones were fragmented with ill-defined erosion, and there was mild superior mediastinal node enlargement. Differentials included unusual presentation of localized severe trauma, septic joint with destructive osteomyelitis and associated deep and superficial cellulitis, and sarcoma/tumor.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA needle biopsy of the manubrium, clavicle and 1st costomanubrial joint was performed under CT-guided IR. This was sent for culture, and infectious disease was consulted for antibiotic management. The patient was started on \u0026nbsp;Zosyn 4.5 g IV q.8 hours and vancomycin 1.75 g IV q.12 hours. The patient was referred to the Cardiothoracic surgery for open drainage of sternoclavicular abscess with widespread debridement of soft tissue and bone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eHospital Course and Management\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eOperative Procedure\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWith informed consent, the patient was taken to the operating room where after adequate endotracheal intubation and anesthesia she was positioned, prepped and draped in the usual fashion. Next a curvilinear incision was made over the right clavicle down onto the upper sternum and manubrial area. This was carried deep until the manubrium was encountered. \u0026nbsp; As the soft tissues were divided with electrocautery over the clavicle and abscess cavity was entered that had a proximally 20 ml of cloudy fluid. This was cultured.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSoft tissue was then removed from the manubrial area as well as the anterior surface of the clavicle which was inflamed. A rongeur was then used to remove bony tissue in the manubrium until healthy bleeding bone was encountered. \u0026nbsp;Soft tissues were debrided in the walls of the abscess cavity. The head of the clavicle which was totally separated from the manubrium was then removed with bites from a rongeur until healthy bleeding bone was encountered. \u0026nbsp;These bony fragments were sent for Surgical Pathology. More phlegmacious soft tissue was removed with electrocautery until normal bleeding fatty tissue was also encountered. Adequate hemostasis was obtained. \u0026nbsp;The cavity was then packed with 0.25% Dakin solution and a sterile dressing applied. Following surgery, the patient\u0026rsquo;s postoperative wound looked as shown in the images below (Figures III-V):\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFigure III: Wound 02/05/24 Incision Sternum Anterior;Upper\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cstrong\u003e\u003cem\u003eFigure IV: Wound 02/05/24 Incision Sternum Anterior;Upper. Areas of necrosis encountered and debrided during procedure\u003c/em\u003e\u003c/strong\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cstrong\u003e\u003cem\u003e\u003cstrong\u003e\u003cem\u003eFigure V: Necrotic process infiltrating sternum, manubrium, and clavicle.\u003c/em\u003e\u003c/strong\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eBiopsy Results\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sternal biopsy results read as follows: \u0026ldquo;Right Proximal Clavicle needle biopsy: Fragments of benign bone and cartilage with features of acute Osteomyelitis and severe inflammation surrounding soft tissue.\u0026rdquo; Blood and aspirate culture results were also positive for ESBL Escherichia coli with sensitivities shown in the table below (Table I). No other organisms were identified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1: Antibiotic susceptibilities\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntibiotics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrom Liquid media Escherischia coli\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(MIC)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSensitivities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eAmpicillin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;=32 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eResistant\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eAmpicillin + Sulbactam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e8 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSusceptible\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eCefazolin\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;=64 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eResistant\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eCefepime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eResistant\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eCeftriaxone (Non-csf)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e32 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eResistant\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eCiprofloxacin\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.25 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSusceptible\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eGentamicin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;=1 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSusceptible\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eImipenem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;=0.25 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSusceptible\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eLevofloxacin\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSusceptible\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003ePiperacillin + Tazobactam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;=4 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSusceptible\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eTobramycin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;=1 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eSusceptible\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eTrimethoprim + Sulfamethoxazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;=320 ug/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eResistant\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe patient was diagnosed with Sternoclavicular Septic arthritis/osteomyelitis with ESBL E. coli on culture. \u0026nbsp;Given the patient\u0026rsquo;s susceptibilities, her antibiotics were updated. Vancomycin and Zosyn were discontinued and Meropenem was initiated. \u0026nbsp; On post op day 2, a wound VAC was placed to assist with the wound healing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eWound care management and discharge\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient remained in the hospital for an additional eight days following the procedure. \u0026nbsp; Her white blood cell count was within normal limits, and she remained afebrile for the duration of her admission. The patient was a behavioral health admission and had little to no support to assist with her wound care and postoperative healing. \u0026nbsp;Furthermore, she resided in an area with very limited outpatient wound VAC management options. As such a decision was made to keep her for a week to jump start her wound healing process, and for her to return to the \u0026nbsp; outpatient wound care center 2 days following her discharge to monitor her wound VAC. \u0026nbsp;She was discharged in the care of her godmother, who was her only current support system.\u003c/p\u003e\n\u003cp\u003eThe patient was seen by the wound care team at the appointed time 48 hours later, at which time the postsurgical was noted to be appropriate appearing, with no obvious exposed bone and no foul odor, as seen in the image below:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePost Op day 10, wound edges looking healthy and healing appropriately. \u0026nbsp;No obvious signs of infection or necrosis noted\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003e\u0026nbsp;Hospital readmission\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Eight days after her outpatient follow-up, the patient presented to the ER with concerns of postoperative pain. \u0026nbsp;She was postop day 18, and initially had an appointment to see wound care. \u0026nbsp;She stated she was feeling unwell and as such decided to come to the ED to get her pain checked. \u0026nbsp;She denied taking any home medications for pain. \u0026nbsp;Additionally she endorsed suicidal thoughts and ideations, depressed mood, poor energy levels, \u0026nbsp;and long periods of tiredness despite sleeping \u0026nbsp;10-12 hours a day. \u0026nbsp; The patient stated she had a lot of stressors in her life including not having a stable living situation, not having many living family members or robust support system, and having to deal with the wound VAC with her recent osteomyelitis/abscess. She denied tobacco, alcohol, recreational drug use. \u0026nbsp;During this ED presentation her wound looked as shown in the image below:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSternal incision site wound, it post op day 18. \u0026nbsp; No evidence of erythema or infection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;After discussion with her prior treatment team, it was decided that she may not have the capacity to care for herself, \u0026nbsp;her other chronic conditions and her \u0026nbsp;surgical wound outside of the hospital. \u0026nbsp;The decision was made to readmit her into the hospital. Her blood cultures were negative. She was evaluated by CV surgery and no interventions were recommended. She was started on ciprofloxacin 500 mg b.i.d. In addition to her regular medications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the time of the writing of this paper, the patient had been in the hospital for 3 days. \u0026nbsp;Her wound was healing nicely, with the wound VAC draining serosanguineous fluid. \u0026nbsp; \u0026nbsp;The patient remained afebrile, white blood cell count within normal limits, and no obvious signs of infection. \u0026nbsp; At this time, the wound looked as seen in the picture below:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSternal incision site wound, it post op day 21. \u0026nbsp; Wound healing appropriately, healthy pink tissue, no obvious signs of infection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHer treatment team, particularly case management, continued to work on areas of placement given the patient\u0026rsquo;s housing instability and family issues. In the meantime the patient continued to receive inpatient treatment. At the time of the writing of this paper the patient was still admitted.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case describes a patient with a subacute, infectious, destructive process, secondary to previous trauma. In this case, the patient was diagnosed with septic arthritis and osteomyelitis of the sternoclavicular joint secondary to \u003cem\u003eE. coli.\u003c/em\u003e While Septic arthritis and osteomyelitis can occur simultaneously, their pathophysiologies are slightly different. Septic arthritis is defined by an invasion of a joint space by microorganisms, particularly bacteria (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). This can occur by direct inoculation, contiguous spread from an infected site, or almost commonly via hematogenous spread. Osteomyelitis on the other hand, involves infection of bone that can occur due to hematogenous seeding or direct Extension. Sternoclavicular joint osteomyelitis is a rare disease, with less than 250 cases reported in the past 50 years (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). Septic arthritis of the sternoclavicular joint is a rare but serious disease with an incidence of 5.7 cases per 100,000 person years (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eOsteomyelitis can be acute, subacute or chronic. Acute osteomyelitis typically presents within 2 weeks of disease onset. Symptoms include local changes such as warmth, edema and erythema, with possible constitutional symptoms including fever, malaise, and lethargy. In subacute osteomyelitis, symptoms typically present within 2 weeks of disease onset, usually with mild or minimal pain, and little to no constitutional symptoms. Patients can also have concurrent septic arthritis if the joint capsule is involved (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eWe performed a literature review of SCJ osteomyelitis and septic arthritis. A concise report of our results is listed in Table II below.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cstrong\u003e\u003cem\u003eTable 2: SCJ Osteomyelitis/Septic Arthritis literature review\u003c/em\u003e\u003c/strong\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCriteria\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFindings/results\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePubmed Search keywords\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● \u0026ldquo;Sternoclavicular osteomyelitis\u0026rdquo;: 164 hits\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;Rib osteomyelitis\u0026rdquo;: 295 hits\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;Sternoclavicular Septic Arthritis\u0026rdquo;: 302 hits\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;Sternoclavicular septic arthritis and osteomyelitis\u0026rdquo;: 63 hits\u003c/p\u003e\n \u003cp\u003e● \u0026ldquo;Sternoclavicular Osteomyelitis and \u0026ldquo;E. coli\u0026rdquo;: 6 hits\u003c/p\u003e\n \u003cp\u003e● Filtered by Case Reports only: 105 hits\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMost common Causative Agent\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Staphylococcus aureus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther Causative Agents\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Streptococcus agalactiae\u003c/p\u003e\n \u003cp\u003e● Streptococcus pneumoniae\u003c/p\u003e\n \u003cp\u003e● Escherichia coli\u003c/p\u003e\n \u003cp\u003e● Cutibacterium acnes\u003c/p\u003e\n \u003cp\u003e● Salmonella typhi\u003c/p\u003e\n \u003cp\u003e● Mycobacterium kansasii\u003c/p\u003e\n \u003cp\u003e● Moraxella nonliquefaciens\u003c/p\u003e\n \u003cp\u003e● Coxiella burnetii\u003c/p\u003e\n \u003cp\u003e● Aggregatibacter aphrophilus\u003c/p\u003e\n \u003cp\u003e● Mycobacteria\u003c/p\u003e\n \u003cp\u003e● Fungi\u003c/p\u003e\n \u003cp\u003e● Parasites\u003c/p\u003e\n \u003cp\u003e● Viruses\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethods of infection\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Hematogenous spread/seeding (most common)\u003c/p\u003e\n \u003cp\u003e● Direct inoculation/extension\u003c/p\u003e\n \u003cp\u003e● Contiguous spread from infected site\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk Factors\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Diabetes mellitus\u003c/p\u003e\n \u003cp\u003e● Intravenous drug use,\u003c/p\u003e\n \u003cp\u003e● Trauma\u003c/p\u003e\n \u003cp\u003e● Central line associated bloodstream infections (CLABSI)\u003c/p\u003e\n \u003cp\u003e● Immunodeficiency\u003c/p\u003e\n \u003cp\u003e● Male sex\u003c/p\u003e\n \u003cp\u003e● Older age (50+) and Pediatric patients (neonates \u0026minus;\u0026thinsp;12yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommon Signs and Symptoms\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Fever\u003c/p\u003e\n \u003cp\u003e● Pain (chest, shoulder, generalized)\u003c/p\u003e\n \u003cp\u003e● In Subacute presentation, patients can be asymptomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean duration of symptoms prior to presentation\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● 14 days\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreferred Imaging Methods\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Computed Tomography (CT)\u003c/p\u003e\n \u003cp\u003e● Magnetic Resonance Imaging (MRI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment Modalities\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Conservative (Antibiotics, fluids, antipyretics)\u003c/p\u003e\n \u003cp\u003e● Surgical (Drainage, Debridement, Washout)\u003c/p\u003e\n \u003cp\u003eMost patients require surgical management.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e● Bacteremia and sepsis\u003c/p\u003e\n \u003cp\u003e● Chest wall abscess\u003c/p\u003e\n \u003cp\u003e● Mediastinitis\u003c/p\u003e\n \u003cp\u003e● Phlegmon\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eWe searched PubMed with keywords \u0026ldquo;Sternoclavicular osteomyelitis,\u0026rdquo; which returned 164 hits. A search using the more generalized terms \u0026ldquo;Rib osteomyelitis\u0026rdquo; generated 295 articles. A narrowed search for \u0026ldquo;Sternoclavicular Osteomyelitis and \u0026ldquo;E. coli\u0026rdquo; returned 6 hits. We then searched PubMed using the terms \u0026ldquo;Sternoclavicular Septic Arthritis.\u0026rdquo; This returned 302 articles. \u0026ldquo;Sternoclavicular Osteomyelitis and Septic Arthritis\u0026rdquo; returned 63 articles. A filtered search for case reports only generated 105 articles.\u003c/p\u003e\n\u003cp\u003ePer our review, the most common cause of osteomyelitis and septic arthritis is a bacterial infection secondary to Staphylococcus aureus (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e) (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). Less common causes include Streptococcus agalactiae (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e), Streptococcus pneumoniae (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e), Escherichia coli (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e), Cutibacterium acnes (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e), Salmonella typhi (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e), Mycobacterium kansasii (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e), Moraxella nonliquefaciens (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e), Coxiella burnetii (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e), and rat bite fever (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). The top three risk factors for SCJ osteomyelitis/Septic Arthritis included Diabetes mellitus, Intravenous drug use and trauma (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). Central line associated bloodstream infections (CLABSI), distant site infections (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e) and various forms of immunodeficiency (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e) were also implicated.\u003c/p\u003e\n\u003cp\u003eOf the case reports reviewed, 60% involved male patients. CT and MRI were the primary modalities for identification of the destructive and inflammatory processes of the involved bones and surrounding tissue. Joint fluid aspiration was used to detect the presence of causative organisms when septic arthritis was suspected. Treatment modalities included conservative therapy with IV fluids, antipyretics and anti-inflammatory medications. If these failed, surgical intervention was required, which included debridement of bone and washout of the septic joint. In our review 43.8% of cases required surgical intervention.\u003c/p\u003e\n\u003cp\u003eIn a review of 180 cases of SCJ septic arthritis performed by Ross and Shamsuddin in 2004 (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e), the mean age of infected patients was 45, with 73% of cases being male patients. 77% had risk factors including Diabetes mellitus, trauma, IV drug use, and central line infection. However 23% presented with no prior risk factors. In 49% of the cases the causative agent was determined to be Staphylococcus aureus. In this review, CT and MRI were recommended to assess for complications and ongoing infectious processes. Surgical interventions recommended where indicated included surgical resection with empiric antibiotic coverage until the specific causative agents were identified. Our review of the literature closely aligns with this, and as such we support the recommendations for prompt identification and treatment when SCJ osteomyelitis/Septic arthritis is suspected to avoid complete destruction of bone and joint, and curtail possibly life-threatening complications.\u003c/p\u003e\n\u003cp\u003eIn the case of our patient, there were several risk factors that made her vulnerable to SCJ osteomyelitis and septic arthritis. The patient had a past medical history of Type II Diabetes, and had a recent history of trauma to the area. However, there are a number of reasons why we believe this was a uniquely interesting case. Firstly, as mentioned above in the introduction, the most common presentation of acute SCJ osteomyelitis/septic arthritis is fever and pain at the site. Our patient presented with no pain, and some mild discomfort, allowing for the diagnosis of her condition as subacute.\u003c/p\u003e\n\u003cp\u003eSecondly, \u003cem\u003eE. coli\u003c/em\u003e, the causative agent of the condition in this case, has been associated with SCJ Osteomyelitis and/or Septic Arthritis in only a handful of presentations. From our review of the PubMed database, few pertinent cases of the condition with this pathogen are reported. Luu et al. (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e) describe a case of a patient with SCJ osteomyelitis in an immunocompetent patient with no prior history of trauma to the area, but with a concurrent urinary tract infection (UTI) and signs of prostatic abscess confirmed with imaging. When \u003cem\u003eE. coli\u003c/em\u003e was cultured from both the abscess and the SCJ, it was concluded that the patient\u0026rsquo;s SCJ osteomyelitis had resulted from hematogenous spread of the bacteria to that area. In the case presented by Elshikh et al. (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e), the patient presented with an acute case of SCJ osteomyelitis compounded by pleural involvement and subcutaneous emphysema diagnosed via CT scan. Our patient had a primary SCJ infection with no evidence of hematogenous seeding. We believe our case is the first reported of a primary subacute SCJ infection secondary to \u003cem\u003eE. coli.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThirdly, our patient had a long behavioral health history to include suicidal attempts and ideations. Her family living situation was unstable, and prior to this visit and procedure she was constantly admitted and readmitted to the hospital and placed in temporary housing assignments. Her recovery was further complicated by the fact that wound vac care was limited in her home location. As such the patient remained in the hospital until suitable accommodations were arranged for her post-op care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case describes a patient who developed subacute SCJ osteomyelitis and septic arthritis secondary to a \u003cem\u003eE. coli\u003c/em\u003e after a fall. The patient was treated with antibiotics initially, and after failure of medical treatment, a debridement and washout procedure was performed at the site of infection. The patient remained in hospital for a period of twenty one days, after which she was discharged with the expectation of a full recovery. Our patient case delves into the critical process of caring for patients needing surgical treatment, and the even more challenging issue of deciding how to navigate patients with medical, behavioral and socioeconomic limitations. The patient received care and treatment from a dedicated team of specialists including internists, cardiothoracic surgeons, infectious disease specialists and behavioral health case managers. This allowed for her to have excellent care for her current and previous medical conditions, and to remain close to prompt post-operative care until she was medically ready for discharge.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003ePatient Consent Statement\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten, informed consent was obtained from the patient for the publication of their case.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eVN wrote the main manuscript text and prepared the tables and figures. WH provided editing and subject matter expertise. Both authors reviewed and approved the final manuscript prior to submission\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBrusch JL. Septic Arthritis. Medscape [serial online] 2014. Mar, [cited 2015 Sep 20]. Available from: http://emedicine.medscape.com/article/236299-overview. [Ref list]\u003c/li\u003e\n\u003cli\u003eKhan K, Wozniak SE, Mehrabi E, Giannone AL, Dave M. Sternoclavicular osteomyelitis in an immunosuppressed patient: a case report and review of the literature. The American Journal of Case Reports. 2015;16:908.\u003c/li\u003e\n\u003cli\u003eYaphe S, Bahcheli K. \u003cem\u003eCutibacterium acnes\u003c/em\u003e sternoclavicular joint osteomyelitis in an otherwise healthy 55-year-old man. \u003cem\u003eBMJ Case Rep\u003c/em\u003e. 2021;14(7):e241778. Published 2021 Jul 19. doi:10.1136/bcr-2021-241778\u003c/li\u003e\n\u003cli\u003ePrincess I, Theckumparampil NPJ, Dorairajan SK. \u003cem\u003eSalmonella Typhi\u003c/em\u003e sternoclavicular abscess with osteomyelitis-a rare case report. \u003cem\u003eIndian J Thorac Cardiovasc Surg\u003c/em\u003e. 2024;40(2):250-253. doi:10.1007/s12055-023-01648-8\u003c/li\u003e\n\u003cli\u003eBhatt K, Banavathi K. \u003cem\u003eMycobacterium kansasii\u003c/em\u003e osteomyelitis - a masquerading disease. \u003cem\u003eJMM Case Rep\u003c/em\u003e. 2018;5(1):e005114. Published 2018 Jan 2. doi:10.1099/jmmcr.0.005114\u003c/li\u003e\n\u003cli\u003eSaad Aldin E, Sekar P, Saad Eddin Z, Keller J, Pollard J. Incidental diagnosis of sternoclavicular septic arthritis with \u003cem\u003eMoraxella nonliquefaciens\u003c/em\u003e. \u003cem\u003eIDCases\u003c/em\u003e. 2018;12:44-46. Published 2018 Mar 14. doi:10.1016/j.idcr.2018.03.011\u003c/li\u003e\n\u003cli\u003eAngelakis E, Thiberville SD, Million M, Raoult D. Sternoclavicular joint infection caused by Coxiella burnetii: a case report. \u003cem\u003eJ Med Case Rep\u003c/em\u003e. 2016;10(1):139. Published 2016 May 31. doi:10.1186/s13256-016-0948-x\u003c/li\u003e\n\u003cli\u003ePena E, Jord\u0026atilde;o S, Sim\u0026otilde;es MJ, Oleastro M, Neves I. A rare cause of vertebral osteomyelitis: the first case report of rat-bite fever in Portugal. \u003cem\u003eRev Soc Bras Med Trop\u003c/em\u003e. 2019;53:e20190328. Published 2019 Dec 20. doi:10.1590/0037-8682-0328-2019\u003c/li\u003e\n\u003cli\u003eC.J. Kaandorp, H.J. Dinant, M.A. van de Laar, H.J. Moens, A.P. Prins, B.A. Dijkmans. Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis, 56 (1997), pp. 470-475\u003c/li\u003e\n\u003cli\u003eChiang C, Huang YC, Chang JM, Chen KH. Septic sternoclavicular arthritis, osteomyelitis and mediastinitis. Journal of Acute Medicine. 2016 Jun 1;6(2):46-8.\u003c/li\u003e\n\u003cli\u003eDobaria DG, Cohen HL. Osteomyelitis Imaging. 2023 Aug 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan\u0026ndash;. PMID: 37603633.\u003c/li\u003e\n\u003cli\u003eMurthy R, Petrescu D, Salit IE. Osteomyelitis with a twist: Streptococcus pneumoniae causing sternoclavicular septic arthritis. \u003cem\u003eCan J Infect Dis Med Microbiol\u003c/em\u003e. 2015;26(5):251-252. doi:10.1155/2015/426704\u003c/li\u003e\n\u003cli\u003eLuu T, Reid G, Lavery B. \u003cem\u003eEscherichia coli\u003c/em\u003e associated hematogenous sternoclavicular joint osteomyelitis: A rare condition with a rare causative pathogen. \u003cem\u003eIDCases\u003c/em\u003e. 2022;27:e01381. Published 2022 Jan 6. doi:10.1016/j.idcr.2022.e01381\u003c/li\u003e\n\u003cli\u003eCorey SA, Agger WA, Saterbak AT. Acromioclavicular septic arthritis and sternoclavicular septic arthritis with contiguous pyomyositis. \u003cem\u003eClin Orthop Surg\u003c/em\u003e. 2015;7(1):131-134. doi:10.4055/cios.2015.7.1.131\u003c/li\u003e\n\u003cli\u003eCostales C, Butler-Wu SM. A Real Pain: Diagnostic Quandaries and Septic Arthritis. \u003cem\u003eJ Clin Microbiol\u003c/em\u003e. 2018;56(2):e01358-17. Published 2018 Jan 24. doi:10.1128/JCM.01358-17\u003c/li\u003e\n\u003cli\u003eRoss JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e. 2004;83(3):139-148. doi:10.1097/01.md.0000126761.83417.29\u003c/li\u003e\n\u003cli\u003eCarlos GN, Kesler KA, Coleman JJ, Broderick L, Turrentine MW, Brown JW. Aggressive surgical management of sternoclavicular joint infections. \u003cem\u003eJ Thorac Cardiovasc Surg\u003c/em\u003e. 1997;113(2):242-247. doi:10.1016/S0022-5223(97)70319-2\u003c/li\u003e\n\u003cli\u003eSchattner A, Vosti KL. Bacterial arthritis due to beta-hemolytic streptococci of serogroups A, B, C, F, and G. Analysis of 23 cases and a review of the literature. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e. 1998;77(2):122-139. doi:10.1097/00005792-199803000-00004\u003c/li\u003e\n\u003cli\u003eElshikh A, Gowda N, Glass L, Maximos RB. Emphysematous osteomyelitis of the clavicle: a pleural process?. \u003cem\u003eBMJ Case Rep\u003c/em\u003e. 2020;13(7):e235764. Published 2020 Jul 28. doi:10.1136/bcr-2020-235764\u003c/li\u003e\n\u003c/ol\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":false,"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, Osteomyelitis, Septic Arthritis, E. coli, Debridement, Cardiothoracic, Behavioral health","lastPublishedDoi":"10.21203/rs.3.rs-4237927/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4237927/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSternoclavicular Joint (SCJ) Osteomyelitis is a rare condition that can arise from a number of causes including trauma, infection via direct inoculation or hematogenous seeding. It is commonly caused by Staphylococcus aureus, and infrequently by other bacteria. Only cases of E. coli osteomyelitis have been reported in the literature. Patients with risk factors such as Diabetes, smoking history, and intravenous drug use are particularly susceptible. When infection seeds the joint space, septic arthritis can occur concurrently. Acute and subacute presentations of SCJ osteomyelitis and septic arthritis have been documented, with treatment modalities ranging from conservative treatment to surgical management.\u003c/p\u003e \u003cp\u003eWe describe a patient with an interesting case of SCJ Osteomyelitis with concurrent Septic Arthritis secondary to trauma to the area from a fall. We detail the patient\u0026rsquo;s presentation, hospital admission and course of treatment. We delve into her pre-existing conditions and comorbidities and outline the many challenges we faced in managing the patient from onset of presentation into recovery. We also perform a literature review of previously reported cases of SCJ Osteomyelitis. We determine that less than 350 cases have been identified and described in the literature, and we outline examples of some of these while comparing and contrasting pertinent aspects of some of these cases with our patient\u0026rsquo;s presentation and hospital course.\u003c/p\u003e \u003cp\u003eSCJ Osteomyelitis and Septic Arthritis is a rare condition that warrants prompt identification and management to prevent destruction of bone and joint, bacteremia and sepsis, or other debilitating complications. A multidisciplinary approach must be therefore undertaken in caring for patients with existing comorbidities and/or risk factors. This includes expeditious testing and identification of causative organisms, administration of appropriate antibiotics and antipyretics as needed, and swift determination of patients' need for surgery to curtail the spread of infection and restore bone and joint health.\u003c/p\u003e","manuscriptTitle":"Diagnosis and Management of Subacute Sternoclavicular Osteomyelitis and Septic Arthritis Secondary to Escherichia coli Infection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-23 16:06:05","doi":"10.21203/rs.3.rs-4237927/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":"c226d1f7-ca27-4c23-b63f-a84a4ecba8d9","owner":[],"postedDate":"April 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T05:39:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-23 16:06:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4237927","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4237927","identity":"rs-4237927","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}