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General Medical Conditions: Case Reports

Noniatrogenic Septic Olecranon Bursitis

Report of Two Cases and Review of the Literature

Harris-Spinks, Christine MD, MPH1; Nabhan, Dustin DC, DACBSP, CSCS2; Khodaee, Morteza MD, MPH, FACSM1

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doi: 10.1249/JSR.0000000000000220
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Introduction

The olecranon bursa is a fluid-filled synovial pouch that overlies the olecranon process (12). Historically, enlargement of a bursa (e.g., prepatellar and olecranon) has been called “bursitis”; however in the majority of cases, no true inflammatory process exists in the bursal tissues (1). Rheumatologic conditions (e.g., rheumatoid arthritis) and gout can cause inflammatory bursitis (1,21). Bursitis can present as an acute process secondary to macrotrauma (hemorrhagic) or infection. It can also present as a chronic condition secondary to repetitive microtrauma (1). Although approximately 80% of olecranon bursitis cases are aseptic, it is imperative to rule out septic bursitis (3). Infectious bursitis is usually due to direct inoculation of Staphylococcus aureus (6). It is not clear what percentage of septic bursitis cases are iatrogenic (11,21,23). This case series describes two cases of noniatrogenic septic bursitis presenting to sports medicine clinics and review of the literature.

Case Presentation

Case 1: basketball player with a scratch.

A healthy 32-year-old male basketball player visiting from out of state for a competition presented with left elbow redness and swelling. He reported no trauma on his elbow other than a small superficial scratch on his left elbow which occurred during basketball practice 2 d prior. His vital signs were unremarkable with a temperature of 37.1 °C and pulse rate of 70 bpm. He was a well-appearing athletic individual. There was an excoriation in the lateral left elbow with significant erythema and edema (Fig. 1A). Palpation of the left posterior elbow demonstrated warm skin overlying fluctuant swelling superficial to the olecranon process. The patient was unable to fully flex and extend his arm because of the swelling and pain.

Figure 1
Figure 1:
Case 1 (basketball player). (A) Clinical appearance at the time of presentation. Note that the scratch is easily visualized. (B) Appearance of the bursal fluid at the time of first bursal aspiration. (C) Appearance 1.5 d after initial presentation.

Aspiration of the left olecranon bursa was performed yielding a straw-colored fluid (Fig. 1B). Initial Gram stain found many polymorphonuclear (PMN) leukocytes but no organisms. He was diagnosed with cellulitis and septic olecranon bursitis. He was started on oral trimethoprim/sulfamethoxazole. Culture of the fluid later grew oxacillin-sensitive S. aureus (OSSA). One and a half days later, he awoke with his arm erythematous, warm, swollen, and quite painful. The erythema extended from the mid-upper arm to the mid-forearm (Fig. 1C). He was transported to a local emergency department where repeated aspiration of the bursa yielded a dark purulent fluid. He was given a dose of intravenous (IV) ceftriaxone and started on IV vancomycin. He continued receiving IV vancomycin for a total of 1 wk in the hospital and then was discharged home on oral antibiotics for 2 wk. He fully recovered and returned to play basketball with no restriction (Table 1).

Table 1
Table 1:
Summary of the two cases of noniatrogenic septic olecranon bursitis.

Case 2: outdoor cyclist with mosquito bites.

A 43-year-old man presented with right posterior elbow pain and swelling. He first noticed this after waking up in the morning 6 d prior. He did not recall any discrete injury or fall. He had been enjoying a lot of time outdoors including bike racing and had received a number of mosquito bites. He had never had this issue before. The patient denied fever and was taking ibuprofen for the pain.

Physical examination revealed normal vital signs. He had reduced flexion and extension of the right elbow. Tenderness was present over the olecranon process. There was tender, fluctuant swelling on the posterior aspect of the right elbow (Fig. 2A). There was mild erythema and warmth of the overlying skin (Fig. 2B). Plain radiography found only soft tissue swelling on the posterior aspect of the elbow without bony abnormality.

Figure 2
Figure 2:
Case 2 (outdoor cyclist). (A and B) Clinical appearance at the time of presentation. Notice erythema, surrounding edema, and mosquito bite marks.

Aspiration of the right olecranon bursa acquired 3 mL of purulent fluid. Gram stain found multiple PMN leucocytes without any organisms. He was started on oral trimethoprim/sulfamethoxazole. When his symptoms worsened the next day, he was admitted to the hospital for IV vancomycin treatment. After culture confirmed the OSSA, the patient was switched to IV cefazolin. The IV cefazolin was continued as an outpatient treatment via a peripherally inserted central catheter line to complete a 2-wk course. Then he was placed on oral trimethoprim/sulfamethoxazole for an additional 2 wk. He fully recovered and did well (Table 1).

Discussion

Olecranon bursitis (also known as miner’s elbow, student’s elbow, and draftsman’s elbow) is the most common superficial bursitis (1,7,14). Olecranon bursitis is a relatively common condition, but its exact prevalence particularly in outpatient setting is unknown (10,12). It is more common among male adults and those involved in manual labor (e.g., auto mechanics, carpet layers, plumbers, and gardeners) or among some types of athletes such as wrestlers, gymnasts, and dart players (3,7,14). As many as 7% of chronic hemodialysis patients develop olecranon bursitis (14). Although the cause of this high incidence is unknown, it seems to be most likely due to repetitive microtrauma of the arm with arteriovenous (AV) fistula during the hemodialysis procedures (18).

When evaluating a patient with olecranon bursitis, it is imperative to differentiate between aseptic traumatic (either acute or chronic), aseptic inflammatory, and septic bursitis. Table 2 summarizes clinical presentation, diagnosis, and potential management of these different types of olecranon bursitis. This table illustrates that there is considerable overlap in clinical presentation and physical examination between the different etiologies of olecranon bursitis. A clinical history of skin trauma (break) near an affected bursa leads to a significantly higher risk of septic bursitis (3,7,26,27). Both of the above cases demonstrate septic olecranon bursitis that occurred after minor trauma that broke the skin. Recent attempt to aspirate the bursa is a significant risk factor for septic olecranon bursitis (11). Other causes of septic olecranon bursitis can be infection of an already inflamed bursa by overlying cellulitis or via hematogenous spread (3). Up to half of the cases of septic bursitis occur in patients with chronic systemic conditions like diabetes and chronic kidney disease (3,7). The presence of fever has mostly been reported with septic bursitis and therefore a patient with a fever and bursitis should be considered to have septic bursitis until proven otherwise (3). However, it is common to have septic bursitis without a fever such as the two cases presented above (Table 1). In one study, a temperature differential of >2.2 °C of the skin overlying the affected bursa and the contralateral nonaffected bursa was predictive of septic bursitis (20).

Table 2
Table 2:
Summary of different types of olecranon bursitis.

Plain radiography is not usually indicated in cases of olecranon bursitis unless there is a recent trauma with concern for fractures. Ultrasound can be a useful modality in visualizing the enlarged bursa particularly in cases of significant soft tissue edema due to cellulitis (5,7). Color Doppler may help visualize the inflammatory process in and around the bursa. Ultrasound also can help with needle placement for aspiration in difficult cases (5,7). Magnetic resonance imaging (MRI) can help characterize soft tissue, but it is not able to accurately differentiate between septic and aseptic bursitis (7,9).

Patients with septic bursitis will typically exhibit elevated leukocytes and C-reactive protein (CRP); however, these markers also may be elevated in patients with aseptic inflammatory bursitis (Table 2).

After history, physical examination, and applicable blood tests and imaging, if there is still uncertainty regarding the cause of the bursitis, particularly if there is a question of septic bursitis, an aspiration of the bursal fluid should be performed (2,3,7,10,12,14,25,28). A Z-track method of inserting the needle in which the skin and deeper layers are not in the same plane after injection helps seal the path (16). The bursal aspiration should be performed prior to the administration of the first dose of antibiotics (2). The aspirated fluid should be sent for cell count, Gram stain, culture, and crystal analysis (Table 2). In general, bursal fluid that is cloudy or purulent in appearance is more suggestive of septic bursitis as is positive Gram stain, numerous white blood cells (WBC) or PMN, and growth on a culture (2,3,14,19,25,28). In addition to aiding in diagnosis, bursal aspiration for a patient with septic bursitis can improve symptoms and reduce bacterial load and may be repeated daily as part of the treatment regimen if indicated (2,3,7). The use of a compressive bandage after aspiration may help reduce reaccumulation of the bursal fluid (2,3,13).

Other conservative methods of managing aseptic bursitis such as relative rest, ice, elevation, nonsteroidal anti-inflammatory drugs, avoidance of trauma or pressure to the area, an elbow pad, and sometimes splinting can be concurrently used in patients with septic olecranon bursitis (3,7,17). In cases of aseptic olecranon bursitis, if the patient is quite symptomatic or has reduced range of motion, a bursal aspiration may be warranted (3,7,8,11,17). In situations where the etiology is clearly aseptic chronic traumatic bursitis and the patient has full range of motion, the authors do not recommend bursal aspiration as this can potentially lead to iatrogenic olecranon bursitis.

For chronic microtraumatic aseptic bursitis, a corticosteroid injection may be considered for those who have failed conservative management (3,7). There is a risk of complications with corticosteroid injections and therefore they should not be a first-line treatment. A systematic review of olecranon bursitis found that receiving a corticosteroid injection did not improve resolution of the bursitis and about 11% of those who were injected developed skin atrophy (17). Occasionally, a patient with perpetual or recurrent olecranon may require surgical bursectomy (3,7). Surgical intervention is associated with complications, and nonsurgical management is preferable when possible (3,17).

Management of other types of bursitis is aided by the understanding of the underlying disorder. In the case of aseptic inflammatory bursitis after ruling out septic bursitis with a bursal aspirate analysis and culture, a corticosteroid injection can assist in the resolution of bursitis (7).

In both of these cases, the initial bursal aspirate had numerous PMN and a negative Gram stain. Also in both cases, the organism infecting the olecranon bursa was OSSA. It is well documented that S. aureus is responsible for approximately 80% to 85% of septic olecranon and prepatellar bursitis (6,15,28). Other organisms found to cause septic bursitis are Streptococcus pyogenes (most commonly group A) and less commonly Staphylococcus epidermidis (7,12,28). Rarely, Escherichia coli and Candida species have grown from cultured septic bursal aspirate (6).

There is wide geographical variation in the treatment of septic olecranon bursitis and lack of strong evidence-based guidelines regarding management (2–4,7,14,22,28). For example, some institutions may use surgical debridement or bursectomy as a first-line treatment for septic bursitis, whereas others may opt to start with antibiotic therapy and resort to surgical options only if more conservative options fail (2–4,7,14,15,22,28). The majority of the data collected in the diagnosis and management of septic olecranon bursitis are based on retrospective case series and systematic reviews of small studies (2,3,17,28). Sayegh et al. (17) describes the lack of evidence in treating septic bursitis and how this lends itself to practice being directed by personal preference. This systematic review also was limited by the quality of current studies (17). However, they did find that nonsurgical management resulted in better resolution of symptoms and lower rate of persistent drainage compared with surgical management (17).

In both of the cases described here, the patients were hospitalized briefly and were treated with a combination of IV and oral antibiotics. With the limited data available, Baumbach et al. (3) has attempted to develop a treatment algorithm for olecranon and prepatellar bursitis. When septic bursitis is strongly suspected or confirmed, but the care team is awaiting culture results, the patient should be started on an antibiotic regimen that covers S. aureus and Streptococcus such as a first-generation cephalosporin or a penicillinase-resistant penicillin (3). Once culture results and sensitivities return, the antibiotic regimen can be tailored appropriately. In the situation of mild to moderate septic olecranon bursitis in an immunocompetent host, the patient can be started on oral antibiotics and monitored closely as an outpatient (2,3). Patients with septic olecranon bursitis with systemic inflammatory response syndrome criteria or who are immunocompromised should be hospitalized and started on IV antibiotics (3). Hospitalization and IV antibiotics also have been recommended in patients with cellulitis, fever, chills, and prolonged symptoms (2,3,7). Recommended duration of antibiotic therapy varies but appears to be in the 10- to 14-d range (2,3,7).

In a situation where the patient with septic bursitis is acutely ill, or if there is persistence or recurrence of the septic bursitis, it may be appropriate to proceed directly to surgery or bursectomy without a preceding course of antibiotic therapy (3,7,14,24). In a retrospective study, Perez et al. (15) reported a potential benefit of a short-course adjuvant antibiotic therapy. Endoscopic bursectomy seems to result in lower rate of delayed or complicated wound healing compared with open surgical techniques (3,14).

Conclusion

Septic olecranon bursitis is uncommon. When it does occur, S. aureus is the most common organism. When there is concern for septic olecranon bursitis, appropriate management is to aspirate and send the fluid for Gram stain, cell count, and culture. There is no good data supporting treatment with oral versus IV antibiotics.

Acknowledgment

Authors would like to thank Mrs. Carol M. Odell, FNP for her clinical contributions.

The authors declare no conflicts of interest and do not have any financial disclosures.

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