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Ann Thorac Surg 2007;83:1190-1194
© 2007 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
b Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
Accepted for publication July 18, 2006.
* Address correspondence to Mr Walker, Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, UK (Email: william.walker{at}luht.scot.nhs.uk).
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Introduction |
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A 28-year-old man was referred to the cardiothoracic unit with a mass at the manubriosternal area. He was a well-built, active rugby player representing a local club and also worked as a joiner. Before his admission, he presented 10 days earlier to the emergency department with chest pain secondary to a "strain" endured at work after heavy lifting. He received opiate analgesia and was discharged home.
He was subsequently admitted with worsening central chest pain and swelling over the manubriosternal area. The symptoms were aggravated by any movement, stooping down particularly. Systems review was unremarkable, including any chest or urinary symptom. He had previously undergone two elective open distal clavicle resections, 7 months and 1 year previously, both with uneventful recovery. He was otherwise fit without significant medical history. He denied any substance abuse or risk factor for HIV infection. He was a nonsmoker, and there was no history of alcohol excess. There was no recent travel history.
On admission, he had temperature 38.9°C, white cell count of 11.7 x 109/L, C-reactive protein level of more than 300 mg/L, and an erythrocyte sedimentation rate of 96 mm/h. He had a tender, fluctuant swelling over the manubriosternal joint. A chest roentgenogram (posteroanterior view) showed left lower lobe collapse. An echocardiogram, which was requested to exclude pericarditis, showed a mass impinging on the right ventricle. A computed tomography (CT) chest scan showed a 7-cm inflammatory mass centered on the manubriosternal joint with mixed fluid and gas density. The mass extended anteriorly into the subcutaneous tissue and posteriorly into anterior mediastinum but did not directly involve the heart or pericardium. The manubriosternal joint looked irregular and widened (Fig 1). There was a partial collapse of the left lower lobe with small bibasal effusions.
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One blood culture sample grew diphtheroids of doubtful significance. Several cultures including pus from the joint, blood, urine, and stool failed to yield any organism. Microscopic examination of the drained abscess revealed many pus cells but no organism. Test for acid-fast bacillus was negative.
He was discharged home with regular wound dressing under the care of the district nurse until 6 weeks after the initial operation. He was well and the wound had healed completely at 6 months’ follow-up (Fig 2, right).
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The source of this rare infection is conjectural. Both local and hematogenous spread from elsewhere has been proposed. The primary focus of bacteremic spread has included septic knee arthritis, cellulitis, and gastrointestinal infection [3, 6, 8]. Locally deranged joint anatomy predisposes to septic arthritis hence underlying inflammatory joint disorder is a risk factor. Manubriosternal joint involvement in seronegative arthritides is well reported.
Although the underlying condition in our patient leading to manubriosternal pyarthrosis remains elusive, onset of chest pain after heavy lifting and subsequent subclinical hematoma formation may have led to superimposed infection.
Relevant Anatomy
Septic arthritis is far more common in the synovial joint than in other types of joints. The manubriosternal joint is a secondary cartilaginous joint (symphysis) that represents a fibrocartilaginous union of the lower edge of the manubrium and the upper edge of the sternum, each covered by a hyaline cartilage. Suppurative involvement of the intervertebral discs (a symphysis) is well established. Although approximately 100 cases have been reported, involvement of the symphysis pubis is still uncommon [10]. The occurrence of manubriosternal septic arthritis is exceptionally rare.
Anatomically adjacent to the manubriosternal junction is the sternoclavicular joint, an atypical synovial joint. Septic arthritis involving this joint is relatively rare but far better known than the manubriosternal infection. Septic arthritis of both the sternoclavicular and manubriosternal joints seems to occur in younger age group (mean age, 45) compared with infection of other joints [11]. The most common risk factor is intravenous drug abuse, this being related to upper limb injection, and subclavian phlebitis, neck injection, and potential needle breech into the joint itself. Intravenous drug abuse was the predisposing factor in only one patient with manubriosternal septic arthritis.
Investigation
Laboratory investigations will invariably revealed leukocytosis and the erythrocyte sedimentation rate is often more than 40 mm/h. Normal white cell count and C-reactive protein have been reported in one case [9]. Posteroanterior chest roentgenogram is usually unremarkable, but some may show bibasal effusion [7]. Lateral roentgenogram of the joint is more sensitive, and findings include substernal soft tissue swelling, periosteal elevation, erosion of the joint margin and widened joint space [1, 3, 4, 6, 9]. In early cases, the lateral roentgenogram may be normal [5]. Early diagnosis may be achieved with radionuclide scan, which shows an increased uptake at the joint, although a false-negative finding has been reported [2–5]. CT scan is more likely to be positive at later stage, the findings include inflammatory fluid collection at the joint area, infiltration of soft tissue, and destroyed sternum [4]. Superior visualization of the soft tissues and bony planes may be obtained by magnetic resonance imaging [9].
Microbiology
Coagulase positive Staphylococcus aureus is implicated in 60% of the cases. Pseudomonas pseudomallei was reported in 1 patient (1/10, 10%). The risk of acquiring this unusual organism is travel to an endemic area. Salmonella brandenburg was grown from pus in 1 patient (1/10, 10%). In 2 patients (2/10, 20%), microbiologic culture failed to grow any organism. Blood culture was positive in 40% of the patients.
Management
Delayed diagnosis as a result of misdiagnosis is not uncommon. In the presence of a systemic inflammatory joint disorder, this can be confused with exacerbation of disease activity and lead to increased steroid dosage. This, in turn, aggravates the septic process. Intravenous antibiotic alone may suffice at an early stage before pus formation has occurred [4–6]. Surgical drainage is required in 60% of cases. If the defect is sizeable after surgical débridement, this can be covered by pectoralis flap [8, 9]. Subsequent prolonged antibiotics are necessary to prevent recurrence and sternal osteomyelitis [8].
Although a pectoralis flap is useful to cover a sizeable wound defect, as reported in few cases, this will need to be considered along with other factors such as the patient’s occupation and leisure activities. The wound in our patient was relatively localized to a small but deep wound cavity. The pectoralis major is a medial rotator and a powerful adductor of the arm. Its use for flap reconstruction may not be ideal for an active sportsman or a manual worker, with its other potential complications related to the flap itself and risk of converting a localized infection to a more widespread one. Therefore whilst the role of pectoralis muscle flap cover has been shown in two reports, we believe its use should be carefully considered within the context of each individual patient’s needs. Its role in the early stage of management needs further appraisal, especially when it is still uncertain if the infection has been fully eradicated.
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This article has been cited by other articles:
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  A. Balasanthiran, T. Vakilgilani, K. Darzy, and J. Axon A case of severe staphylococcal septicaemia: septic arthritis and a mediastinal abscess following leflunamide therapy for rheumatoid arthritis BMJ Case Reports, August 19, 2010; 2010(aug17_1): bcr0720092082 - bcr0720092082. [Abstract] [Full Text] [PDF]
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