A 70-year-old woman comes to the office due to pain and redness of the right elbow. The patient is a freelance writer and recently began writing regularly for a local newspaper. She first noticed the symptoms 2 days ago when her arm was supported on an arm rest while she used her computer. The pain has increased and she now feels a "bump" in the area. She does not recall any trauma to her elbow. The patient has had occasional knee pain after prolonged walking but no other joint pains. Medical history is notable for type 2 diabetes mellitus, hypertension, and osteoporosis.
Temperature is 38.3 C (101 F) , blood pressure is 134/84 mm Hg, and pulse is 84/min. There is a fluctuant swelling on the back of her right elbow with overlying erythema, warmth, and tenderness but passive range of motion is normal.
Leukocyte count is 9,200/mm³, blood glucose is 130 mg/dL, and serum creatinine is 0.8 mg/dL. Aspiration of the swelling yields 35 mL of clear yellowish fluid with a decrease in size of the swelling. The nucleated cell count on the fluid is 10,500/mm³. Gram stain and crystal analysis are negative.
Which of the following is the best next step in management of this patient's condition?

Question

Quizplus · Accepted Answer

11ec193a_9914_b067_853d_eb74207048d9_MD0002_00 A bursa is a synovial sac that alleviates friction at bony prominences and ligamentous attachments. Bursae are vulnerable to acute injury or chronic repetitive pressure and may become inflamed due to infection (septic bursitis), acute trauma, crystalline arthropathy (eg, gout), or autoimmune conditions (eg, rheumatoid arthritis). When infection occurs, it is usually due to skin flora (eg, Staphylococcus aureus), which can gain entry to the bursa via penetrating trauma, repetitive friction, or extension from local cellulitis. Clinical features of acute septic bursitis include localized pain, warmth, swelling, and erythema. Active range of motion is often decreased or painful, but passive motion is usually normal as it causes less pressure on the inflamed bursa. Most patients with acute olecranon bursitis warrant bursal fluid analysis to identify crystals and rule out infection. Fluid should be sent for cell count, polarized microscopy, Gram stain, glucose, and culture. Sterile fluid typically has a cell count <500-1,500/mm³, although counts may be higher (up to 20,000/mm³) in gouty bursitis. In patients without a history of gout or rheumatoid arthritis, counts >3,000-5,000/mm³ suggest septic bursitis, even if Gram stain is negative. This patient has a fever and a high bursal leukocyte count, suggesting septic bursitis. Appropriate management includes drainage of the infected fluid and systemic antibiotics. ³ ³ (Choice B) Intrabursal glucocorticoids are often helpful in noninfectious deep bursitis (eg, trochanteric, subacromial) but are not recommended for superficial bursitis due to possible infection, skin atrophy, and sinus tract formation. (Choice C) Management of sterile or crystalline bursitis includes protection with either padding or a hard orthosis and nonsteroidal anti-inflammatory drugs (NSAIDs). Septic bursitis, as in this patient, requires antibiotics. (Choice D) In addition to NSAIDs, options for crystalline bursitis (eg, gout) include oral colchicine and oral glucocorticoids (eg, prednisone). However, gout and pseudogout are uncommon causes of olecranon bursitis, and septic bursitis is much more likely in this patient. (Choice E) Imaging is not needed for most patients with olecranon bursitis, and the diagnosis can be made based on clinical features and fluid analysis. Ultrasound is sometimes employed to guide needle aspiration. X-ray findings in bursitis are nonspecific, and x-ray of the elbow is more useful to identify fractures or dislocation in patients with acute traumatic injury. Educational objective: Septic olecranon bursitis is characterized by acute erythema, warmth, and swelling, and is usually due to infection by skin flora. Bursal fluid analysis can confirm the diagnosis. Treatment includes drainage of infected fluid and systemic antibiotics. __________ References: Olecranon bursitis. (http://www.ncbi.nlm.nih.gov/pubmed/26577126)

A 70-Year-Old Woman Comes to the Office Due to Pain