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Opioid withdrawal syndrome: case report A 19-year-old man developed opioid withdrawal syndrome (OWS) during treatment with oxycodone/paracetamol for pain relief following anterior cruciate ligament (ACL) reconstruction. The man underwent right knee ACL reconstruction with hamstring autograft as well as partial lateral meniscectomy. His postoperative course was complicated with 24 hours of acute onset of a low-grade fevers, chills, malaise, and nausea. He also reported residual pain above his right knee that worsened over that period. He presented to a local urgent care center 7 days after surgery. A review of systems detected an increased frequency of bowel movements. He had been taking a total regimen of 2 oxycodone/paracetamol [Percocet] 5/325 mg tablets every 4 hours from postoperative day 0 through 6 for postoperative pain until running out of medication the day prior to presentation to the urgent care center. He had not taken oxycodone/paracetamol for a day, but instead took 2 paracetamol [acetaminophen] 325 mg tablets every 4 hours on postoperative day 7. Urgent care physician evaluated him and he was found to be febrile to 101.6°F (38.7°C). Physical examination of his right lower extremity showed moderate effusion and he was able to range his right knee from 0° to 90° of flexion. He was able to weight bear without pain. Incisions were seen to be healing appropriately without erythema, warmth, or drainage. The urgent care physician aspirated 2mL of bloody fluid from the joint. After discussion with the operative surgeon, he was placed on a course of unspecified cephalosporin. Two days later, on postoperative day 9, he met operative surgeon in the office setting and again expressed concerns of having subjective fevers of 99°F (37.2°C). He also continued to note vague GI upset and flu like symptoms. Furthermore, it was decided to aspirate the right knee, for evaluation of possible acute postoperative infection and 30mL of bloody fluid was retrieved. He was closely monitored for the next 24 hours while the aspirate results were pending. Based on the results of the joint aspirate and the symptoms, the decision to undergo an arthroscopic right knee irrigation and debridement would have been made; however, the symptoms of fevers, chills, and GI upset spontaneously resolved on postoperative day 10. The aspirate results came back showing 4.7 million RBC, 10.7 thousand WBC, and no organisms seen on Gram stain. The final culture of the aspirate showed no growth at 14 days. The remainder of the postoperative course was unremarkable. Based on these findings a diagnosis of OWS was made as he had ran out of oxycodone/paracetamol prior to the presentation of the symptoms. Kong Q, et al. Acute opioid withdrawal mimicking postoperative joint infection following anterior cruciate ligament (Acl) reconstruction: A case report. American Journal of 803497877 Case Reports 21: 1-5, Jan 2020

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Reactions 22 Aug 2020 No. 1818