Bilateral shoulder arthritis in COVID-19 patient after prolonged mechanical ventilation assist

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Availableonlineatwww.sciencedirect.com

journalhomepage:www.elsevier.com/locate/radcr

Case report

Bilateral shoulder arthritis in COVID-19 patient after prolonged mechanical ventilation assist: a case report ^✩ ^, ^✩✩

Teresa Resende Neves, MD

^a^,^b^,^∗

, Ana Luísa Lourenço, MD

^c

, Pedro Alves, MD

^d

, Carlos Teiga, MD

^e

, António Proença Caetano, MD

^a^,^b

aRadiologyDepartment,HospitalCurryCabral,CentroHospitalarUniversitáriodeLisboaCentral(CHULC), 1069-166,Lisbon,Portugal

bNovaMedicalSchool,FaculdadedeCiênciasMédicas,UniversidadeNovadeLisboa,Lisbon,Portugal

cRadiologyDepartment,HospitaldeSantoAntóniodosCapuchos,CentroHospitalarUniversitáriodeLisboaCentral (CHULC),1069-166,Lisbon,Portugal

dRadiologyDepartment,HospitaldeDonaEstefânia,CentroHospitalarUniversitáriodeLisboaCentral(CHULC), 1069-166,Lisbon,Portugal

eRadiologyDepartment,HospitaldeCurryCabral,CentroHospitalarUniversitáriodeLisboaCentral(CHULC), 1069-166,Lisbon,Portugal

a r t i c l e i n f o

Articlehistory:

Received18June2021 Revised27June2021 Accepted29June2021 Availableonline1August2021

Keywords:

Covid-19 SARS-CoV2 arthritis immobilization mechanicalventilation musculoskeletal

a b s t r a c t

Prolongedimmobilizationand,inparticular,mechanicalventilation,havebeenlinkedto muscleatrophy.Anecdotalreportsintheliteraturedescriberhabdomyolysisasapotential latecomplicationofCOVID-19infectionwhich,inseverecases,maycoexistwithfluidcol- lections.Wereportacaseofa28-year-oldpatientthathadbeenrecentlyhospitalizedwith SARS-CoV-2pneumonia,withneedforinvasiveventilationsupport.Daysafterbeingdis- charged,thepatientpresentswithretrosternalthoracalgiairradiatingtotheleftupperlimb.

Onphysicalexamination,abductionandexternalrotationwerelimitedduetopaincom- plaintsandtherewassofttissueswellingofthecorrespondingshoulderandarm.Imaging evaluationwasessentialtoestablishtheunderlyingcondition,revealingbilateralarthritis communicatingwithlargerotatorcuffcollections,whichwasconsideredofsepticnature.

ThisisanopenaccessarticleundertheCCBY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/)

✩ Acknowledgments:Thisresearchreceivednospecificgrantfromanyfundingagencyinthepublic,commercial,ornot-for-profit sectors.

✩✩Competinginterests:Theauthorsdeclarethatthereisnoconflictofinterest.

∗Correspondingauthor.

E-mailaddress:[email protected](T.R.Neves).

https://doi.org/10.1016/j.radcr.2021.06.085

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Introduction

Coronavirusdisease-2019(COVID-19),anatypicalpneumonia causedbysevereacuterespiratoryvirus2(SARS-CoV-2),has emergedin 2019.Clinicalfindings in COVID-19pneumonia gobeyondthe respiratorytract,whichcanbeexplainedby theubiquitousnatureofitsmajorentryreceptor,angiotensin- convertingenzyme2(ACE-2).ACE-2isfoundintheendothe- liumofsmallvessels,bowel,smoothmuscle,skeletalmuscle andsynovialtissue[1].

COVID-19ismostly knownforcausingpulmonaryman- ifestations,but canalsoresultinmultipleextra-pulmonary conditions [2,3]. Several reports in the literature have re- portedoncardiac,neurologic,abdominal,dermatological,oc- ular and, less commonly, musculoskeletal manifestations.

Currentmusculoskeletalcomplicationsreportedinpatients withCOVID-19infection,however,areanecdotal.

Case report

A 28-year-old male patient, otherwise healthy, attended a healthcenterwithsymptomsoffatigue,anosmiaanddyspnea forprogressivelyshorterefforts.SpO2levelswere55%,which improvedto75%withnasalcannulaoxygentherapy.

Thepatientwas hospitalizedandevaluatedatanemer- gencydepartment.Achestradiographywasorderedwhichre- vealedbilaterallunginfiltrates.RT-PCRswabtestedpositive forSARS-CoV-2infectionandthepatientwasadmittedina COVID-19infirmaryunit.

Non-invasive ventilation support was unsuccessful and therewasneedforintubationandinvasivemechanicalven- tilationwithventraldecubituspositioning.Twodaysafterad- mission,Escherichiacoliandmethicillin-sensitiveStaphylococ- cusaureusweredetectedonsputumcultureandconfirmedsu- perinfection,whichledtoprescriptionofan8-dayregimenof amoxicillin.Bloodculturealsorevealedmethicillin-resistant Staphylococcusaureus,whichwasdismissed.

Therewassteadyclinicalimprovementinthesubsequent days and the patient was extubated and eventually dis- charged.

Sevendayslater,however,thepatientattendedtheemer- gency department of our hospital with complaints ofret- rosternalthoracalgiairradiatingtotheleftupperlimb,which hadreportedlystartedshortlyaftertransferfromtheinten- sivecareunittotheinfirmaryintheprevioushospital.

Onphysicalexamination,abductionandexternalrotation werelimitedduetopaincomplaints.Therewas softtissue swellingoftheshoulderandarm,fever,andincreasedlevels ofC-reactiveprotein.Hemocultureandurinecultureproved negative.AchestradiographandthoracicCTwereperformed whichshowedtypicalchangescompatible withsequelaeof Covid-19pneumonia(Fig.1).

Duetopoorprogressionofthecondition,hewasadmitted forfurtherinvestigationandtreatmentplanning.Takinginto accountthepreviousbloodculturethathadbeendismissed, gentamicinwasprescribedandadministeredthroughoutthe wholelengthofhospitalstay.

ThoracicCTwithintravenouscontrastadministrationper- formed9daysafteradmissionrevealedscapulohumeralsyn- ovitis,withmultipleintra-muscularcollectionsthatshowed continuitywiththeglenohumeraljoint.Ontherightshoulder, therewasalsoscapulohumeralsynovitisandlesspronounced jointfluid(Fig.2).

Bilateralshouldermagneticresonanceimaging(MRI)with intravenouscontrast administrationwasperformed,dueto persistentshoulderpainandweakness.Findingsincludedin- fraspinatus fossa and subscapular fossa collections on the leftshoulder,extendingandcommunicatingwiththegleno- humeral joint,with capsular thickening and increasedsig- nalintensitypost-gadoliniumadministration(Fig.3);theright shoulder showed similar changes but they were less pro- nounced. These features were suggestive of septic arthri- tisandrotatorcuffcollections,possiblyassociatedwithmy- onecrosis.

Aspiration ofthe infraspinatusfossa collectionwas per- formedand20ccofseropurulentfluidwassentforanalysis.

An8,5Frdrainagecatheterwasleftontheleftinfraspinatus collection,butwasremovedthedayafterduetopatientcom- plaintsofdiscomfort.Evaluationoftheaspirateincludedboth directandculturetestsforMycobacteriumtuberculosis,anaero- bicandaerobicbacteria,whichwerenegative.

Therewassomeimprovementofleftshoulderrangeofmo- tion,afterphysicalrehabilitationexercises.Patientwaseven- tuallytransferredtoanotherhospitalwithindicationtocon- tinuephysicaltherapyandrehabilitationexercises.

Discussion

Prolongedimmobilizationand,inparticular,mechanicalventilation,havebeenlinkedtomuscleatrophyandconsidereda riskfactorfordevelopmentofheterotopicossificationaround theshoulder[4,5,6].

Patientswhosurviveafterprolongedmechanicalventila- tionarepronetodevelopdelirium,lungdamage,muscleat- rophyandweakness.Evenafterresolutionofthepulmonary symptoms,reconstitution ofnormalcognitive andphysical aptitude requiresa long-termrehabilitationprocess,where physicalandoccupationaltherapistsplayafundamentalrole [2].

ApotentiallatecomplicationofCOVID-19infectionisrhab- domyolysis[7,8],alife-threateningconditionwithadiagnosis thatismainlyclinical,manifestingasmyalgia,fatigue,pig- menturiaandacuterenalfailure[9].Imagingfindingsinclude enlargementoftheaffectedmuscles,whichmaybeheteroge- neousandhypodenseonCT.

MRIisthebestmodalitytodepictextentandseverityof injury,withhyperintensesignalonfluid-sensitivesequences andheterogeneousenhancementfollowingintravenouscon- trast administration [10]. An alternative presentation may showrimenhancement.Inseverecases,myonecrosismayco- existintheformofsmallheterogeneousmusclefociwithhy- perintensesignalonfluid-sensitivesequenceswithrimen- hancement.

Aside from rhabdomyolysis, a few cases of arthritis associated with COVID-19 infection have been reported

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Fig.1– Chestx-ray(A)andthoracicCT(B)performedatadmissionatourhospitalshowtypicalfindingsofCOVID-19 pneumonia,namelybilateralperipheralgroundglassopacitieswithgreaterinvolvementofthelowerlobes.

Fig.2– Post-contrastThoracicCT(axialview)performed9dafteradmissionatourhospitalrevealsrotatorcuffcollections andglenohumeraljointfluidwithcapsuleenhancementontheleftshoulder.Thereissomeheterogeneityand

enhancementoftherightinfraspinatusmuscle.

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Fig.3– Axial(A),coronal(B)fat-saturatedPDandaxialpost-contrastfat-saturatedT1-weighted(C)MRIperformed12days afteradmissiontoourhospitalshowsalargeleftshoulderrotatorcuffcollectioncommunicatingwiththeglenohumeral joint,whichisdistendedwithfluidanddemonstratescapsulehyperenhancementcompatiblewithsynovitis.Axial fat-saturatedPDMRIoftherightshoulder(D)demonstratessimilarbutlesspronouncedfindingsontheleftshoulder.

[11–16].Indeed,asystematicreviewofrheumatologicfindings inCOVID-19patientsconcludesthatmusclepainandfatigue arepresentin19%and32%ofpatientsasaninitialpresen- tation,withanoverallprevalenceof16%and 36%through- outthecourseofthedisease,respectively[17].Recentreports claimthatarthralgiaispresentinabout2,5%ofpatientsaf- fectedbythisdisease.[18]Furthermore,therehavebeensome reportsregardingtriggeringofchronicrheumatologicdiseases byCOVID-19infection,whichwillhavefeaturesthatarechar- acteristicoftheunderlyingcondition,inthemajorityofcases [18]. Serological and joint fluid tests helpto excludeother causesofarthropathy[18],since,tothebestofourknowledge, thereisnocharacteristicimagingfeatureofCOVID-19induced arthralgia.

Regardingourcase,thepatienthad noknownarthropa- thy,therewerenopreviousshoulderproblemsorepisodesof arthritisreported.Nocausative agentwasdetected,but he wasunderanantibioticregimen,whichmay haveaffected labresults.Ultimately,thecauseofbilateralshoulderarthritis remainedunknown,butwaspresumedofsepticnatureand treatedaccordingly.

Patient consent

Writteninformedconsentwasobtainedfromthepatient.

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Bilateral shoulder arthritis in COVID-19 patient after prolonged mechanical ventilation assist

Case report

Bilateral shoulder arthritis in COVID-19 patient after prolonged mechanical ventilation assist: a case report ✩ , ✩✩

Teresa Resende Neves, MD

, Ana Luísa Lourenço, MD

, Pedro Alves, MD

, Carlos Teiga, MD

, António Proença Caetano, MD

Introduction

Case report

Discussion

Patient consent

Bilateral shoulder arthritis in COVID-19 patient after prolonged mechanical ventilation assist: a case report ^✩ ^, ^✩✩