Abstract

To the Editor:

A 68-year-old man presented to the ER with complaints of sudden onset, nonradiating right shoulder pain and fever for 10 days. There was no history of antecedent trauma or shoulder overuse. His past medical history was significant for medication-controlled chronic obstructive airway disease. On initial examination, temperature was 101° F, BP 110/65, pulse 100/minute, and respiratory rate 22/minute. Examination of the extremities revealed erythema, induration and tenderness over the anterolateral aspect of the right shoulder. Cardiac and systemic examinations were normal. Initial laboratory investigations showed a white cell count of 21,700 cells/cu mm with 90% polymorphonuclear cells. Magnetic resonance imaging (MRI) of the shoulder showed a very large subdeltoid bursal fluid collection consistent with bursitis associated with myositis (Fig.). Incision and drainage was performed and the patient was started empirically on intravenous vancomycin. Microscopic examination of the fluid revealed Gram-positive cocci in chains, and cultures were positive forStreptococcus pneumoniae (penicillin MIC—0.5 mcg/mL). Admission blood cultures were also positive for Streptococcus pneumoniae as the causative organism with the same profile. In view of persistent fever, a transesophageal echocardiogram was done, which revealed a mobile echo density on the anterior leaflet of the mitral valve suggestive of vegetation. He responded to four weeks of intravenous ceftriaxone and is symptom free at a 3-month follow up.