75 yo CF with PMH of (B) hip replacement and right knee replacement is
admitted to the hospital with CC: left leg pain and weakness for 5 days.
PMH:
Seven left hip replacements, one left knee replacement 10 years ago. She developed a septic arthritis of left knee 2 years ago and was treated with antibiotics. She was treated with antibiotic suppressive therapy of Cipro and Rifampin and was doing reasonably well.
Two months ago the ID specialist stopped her Rifampin and Cipro dose was cut down from 500 mg PO bid to 250 bid.
What do you think is going on?
Joint infection?
Cellulitis?
DVT?
Physical examination:
T 37.5 C
Extremities: Two red hot areas over the right hip and knee. There is an indurated painful
bump above and laterally to the right knee.
What to do?
BC x 2 and start urgent antibiotic treatment
Recommended ABx are Vanco and Cipro
Don't forget to adjust the dose for CrCl
What labs would you order?
CBCD, CMP, BC, X-rays - right hip and knee
TKR infection-Labs; ESR and CRP (click to enlarge)
Consults?
ID and Orthopedics
Hou would you work-up the anemia?
Fe profile anf ferritin, B 12, Folate, FOBT x 2, Reticulocute count
Fe profile showed IDA. Iron 300 mg IV qod was started.
She will have a GI evaluation of the anemia as an outpatient.
What happened?
Patient felt much better after one day of ABx treatment.
X-rays showed osteomyelitis of the right hip and knee.
There was a pseudoarthrosis and abscess formation around the knee.
Old XR; New XR and close-up; R Knee XR repor (click to enlarge);
Old XR with intact cortex; New XR showing cortex destruction - osteomyelitis, the metallic rod had migrated down the bone canal
New XR of the hips; R hip XR report
Arthrogram of the right hip and knee; Arthrogram report - injected dye spreads in the soft tissues of the thigh indicating a communication between the joint space and the outside tissues
An orthopedic surgeon was consulted. Patient is scheduled to have surgery with a femur replacement once the infection is conrolled.
What did we learn from this case?
In patients with a joint replacement an infection of the joint is always a possibility.
Rule out DVT when there is a clinical suspicion.
source:http://clinicalcases.org
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