11institutetext:
Knowledge-based Systems and Document Processing Research Group
Faculty of Computer Science
Otto-von-Guericke-University Magdeburg
11email: katrin.krieger@ovgu.de
Discussion:
Septic arthritis among individuals who use intravenous (IV), or
intramuscular (IM) tramadol can be a serious complication, especially
considering the potential for introducing pathogens into the bloodstream
or deep tissues during drug administration. Studies have shown a strong
association between the practice of injecting drugs and the incidence of
septic arthritis caused by Staphylococcus aureus, including MRSA
strains. Individuals with a history of injecting drugs have been found
to be at higher odds of developing septic arthritis due to S. aureus,
highlighting the role of this risk factor in the pathogenesis of the
infection6.
In this case report, the patient had MRSA-positive sternoclavicular
septic arthritis following repeated intravenous and intramuscular
tramadol and multivitamin injections. Sternoclavicular joint (SCJ)
infection is an uncommon condition, accounting for only 0.5% - 1.0% of
all septic arthritis cases and less than 0.5% of septic arthritis in
healthy patients7.
The proximity of the sternoclavicular joint to the mediastinum
complicates differentiating between mediastinal masses and malignancies.
A similar case was reported of septic arthritis being initially mistaken
for malignancy, but that case involved Methicillin-Sensitive
Staphylococcus aureus (MSSA) and rhGH (Recombinant human growth hormone)
abuse, which could have influenced the infection’s
development5. In contrast, our case involved
Methicillin-Resistant Staphylococcus aureus (MRSA) and
tramadol/multivitamin abuse, with no apparent role of the drugs in
infection pathogenesis. Our patient was managed with embolization,
long-term IV antibiotics, and physiotherapy, whereas the above-mentioned
patient required multiple surgeries and extended antibiotics due to an
inadequate initial response.
We believe that the spread of infection to the sternoclavicular joint in
particular was due to the injections being frequently administered in
the deltoid region. This is supported by a study that discussed the
possibility of bacteria entering the sternoclavicular joint from
adjacent veins after the injection of contaminated drugs into the upper
extremity8.
Our case of sternoclavicular septic arthritis presenting as a
mediastinal malignancy contributes to the literature by highlighting the
diagnostic challenges when infections mimic malignancies. It
demonstrates the importance of distinguishing between severe infections
and cancer through comprehensive diagnostic approaches and underscores
the effectiveness of advanced imaging and surgical interventions, such
as embolization of a pseudoaneurysm. The case also illustrates the need
for tailored treatment strategies and interdisciplinary collaboration in
managing complex infections, providing practical insights into clinical
decision-making and resource considerations.
The case has several limitations: it focuses on immediate treatment
without long-term follow-up on recurrence or outcomes; advanced
diagnostic and therapeutic techniques used may not be available in
low-resource settings; the patient’s multiple pre-existing conditions
may have complicated the infection’s presentation and management; and
the initial mimicry of a malignancy required extensive and potentially
delayed diagnostic workup, which may not be feasible in all clinical
settings.