PB1262 - Differential diagnosis of haemarthrosis in a patient with severe haemophilia: a case report

Background: The most common complication in patients with haemophilia (PWH) is haemarthrosis. However, other joint involvement can occur in this population.
Septic arthritis (SA) is an uncommon complication but occurs more frequently in PWH than in general population and can lead to accelerated deterioration. Differential diagnosis (DD) with gouty arthritis, pseudogout and avascular necrosis is also necessary. Early management is essential as SA carries a worse prognosis.

Aims: Establish the differential diagnosis of acute joint pathology in PWH.

Methods: Case report of a patient with severe haemophilia A (SHA) with acute arthropathy, precise diagnosis, treatment and complications.

Results: A 39-year-old man with SHA. He went to emergency department with pain in left elbow and ankle and dysthermic sensation of a few hours' evolution. On examination: oedema and local increase in temperature in left ankle. Laboratory tests: elevated C-reactive protein (CRP), leukocytosis (15x109/L). Pain improved with analgesia and FVIII replacement; he was discharged with analgesia and amoxicillin-clavulanic acid. After 24 hours he returned for intensification of pain and inflammation of left ankle and elbow. Laboratory tests: elevated CRP, procalcitonin. Ultrasound and MRI: haemarthrosis with signs of infectious tenosynovitis of tibialis posterior, flexor hallux and flexor digitorum.
He was admitted and started treatment with ceftriaxone and cloxacillin for oligoarticular septic arthritis. An arthrotomy of anterior compartment of ankle and joint cleaning of left elbow and ankle were performed. Intraoperative cultures were negative. As a complication, he presented neurapraxia of left radial arm, requiring postural orthosis and rehabilitation.
He required treatment with intravenous FVIII, adjusted according to interventions, He had a good response.

Conclusion(s): In PWH with acute joint involvement, a DD of haemarthrosis is recommended.
Evidence of systemic involvement (fever and elevated phase reactants) should raise suspicion of SA. Early initiation of empirical antibiotic therapy and/or invasive therapeutic measures is essential to avoid secondary complications.