P uncritically diagnosed as having a

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1 Infected Synovial Cysts Arising as a Complication of Septic Arthritis in a Patient with Rheumatoid Arthritis By ANTHONY P. HALL AND L. A. HEALEY An elderly man with rheumatoid arthritis developed a streptococcal septicemia and arthritis following excision of an elbow nodule. His left calf became swollen; thrombophlebitis was initially ATIENTS with a swollen leg are often P uncritically diagnosed as having a thrombophlebitis. However, in patients with rheumatoid arthritis, a swollen leg may be caused by synovial disea~e'*~~~~~ and the differential diagnosis has been recently delineated and tabulated.5 This report describes a patient with rheumatoid disease who developed a septic polyarthritis followed by swellings about the right elbow and in the left calf which were demonstrated to be infected synovial cysts. CASE REPORT A man aged 63 was admitted to the King County Hospital, Seattle, on August llth, 1966, after a syncopal episode. Rheumatoid arthritis had begun in He had taken salicylates regularly but never corticosteroids. Over the previous year he had noticed increasing weakness and a 30- pound weight loss. On examination he appeared chronically ill and had typical deformities of rheumatoid arthritis in diagnosed, but pus was aspirated from the calf and elbow and arthrograms showed large synovial cysts in both locations. The importance of aspirating any unusual calf swelling is emphasized. both hands and 30" flexion contractures of both knees. Subcutaneous nodules were palpable below both elbows and slightly enlarged lymph nodes were felt in the neck. His temperature was normal. His hematocrit was 35 per cent, white cell count 9,500 per cu. mm. and sedimentation rate 116 mm. in one hour (Westergren method). The latex test for rheumatoid factor was positive. Because it was feared that he might have a neoplastic disease in addition to the rheumatoid arthritis, a cervical lymph node was biopsied. This showed nonspecific hyperplasia. An elbow nodule biopsied at the same time showed histological changes characteristic of rheumatoid disease. Following surgery his temperature steadily rose to 103 F. over the next 4 days. The patient became confused. Meningitis was suspected but a lumbar puncture revealed normal cerebrospinal fluid. His right wrist, both elbows and his left knee became swollen, red and painful. His white cell count rose to 35,000 per cu. mm. The biopsy site on his left elbow discharged pus from which a beta-hemolytic streptococcus was cultured. The same pathogen was detected in pus aspirated from his right elbow and wrist and also from his blood and sputum. Therapy with aqueous penicillin 6,000,000 units intravenously daily resulted in some improvement. From the Department of Medicine, University Medicine, Department of Medicine, Uniuersity of of Washington, Seattle, Washington. Washington, L. A. HFALEY, M.D.: Assistant Pro- This work was supported in part by Arthri- fessor of Medicine, Department of Medicine, Unitis Training Grant #AM from the Na- versity of Washington. tiond Institutes of Health (NIAMD) and AT- Requests for reprints may be addressed to L. A. thritis Study Center Grant #CRMC36 from the Healey in the Department of Medicine, Uniuersity Arthritis Foundation. of Washington, Seattle, Washington. ANTHONY P. HALL, MBBS, MRCP.: FeUow in ARTHRITIS AND RHEUMATISM, VOL. 11, No. 4 (AUGUST 1968) 579

2 580 HALLANDHEALEY Fig. 1.-A large swelling along the medial border of the right upper arm. Its connection with the distended olecranon bursae is not obvious in this view. However, one week later, he still appeared ill and lethargic, with a temperature of 100 F. A distended right olecranon bursa was now noted which was contiguous with a swelling of the medial border of the right upper arm just above the elbow ( Fig. 1 ). Cross-fluctuation could be elicited between the olecranon bursa and the arm swelling; 300 ml. of sanguinous purulent fluid were aspirated from the swelling. On the next day 30 ml. of contrast medium (50 per cent Hypaquea) was injected into the upper part of the swelling. Radiographs showed a redundant, multiloculated cyst extending from the right elbow a distance of 16 cm. proximally along the humerus and 7 cm. distally from the olecranon process (Fig. 2). During this time the patient began to complain about a pain in his lower leg and one observer thought he could feel a tense swelling in the tender calf. There was no fluid palpable in the knee-joint. The diagnostic concensus of house staff was thrombophlebitis. A day later, however, there could be felt in the popliteal fossa a bulge which became more tense when pressure was applied in the calf (cross-fluctuation). A needle of 18 S.W.G. was inserted at a right angle into the calf 5 cm. below the popliteal fossa. At a depth of 2 cm., 5 ml. of thick pus were aspirated. Forty ml. of 50 per cent Hypaque@ were then injected through the same needle and a radiograph showed a large cyst in the calf with a narrow channel leading up to the knee-joint (Fig. 3a). After a tight bandage had been applied to the calf and the foot elevated, the contrast material passed into the knee-joint and suprapatellar pouch (Fig. 3b). At the end of the procedure 190 ml. of purulent bloodstained fluid were removed from the cyst. A therapeutic concentration of penicillin (2.56 micrograms per cent) was found in the fluid from the calf cyst. It was decided to treat the patient with repeated aspiration of the cysts rather than

3 INFECTED SYNOVIAL CYSTS I" A PATIENT WlTH RA 581 Fig. 2.-Positive contrast cystogram showing a multiloculated swelling of the arm communicating with a distended olecranon bursa. by open drainage, Large amounts of pus were as- later, the left calf was still swollen (Fig. 4). pirated from the calf on 2 occasions. Following One hundred nil. of bloody purulent fluid was the removal of 240 ml. of pus from the olecranon removed. The upper calf then felt flaccid in comcyst the swelling in the arm did not recur (Fig. parison with the lower calf, which was firm, with I). The penicillin therapy was continued for 2 thick pitting edema. Between these 2 areas there weeks, during which time the patient gradually was a surprisingly sharp line of demarcation. improved and became afebrile. However, one week The patient was discharged home where he has

4 582 HALL AND HEALEY Fig. 3.-a: Synovial cyst in the calf with narrow channel leading up to the kneejoint. b: Following pressure on the calf, contrast has filled the knee-joint. since been chairbound because of severe flexion deformities of the knees. The calf cyst was aspirated again on one occasion 7 months after discharge. The fluid obtained was bloody but not purulent. The cyst now caused a slight intermittent ache only. The elbow swelling had completely disappeared apart from a small olecranon bursa. But for his poor general condition, the cysts would probably be excised. There has been no recurrence of his infection. DISCUSSION This elderly man with severe rheumatoid disease developed a streptococcal septicemia with polyarthritis following excision of an elbow nodule. Abscesses then developed in huge synovial cysts in the left calf and at the right elbow. Calf swellings in patients with arthritis are usually diagnosed as thrombophlebitis,1.2*3s4 but in 15 rheumatoid patients admitted with a swollen leg and submitted to arthrography, the diagnosis of thrombophlebitis was made in only one patient. The other 14 patients had an intact synovial cyst or a rupture of a cyst of the kneejoint itself.s To our knowledge, the occurrence of infection in synovial cysts has not previously been reported. In the present case one observer thought that there might

5 INFECTED SYNOVIAL CYSTS IN A PATIENT WITH RA 583 Fig. 4.-Swelling of left calf caused by synovial cyst. After aspiration IOO ml., the upper calf was flaccid, in comparison with lower calf which was still tense. with pitting edema. be a cyst in the calf and arthrography clearly made the diagnosis. The importance of aspiration of unexplained swellings in ill patients is emphnsized by this report. The diagnostic aspirations were performed in the radiographic department so that contrast medium could be injected through the same needle. Experience in this and other patients has shown that the fluid in these cysts may be viscous and difficult to aspirate with a needle of gauge ofr 18 or more. A 15 gauge needle may be needed in some instances. Although penicillin was detected in the cystic fluid in apparently adequate concentration, the Mammation did not subside until the cysts had been aspirated several times. Open drainage was not necessary. We feel that such aspiration may often be the procedure of choice in this clinical situation. Open drainage is probably indicated in a more fulminating case. This opinion is at variance with orthodox orthopedic opinion. The virtual disappearance of the arm swelling after aspiration was surprising. The calf cyst has persisted in a non-infected state and excision has not been considered because of the poor general condition of the patient.

6 584 HALL AND HEALEY Despite the frequent assertion that sep- to Kellgren et al.,i the most useful indicatic arthritis may be dif6cult to diagn0se,7*~~~ tion of bacterial infection in a patient with fever, leukocytosis and focal signs of in- rheumatoid arthritis is the occurrence of fection in the joints developed early in this rigors (shaking chills). The most important and most other patients we have seen. Any diagnostic test for septic arthritis is, of delay in diagnosis is due to the physician s course, examination of joint fluid.s not examining the joints daily. According SUMMARIO IN INTERLINGUA Un masculo de etate plus tosto avantiate con arthritis rheumatoide disveloppava un septicemia streptococcic e arthritis post le excision de un nodulo cubital. Su sura sinistre deveniva tumide. Initialmente thrombophlebitis esseva diagnosticate, sed pus esseva aspirate ab le sura e le cubito, e arthrographia revelava le presentia de large cystes in ambe sitos. Es sublineate le importantia del aguliamento de omne tumescentia inusual del sura. 1. Harvey, J. P., Jr., and Corcos, J.: Large cysk in lower leg originating in the knee occurring in patients with rheumatoid arthritis. Arthritis Rheum. 3:218, Good, A. E.: Rheumatoid arthritis, Baker s cyst and thrombophlebitis. Arthritis Rheum. 756, Dixon, A. St. J., and Grant, C.: Acute synovial rupture in rheumatoid arthritis. Clinical and experimental observations. Lancet I:742, Hench, P. K., Reid, R. T., and Reames, P. M.: Dissecting popliteal cyst simulating thrombophlebitis. Ann. Intern. Med. 64: 1259, Hall, A. P., and Scott, J. T.: Synovial cysts REFERENCES and rupture of the knee joint in rheumatoid arthritis. An arthrographic study. Ann. Rheum. Dis. 25:32, Hall, A. P.: Personal observations. 7. Kellgren, J. H., Ball, J. Fairbrother, R. W., and Barnes, K. L.: Suppurative arthritis complicating rheumatoid arthritis. Brit. Med. J. 1:1193, Ward, J., Cohen, A. S., and Bauer, W.: The diagnosis and therapy of acute suppurative arthritis. Arthritis Rheum. 3:522, Rimoin, D. L., and Wennberg, J. E.: Acute septic arthritis complicating chronic rheumatoid arthritis. J.A.M.A. 196:617, 1966.