What caused pain in woman's shoulder?

A middle-age woman came to the ER complaining of severe shoulder and chest pain on her right side. The pain was so severe she could barely move her right arm. Still, she endured it for a week until she sought help.

Before this episode, her health was generally good, though she smoked a pack of cigarettes a day and needed medication to control diabetes.

Earlier in the year, she had had an elective abdominal hernia repair at a previous C-section incision site. Her incision healed well.

When she came to the ER, she had a lump below her clavicle, extending to her shoulder and across the sternum. Even a gentle touch to this swelling caused her severe pain. The lump was red and warm, suggesting an infection under the skin.

With a low-grade fever, her white cell count was elevated, as would be expected with an infection. A CT scan of her chest showed evidence of an infection of the muscles and the connecting tissues at the site of the swelling. Her heart, lungs, and bones seemed to be healthy.

She was immediately started on intravenous antibiotics and fluids in the emergency room. An infectious disease consultation was ordered by the medical team. Shortly after her admission, the microbiology laboratory showed positive blood culture results for the streptococcus pneumoniae bacteria.

Most likely, the bloodstream infection started out as a skin and soft-tissue infection near her clavicle that leaked into her bloodstream, causing this potentially deadly infection. Interestingly, she did not have pneumonia.

The streptococcus pneumoniae bacteria is the most common cause of community-acquired pneumonia. In some rare instances, however, it can cause infection elsewhere in the body without causing pneumonia. If it is isolated from a previously sterile body site such as the blood, joints, or the cerebrospinal fluid, it is considered an invasive pneumococcal disease and it can be life-threatening.

The doctors adjusted her antibiotics immediately and she was given strong medications to alleviate the pain.

Her repeat blood cultures became negative fairly quickly and her pain improved gradually. She also regained the ability to freely move her right shoulder. Over the next few days, however, her C-section incision site, which had healed well, opened and pus started to drain. The cultures from the drainage showed streptococcus pneumonia. The bacteria had seeded the mesh material used to repair the hernia.

Her hospital stay was prolonged and she required several weeks of intravenous antibiotics. Eventually, she cleared her infection completely without any conditions developing as a result of her infection.

Still, her doctors wanted to know why this bacterium had so invaded an otherwise healthy woman.

When asked for more details about her history, our patient mentioned her spleen was removed when she was a child because of a medical condition. The spleen is an important immune system organ that fights infections. People who have had a splenectomy are at risk of certain bacterial infections, including streptococcus pneumonia, which is why they should always get the pneumococcal vaccine. Being a smoker was another risk factor for our patient to develop pneumococcal infection.

Despite her strong risk factors, however, she had not received the pneumococcal vaccine.

About 18,000 people die in U.S. each year due to pneumococcal disease. Thousands of others get sick from this illness and require antibiotics, emergency room visits, and hospital admissions. Pneumococcal vaccine is now part of the routine childhood vaccination schedule and is recommended for all adults 65 and older, and anyone who is a smoker or who has conditions such as diabetes, liver cirrhosis, or chronic lung, kidney, or heart disease. Pneumococcal vaccine is also recommended for those with weakened immune systems, such as people with HIV, cancer, a damaged spleen, or who have had an organ transplant and must take antirejection medication.

The best way to prevent pneumococcal disease is to get vaccinated. Pneumococcal vaccines are widely available in doctors' offices, hospitals, and most pharmacies, and most major insurance plans cover them.

Before the patient left the hospital, she got a pneumonia vaccine. She said she certainly did not want to take any more chances.

Dr. Gul Madison is an infectious-diseases specialist with Mercy Philadelphia Hospital.