Arthritis of the sternoclavicular joint masquerading as rupture of the cervical oesophagus: a case report

Introduction

Sternoclavicular septic arthritis is a rare condition and accounts only for 1% of cases of septic arthritis in the general population. The most common risk factors are intravenous drug use, central-line infection, distant-site infection, immunosuppression, trauma and diabetes mellitus. This is a report of an unusual case where this type of arthritis was masquerading as rupture of the cervical oesophagus.

Case presentation

A 63-year-old man presented complaining of right neck pain and dysphagia following a bout of violent coughing. Physical examination revealed cellulitis extending from the right sternoclidomastoid region to the anterior upper chest. Computed tomography showed inflammatory changes behind the right sternoclavicular joint with mediastinitis and ipsilateral pleural effusion. These findings raised the suspicion of spontaneous rupture of the cervical oesophagus. Management involved jejunal feeding along with broad-spectrum antibiotics. The inflammation, however, relapsed after discontinuation of the antibiotics and this time, computed tomography pointed to a diagnosis of arthritis of the sternoclavicular joint. The patient responded completely to a 6-week course of oral penicillin, flucloxacillin and metronidazole.

Conclusion

Sternoclavicular arthritis is a rare condition that has been associated with a variety of predisposing factors. It may, however, occur in otherwise completely healthy individuals and should be included in the differential diagnosis of other inflammatory conditions of the neck and upper chest.

Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC)

We sought to determine the rate of healthcare-associated infection (HCAI), microbiological profile, bacterial resistance, length of stay (LOS) and excess mortality in 12 ICUs of the seven hospital members of the International Infection Control Consortium (INICC) of seven Indian cities. Prospective surveillance was introduced from July 2004 to March 2007; 10 835 patients hospitalized for 52 518 days acquired 476 HCAIs, an overall rate of 4.4%, and 9.06 HCAIs per 1000 ICU-days. The central venous catheter-related bloodstream infection (CVC-BSI) rate was 7.92 per 1000 catheter-days;the ventilator-associated pneumonia (VAP) rate was 10.46 per 1000 ventilator-days; and the catheter-associated urinary tract infection (CAUTI) rate was 1.41 per 1000 catheter-days. Overall 87.5% of all Staphylococcus aureus HCAIs were caused by meticillin-resistant strains, 71.4% of Enterobacteriaceae were resistant to ceftriaxone and 26.1% to piperacillin-tazobactam; 28.6% of the Pseudomonas aeruginosa strains were resistant to ciprofloxacin, 64.9% to ceftazidime and 42.0% to imipenem. LOS of patients was 4.4 days for those without HCAI, 9.4 days for those with CVC-BSI, 15.3 days for those with VAP and 12.4 days for those with CAUTI. Excess mortality was 19.0% [relative risk (RR) 3.87; P < or = 0.001] for VAP, 4.0% (RR 1.60; P=0.0174) for CVC-BSI, and 11.6% (RR 2.74; P=0.0102) for CAUTI. Data may not accurately reflect the clinical setting of the country and variations regarding surveillance may have affected HCAI rates. HCAI rates, LOS, mortality and bacterial resistance were high. Infection control programmes including surveillance and antibiotic policies are a priority in India.

Fluorine-18 fluorodeoxyglucose positron emission tomography in the preoperative staging of thoracic oesophageal and gastro-oesophageal junction cancer: a prospective study

BACKGROUND

The pre-operative staging in oesophageal cancer is often challenging and underestimation of the extent of the disease may lead to unnecessary surgery.

AIM

To audit the use and assess the value of fluorine-18 fluorodeoxyglucose positron emission tomography ((18)F FDG-PET) as a staging tool for thoracic oesophageal and gastro-oesophageal junction (GOJ) cancers in our oncological surgical practice.

PATIENTS AND METHODS

Over a 3 year period, between 2002 and 2004, 134 patients with thoracic oesophageal or GOJ cancer were referred to our unit for treatment. The standard preoperative staging investigation in all cases was CT (thorax, abdomen and pelvis). A preoperative FDG-PET scan was further requested in 22 patients. The case notes of all the patients that underwent a FDG-PET scan were reviewed and compared with the preoperative imaging, the operative findings and the histopathology of the resected tumours.

RESULTS

Eighteen men and 4 women with a median age of 65 (range 43-79) years were studied. After FDG-PET, 13 out of 22 patients (59%) were deemed suitable for tumour resection. Twelve of the 13 patients were fit to undergo surgery. At laparotomy, 2 of those (17%) were found inoperable due to widespread disease. The sensitivity of CT versus FDG-PET to detect infiltrated lymph nodes was 29% (95% CI: 3-70) versus 71% (95% CI: 29-96) (P=0.0412), whereas both tests had 67% specificity (95% CI: 9-99) in detecting lymph nodes. The sensitivity and the specificity of CT versus FDG-PET to detect distant organ metastases (M1b) were 33% (95% CI: 4-77) and 88% (95% CI: 47-99) versus 50% (95% CI: 6-93) and 100% (95% CI: 69-100), respectively (P>0.05). The FDG-PET regarding the N and M status differed from the CT in 11 patients and led to modification of the planned management in 5 of them.

CONCLUSIONS

FDG-PET is more accurate than CT in defining N and M status. It can result in a reduction of unnecessary surgery in a significant number of patients. The combined PET-CT scan as a single imaging modality is expected to further improve diagnostic accuracy of FDG-PET.

Intratesticular cysts and malignant potential: conservative management is an option

Benign intratesticular cysts are rare, but recognition is essential to prevent unnecessary surgical intervention. The diagnostic dilemma is to differentiate these cysts from testicular malignancy. As they are extremely uncommon, experience of their management is limited and controversial. We present a case of a simple intratesticular cyst and discuss the diagnostic and management principles.

Nongynecologic applications of transvaginal US

Transvaginal ultrasonography (US) is a noninvasive, readily available imaging technique that has greatly enhanced diagnostic sensitivity and accuracy for both gynecologic and nongynecologic disease. High-frequency US probes placed in the vagina allow high-resolution assessment of all the pelvic viscera, including portions of the gut and urinary tract. In addition, they allow visualization of the peritoneum of the pelvic pouch and the pelvic side walls without interference from bowel gas or adipose tissue. Evaluation of these areas requires a modified US technique that includes the use of the highest-frequency probes with angulation of the transducer to allow assessment of the region of interest. In women of childbearing age, the similarity of symptoms in gynecologic and gastrointestinal tract disease in particular underscores the potential utility of transvaginal US, which may, for example, help differentiate appendicitis in a pelvic appendix from pelvic inflammatory disease. Transvaginal US may also help determine the correct course of therapy, thereby improving patient management. Other indications for transvaginal US include assessment for pelvic appendicitis and diverticulitis, rectal and perianal complications of Crohn disease, and ureteric and bladder calculi and tumors as well as evaluation of the anal sphincters in women with fecal incontinence. Transvaginal US is also superior to routine US in the detection and characterization of ascites and peritoneal disease. Transvaginal US examination should include the entire pelvic cavity and contents, especially in women at risk for pelvic sepsis or peritoneal disease.

Immunological detection of Bacteroides fragilis in clinical samples

A monospecific polyclonal antiserum, prepared against Bacteroides fragilis common polysaccharide antigen purified by polyacrylamide gel immunoblot detected B. fragilis, B. thetaiotaomicron, B. ovatus and Prevotella melaninogenica in pus samples from various anatomical sites by immunofluorescence microscopy of the pus. With standard clinical laboratory culture methods, 36% of 147 samples were positive for one or more of the above bacteria. Of these, B. fragilis accounted for 33%. By immunofluorescent labelling of pus with the common antigen antiserum the detection of these bacteria in the samples increased to 50%. All nine of the blood cultures in which B. fragilis was detected by culture contained bacteria positive for the common antigen. Immunofluorescent labelling of pus samples with a selection of monoclonal antibodies specific for surface polysaccharides which are known to be antigenically variable in culture in vitro and in an animal model of infection showed that these polysaccharides are also variable in natural infection. The results indicate that the common polysaccharide antigen, in contrast to the variable surface polysaccharides, is a suitable target for the immunodetection of B. fragilis in clinical samples from a range of anatomical sites.

Four outbreaks of nosocomial systemic candidiasis

Candida albicans has recently been described as a cause of nosocomial infection. This paper reports four further outbreaks occurring over a 12-month period in England. There were 13 systemic cases and 6 deaths. The outbreaks were defined by morphotyping and the new technique of immunoblot fingerprinting. Control of the outbreaks was produced by the implementation of strict cross-infection control policies without recourse to systemic chemoprophylaxis.