What's Your Diagnosis? Diagnosis and Management of Acute Joint Pain in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Thoracic Aortic Syndromes in the Emergency Department: Recognition and Management right.

Case Presentation: Diagnosis and Management of Acute Joint Pain in the Emergency Department

A 43-year-old man has arrived by ambulance with complaints of severe pain in his right ankle and left knee. He is unable to ambulate. There is no history of trauma, travel, or rash. You wonder why the patient called EMS for joint pain, but then you see his vital signs: 116 beats/min pulse, 39.2°C temperature, 100/70 mm Hg blood pressure, 22 breaths/min respiration, and pulse ox 98% on room air. You wonder whether you should tap the joints and start empiric antibiotics…

Case Conclusion

You recognized the possibility of sepsis and initiated the sepsis protocol. You sent labs including blood cultures, lactate, CBC, and CMP, and initiated 30 mL/kg of IV lactated Ringer‘s solution. You discovered a history of recent IV drug abuse and noted severe pain with any movement of his right ankle and left knee, with joint effusions clearly present. You performed an emergent arthrocentesis starting with the knee, and decided to use an ultrasound-guided technique. The fluid aspirated was cloudy, and you immediately initiated broad-spectrum antibiotics, with vancomycin 30 mg/kg IV to cover for MRSA, and ceftriaxone 2 g IV for gram-negative coverage. You recognized that early orthopedic involvement for joint drainage by aspiration or open arthrotomy was indicated, and you called orthopedics with the diagnosis of polyarticular septic arthritis.