Richard J Nierenberg1*, Brett Berliner1 and Ari Seidenstein2
1Department of Emergency Medicine, Hackensack University Medical Center, USA
2Department of Orthopedics, Hackensack University Medical Center, USA
Septic arthritis can be associated with significant morbidity, and cause substantial mortality, especially if the diagnosis is delayed. We present here a case of a young woman with a diagnosis of SLE and chronic pain syndrome that progressed to septic shock within hours of presenting to the Emergency Department. It has been emphasized in that the key to treatment of septic shock is early, almost immediate recognition and the institution of aggressive fluid resuscitation and appropriate antibiotic treatment. The importance of prompt and timely diagnosis of the septic joint is well appreciated, but the time course is usually considered to be within the day, and the notion of the “golden hour” for septic shock is not often considered. One important consideration is that a synovial fluid WBC of greater than 50,000 or even more specifically 100,000 with differential of 90% PMNs is commonly cited as indicating bacterial arthritis. Our patient, found to be neutropenic, had a joint fluid WBC of 9000. One needs to be vigilant for the possibility of septic arthritis in a neutropenic patient with a low synovial white count. Finally, one area which is troubling or illuminating about the care of our patient is to question what effect a prior suspicion of pain medication seeking behavior may have had on the pace of her evaluation. In an era of changing perceptions regarding opioid use and increased sensitivity to the possibility of pain management seeking, one has to be increasingly careful to avoid bias and minimization of symptoms.
Nierenberg RJ, Berliner B, Seidenstein A. Infectious Arthritis Leading to Rapid Septic Shock in a Patient with SLE, Leukopenia, and End Stage Renal Disease: A Case Presentation and Cautionary Notes. Ann Clin Case Rep. 2020; 5: 1779.