29 December 2021: Articles
A Case of Native Joint Septic Arthritis Caused by
Rare disease
Duong Tommy Hua
DOI: 10.12659/AJCR.934266
Am J Case Rep 2021; 22:e934266
Abstract
BACKGROUND: Bacteroides fragilis (B. fragilis) is an uncommon cause of native joint septic arthritis (NJSA). It is an anaerobic gram-negative rod that is normally found in the oral cavity, gastrointestinal tract, genitourinary system, and skin, and thus is rarely isolated from the musculoskeletal system. Risk factors for B. fragilis NJSA include inflammatory arthritis, malignancy, sickle cell disease, and ischemic heart disease.
CASE REPORT: We discuss a case of a 65-year-old man with coronary artery disease, heart failure, chronic kidney disease, and gout, who presented with 5 days of right knee pain, redness, swelling, and warmth. His history included a corticosteroid injection in the affected knee 2 months prior to presentation. The patient was febrile with a palpable right knee joint effusion on exam. Labs were significant for leukocytosis and elevated inflammatory markers. Synovial fluid was aspirated, which was diagnostic for septic arthritis, with cultures growing B. fragilis. Blood cultures were negative, so the infection was attributed to the prior joint injection. The patient was subsequently taken to the operating room for irrigation and debridement. He was started on metronidazole, but he unfortunately left against medical advice before treatment was complete and was lost to follow-up thereafter.
CONCLUSIONS: B. fragilis NJSA most often occurs in the setting of bacteremia or contiguous spread from a concomitant infection. Management involves antibiotics such as metronidazole and surgical drainage. Due to the paucity of data on an infection such as in the present case, the optimal duration of metronidazole is not well-established.
Keywords: Arthritis, Infectious, Bacteroides fragilis, Knee Joint, Bacteremia, Bacteroides Infections, Humans, Male, Synovial Fluid
Background
Native joint septic arthritis (NJSA) is an uncommon condition, with an incidence rate of 12/100 000 person-years [1]. Mortality is variable depending on co-morbid conditions and causative organism, but a case series studying 109 patients with NJSA found a mortality rate of 5.6% [2]. The most common organisms isolated in septic arthritis are
We report a case of
Case Report
A 65-year-old man with a complex past medical history, including coronary artery disease with stent, heart failure, atrial fibrillation, sick sinus syndrome with a pacemaker, chronic kidney disease, diabetes mellitus, gout, asthma, hypertension, obstructive sleep apnea, anxiety, and prostate cancer status post prostatectomy, presented to the emergency room with a chief concern of 5 days of right knee pain associated with redness, swelling, and warmth. His symptoms had progressively worsened such that he was unable to bear weight on the affected leg. He denied any fevers or chills. Of note, 2 weeks prior to his presentation, he sought care for a gout flare of his right knee and was given colchicine and prednisone. He had undergone steroid injections in the right knee every 3 months, the last of which was 2 months prior to the current presentation. He denied intravenous drug use. His medication list included albuterol, fluticasone-vilanterol, linaclotide, losartan, amlodipine, famotidine, montelukast, furosemide, glipizide, clonazepam, pantoprazole, evolocumab, and febuxostat.
His vital signs included a temperature of 38.5°C, heart rate of 80 beats per minute, blood pressure of 137/73 mmHg, respiratory rate of 16 breaths/minute, oxygen saturation of 98% on room air, and weight of 92.2 kilograms. His physical exam was remarkable for a right knee that was erythematous, warm, and swollen, and was exquisitely tender to palpation. The patient was unable to tolerate passive range of motion. The remainder of the joints assessed were unremarkable. Auscultation of his heart revealed an irregularly irregular rhythm but was otherwise negative for murmurs.
Notable lab results included a white blood cell count (WBC) of 16.7 K/cumm (reference range 4.5–10 K/cumm) with 78% neutrophils and 1% bands, hemoglobin 12.7 g/dL (reference range 13.5–16.5 g/dL), blood urea nitrogen (BUN) 48 mg/dL (reference range 8–20 mg/dL), creatinine 1.86 mg/dL (reference range 0.64–1.27 mg/dL), c-reactive protein (CRP) 9.15 mg/dL (reference range 0–0.74 mg/dL), and erythrocyte sedimentation rate (ESR) 49 mm/hr (reference range 0–20 mm/hr). Light brown, purulent synovial fluid from the right knee was obtained prior to antibiotic administration and was notable for a nucleated cell count of 218 325 K/cumm (reference range 13–180 K/cumm) with 87% neutrophils (reference range 0–25%), and a red blood cell count of16 127 K/cumm (reference range 0–2000 K/cumm). Sterile specimens were sent to the microbiology lab for aerobic and anerobic screening, revealing no organisms on original gram stain. Cultures plated per hospital protocol on multiple culture media including Blood, Chocolate, MacConkey, and Brucella with H&K (BRUHK) agar showed no growth at 24 h. A radiograph of the right knee demonstrated a small-to-moderate-size joint effusion (Figure 1).
The patient was started on empiric treatment with vancomycin and ceftriaxone for septic arthritis. Orthopedic Surgery was consulted for surgical management. The patient was taken to the operating room on hospital day 1 for irrigation and debridement of his right knee, without any complications. By hospital day 2, the synovial fluid culture obtained from admission revealed heavy growth of
Discussion
No controlled trials or observational studies regarding the management of NJSA due to
The optimal means of achieving source control in NJSA in general remain uncertain. Needle aspiration, arthroscopy, and arthrotomy have all been explored in the literature, but none of these modalities have demonstrated statistically significant superiority [6]. Arthrotomy and needle aspiration have both been employed as modes of source control in cases of NJSA due to
In addition, antibiotic selection has varied widely in documented cases of NJSA due to
The duration of antibiotic therapy in cases of NJSA due to
NJSA due to
The documented mortality occurred in a 71-year-old man with seropositive rheumatoid arthritis and NJSA of his right knee and elbow. The patient had additional comorbidities including chronic obstructive pulmonary disease, coronary artery disease, and congestive heart failure, similar to our patient. Prior to his death, the patient had received surgical drainage of the affected joints and antibiotic therapy with ampicillin, chloramphenicol, clindamycin, and tobramycin. No autopsy was performed [8].
The case of relapsed disease occurred in a 44-year-old man with insulin-dependent diabetes mellitus and NJSA of his right knee. During his initial hospitalization, this patient received a right knee arthrotomy and a 5-week course of clindamycin following the isolation of
Conclusions
NJSA due to
Management requires both antibiotic therapy and source control with surgical drainage. However, the preferred modality of surgical drainage remains controversial [6]. The duration of antibiotic therapy after surgical drainage is dependent upon whether there is a concomitant primary infectious process, such as endocarditis or osteomyelitis, as these would require longer treatment courses. If none of these are present, then 2 weeks of targeted antibiotic therapy is now considered adequate [17].
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