Emily Toy, BS
Medical Student
University of New England College of Osteopathic Medicine
Biddeford, Maine, United States
Dustin Randall, MD
Resident Physician
Stanford University PM&R
San jose, California, United States
Chantal Nguyen, MD
Resident Physician
Stanford University PM&R Program
Redwood City, California, United States
Jenny Aronson, MD
Clinical Assistant Professor
Stanford University, Department of Medicine - Infectious Diseases
Redwood City, California, United States
Brady Evans, MD
Clinical Assistant Professor
Stanford University, Department of Orthopedic Surgery
Redwood City, California, United States
Raymond Chou, MD
Clinical Assistant Professor
Stanford University School of Medicine
Redwood City, California, United States
Multiple Focal Compressive Neuropathies Secondary to Recurrent Septic Elbow Arthritis
Case Description:
A 63-year old male presented with seven weeks of weakness in right wrist flexors and extensors that was found to be secondary to septic arthritis with thickening of radial, ulnar, and median nerve fascicles. Electromyography (EMG) showed severe radial neuropathy with axonal loss between the bifurcation of the superficial radial nerve and the motor branch to the brachioradialis, demyelinating right ulnar neuropathy across the elbow, and axonal denervation in the right flexor digitorum superficialis. He underwent elbow arthrotomy, irrigation, and debridement with complete posterior interosseous nerve (PIN) neurolysis. He then completed eight weeks of trimethoprim/sulfamethaxazole for MSSA septic arthritis, but developed an abscess with a fistula communicating with the elbow two weeks later with ongoing wrist/finger extensor weakness. He underwent six weeks of IV cefazolin and remained on PO cefadroxil for over one year, which led to 70% recovery of his upper extremity strength.
Discussions: This is the first case reporting multiple focal neuropathies secondary to septic arthritis associated with synovitis. Improvement following surgical decompression and antibiotics suggests direct compression of the nerve as a possible etiology of neuropathy, with a subsequent inflammatory cascade leading to a demyelinating and axonal pathology. This lends support for septic arthritis as a possible cause for any type of compressive neuropathy. This case differs from prior reports of management for nerve compression secondary to septic arthritis in that functional outcomes took longer than previously reported in the literature after nerve decompression, including neurolysis.
Conclusions:
Septic arthritis can be a rare cause for multiple focal, prolonged compressive neuropathies even in a healthy, immunocompetent individual. This case suggests that even in prolonged cases of infection causing multi-focal neuropathies, return of motor function can still occur with appropriate management via debridement, neurolysis, and antibiotics.
