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17 April 2023: Articles  Japan

Acute Deterioration of Patient with Sudden Onset of Shock Caused by Group G Streptococcus Infection after Revision Total Knee Arthroplasty: A Case Report

Rare disease

Kensuke Wada1BEF, Tomoyuki Matsumoto1ABCDE*, Kemmei Ikuta2B, Masanori Tsubosaka2B, Naoki Nakano2B, Toshihisa Maeda ORCID logo2B, Yuichi Kuroda2B, Shinya Hayashi2B, Ryosuke Kuroda2E

DOI: 10.12659/AJCR.938905

Am J Case Rep 2023; 24:e938905



BACKGROUND: Periprosthetic joint infection is a difficult complication, especially in patients with rheumatoid arthritis. Life-threatening septic shock due to periprosthetic joint infection caused by group G streptococcus is rare, and there have been few reports about its treatment. We describe a successful case of sudden onset septic shock due to group G Streptococcus infection after revision total knee arthroplasty.

CASE REPORT: A 61-year-old woman with rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs for about 12 years presented with acute right knee pain and shock 6 months after revision total knee arthroplasty. Periprosthetic joint infection caused by group G Streptococcus was diagnosed. She was admitted to the Intensive Care Unit, treated with respiratory support and dialysis, and underwent irrigation, debridement, and polyethylene liner exchange as the first surgery. At 9 days after the first surgery, she underwent the second surgery, consisting of implant removal and antibiotic spacer placement due to failure. It took approximately 7 weeks to normalize the levels of systemic markers of inflammation with intravenous antibiotics and then oral antibiotics for further 12 weeks, but re-revision total knee arthroplasty was successfully performed 1.5 years later. At a 1-year follow-up from the final surgery, she was able to walk with a cane and had no symptoms of infection.

CONCLUSIONS: In such cases with sudden onset of septic shock due to periprosthetic joint infection, appropriate and prompt surgical treatment should be performed to save the infected limb as well as the patient’s life.

Keywords: Arthroplasty, Replacement, Knee, Fasciitis, Necrotizing, Shock, Septic, Streptococcus dysgalactiae


Periprosthetic joint infection (PJI) represents one of the most major complications after total knee arthroplasty (TKA). Rates of PJI in primary TKA range between 0.5% and 1.9% and between 8% and 10% in revision TKA [1–3]. The incidence of PJI among patients with rheumatoid arthritis (RA) is 1.6 times greater than that among patients with osteoarthritis [4]. PJI is a challenging complication that usually progresses slowly with an appropriate combination of surgical and antibiotic treatments, without life-threatening complications. However, PJIs with rapid deterioration are rare, in which the sudden onset of septic shock rarely occurs. In the rare incidence, Streptococcus including the G strain were causatives [5].

Necrotizing fasciitis (NF) is a rare bacterial infection that spreads quickly throughout the body and can cause death. NF is commonly caused by group A Streptococcus. NF after TKA is extremely rare; the only reported case was a lifesaving above-knee amputation [6]. Here, we present a rare case of septic shock due to infection caused by group G Streptococcus after revision TKA. Successful treatment resulted in saving the infected limb as well as the life of a 61-year-old woman with RA treated with biological disease-modifying antirheumatic drugs (bDMARDs).

Case Report

A 61-year-old woman presented to our hospital with pain in her right knee. The patient received a diagnosis of PJI after revision TKA and was given intravenous antibiotic treatment at the previous hospital. The next day, she was referred to our hospital for treatment of septic shock. She had undergone primary TKA (Sigma RP-F, Depuy, Warsaw, IN, USA) for rheumatoid arthritis 10 years previously and revision TKA (P. F. C Sigma TC3, Depuy, Warsaw, IN, USA) due to aseptic loosening 6 months previously. The patient had been receiving oral prednisone (4 mg daily), tacrolimus (1.5 mg daily), and etanercept (50 mg subcutaneous injections weekly). Pain, swelling, and burning sensations were observed in the right knee, and redness and local heat extending to the right lower leg were observed during physical examination. Laboratory examination showed a white blood cell count of 8.1×109/L and C-reactive protein level of 19.9 mg/L. We performed aspiration of the right knee joint, and gram-positive streptococci were detected by staining, which were later identified to be Streptococcus dysgalactiae (group G Streptococcus). She had a temperature of 38.2°C, heart rate of 128 beats/min, and blood pressure of 56/32 mmHg. Laboratory investigations yielded the following values: hemoglobin, 9.5 g/dL; serumglucose, 99 mg/dL; serum creatinine, 2.93 mg/dL; and sodium, 139 mEq/L. Radiography of the right knee showed no osteolytic lesions and no signs of periprosthetic loosening (Figure 1). A computed tomography scan might have helped with the diagnosis but was not performed because it was too dangerous to move the patient, who was in a state of shock, to the examination room. We diagnosed septic shock due to PJI after revision TKA and rapidly performed irrigation, debridement, polyethylene liner exchange, and antibiotic therapy because there were no findings that suggested loosening of the prosthesis and because of the short period of time since the onset of symptoms. During the surgery, a lack of tissue resistance to blunt finger dissection was observed. The patient was rapidly admitted to the Intensive Care Unit for mechanical ventilation after the operation. She was immediately placed empirically on meropenem (1.0 g every 12 h), vancomycin (0.5 g every 12 h), and clindamycin (600 mg every 8 h). We administered continuous hemodiafiltration and started her on nor-adrenaline via a peripheral intravenous catheter. Blood culture tests were performed several times, but the results were all negative. The patient’s clinical condition gradually stabilized, and noradrenaline application was stopped on day 5 of admission. However, on the hospitalization day 8, swelling and burning sensation were again observed in the right knee, and approximately 35 mL of exudate was aspirated. Analysis of the joint aspiration revealed a white blood cell count of 60 100/ μL and a positive alpha-defensin test. We judged eradication failure of the infection and performed irrigation, debridement, implant removal, and antibiotic spacer (1 g of vancomycin per 40 g of cement) placement (Figure 2). The patient’s postoperative period was uneventful. Six weeks after surgery, the inflammatory markers had normalized (C-reactive protein, 0.05 mg/L) with intravenous antibiotic therapy (ampicillin 2 g every 6 h and clindamycin 600 mg every 8 h for 2 weeks and then cefazolin 2 g every 8 h for 4 weeks). Ten weeks after surgery, the patient displayed no clinical signs of infection and was discharged from the hospital with 2 canes. Based on the suggestion of the Department of Rheumatology and Clinical Immunology, she was started on bucillamine (100 mg daily) 1 month after surgery, and the dose was gradually increased to 300 mg daily. At the time of discharge, she was taking busiramine and prednisolone (4 mg daily). We did not resume bDMARDs because her RA was well controlled. She was administrated oral cefalexin 500 mg 3 times a day for 2 months.

Approximately 1.5 years after surgery, she underwent re-revision TKA (NexGen Rotating Hinge Knee, Zimmer-Biomet, Warsaw, IN, USA; Figure 3). Throughout the follow-up period, inflammatory markers were not elevated and no clinical signs of infection were observed. One year after the final surgery, the patient walked with a cane and had no symptoms of infection. No pain, swelling, or burning sensation was observed in the right knee, and right knee motion ranged from 0° of extension to 90° of flexion with no extension lag.


Significant advances in RA treatment have resulted in the introduction of bDMARDs, such as tumor necrosis factor inhibitors (TNFi). Nevertheless, patients with RA still progress to end-stage arthritis and require arthroplasty [7]. Critical outcomes, such as infection and dislocation, were reported to be higher in patients with RA than in those with osteoarthritis. Lee et al reported that the deep infection rate was significantly higher in RA patients than in osteoarthritis patients (3.0% vs 0.9%, P<0.001) [8]. Rene et al reported that patients with RA had an increased risk of PJI (HR: 1.46; 95% CI: 1.13–1.88) and death (HR: 1.25; 95% CI: 1.01–1.55) [9]. Hayashi et al reported that TNFi therapy was found to be significantly associated with the development of late infection after total hip arthroplasty (OR: 11.7; 95% CI: 1.2–109) [10]. In the present case report, RA treated with bDMARDs led to an immunocompromised condition, which might be the reason for this severe infection.

Beta-hemolytic streptococcus can cause PJI; however, Cunningham et al reported that Staphylococcus species such as coagulase-negative staphylococci, methicillin-sensitive Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus represented the largest proportion of infecting organisms, whereas gram-negative organisms and fungi were relatively less prevalent [11]. It was reported that 7% to 12% of PJI are caused by Streptococcus spp. [12,13]. Group C and G streptococcal bacteremias are linked to diabetes mellitus, cardiovascular disease, malignancy, immunosuppression, and breakdown of the skin [14]. Patients infected with group C and G streptococcus presented with septic arthritis more often than those infected with Group B, whereas patients with group A infections had abscesses involving sites deeper than the skin more often than patients with group C and G infections [15]. These reports suggest that immunosuppressed patients with RA, as in the present case, are more susceptible to group C and G streptococcus and are at a higher risk of PJI.

NF is an uncommon, life-threatening, and aggressive soft-tissue infection. NF occurring simultaneously with PJI is a rare occurrence. Hanno et al reported the only case, which was of a 65-year-old woman with NF following TKA who was infected with Staphylococcus epidermidis and underwent above-knee amputation [6]. Establishing a diagnosis of NF is challenging, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is a diagnostic tool. In the present case, the LRINEC score was 8 points, and a score ≥8 was strongly predictive of NF [16]. However, their study showed a probability of necrotizing infections of 75% corresponds to a score of 8. Neeki et al reported a false positive rate for the LRINEC score of 10.7% [17]. Therefore, we need to understand the limitations of the LRINEC score. Because no obvious necrotic tissue was observed intraoperatively, debridement of the lower leg was not performed. In addition, when signs of infection were observed again, we were able to respond rapidly, which saved the patient’s life and preserved her lower leg.


We encountered a rare case of PJI in an immunosuppressed RA patient whose clinical course rapidly worsened, with sudden onset of septic shock caused by group G Streptococcus. Appropriate and prompt surgical treatment and intensive care made it possible to save the affected knee joint as well as the patient’s life.


1.. Kurtz SM, Lau E, Schmier J, Infection burden for hip and knee arthroplasty in the United States: J Arthroplasty, 2008; 23(7); 984-91

2.. Kurtz SM, Ong KL, Lau E, Prosthetic joint infection risk after TKA in the Medicare population: Clin Orthop Relat Res, 2010; 468(1); 52-56

3.. Bozic KJ, Kurtz SM, Lau E, The epidemiology of revision total knee arthroplasty in the United States: Clin Orthop Relat Res, 2010; 468(1); 45-51

4.. Yeganeh MH, Kheir MM, Shahi A, Parvizi J, Rheumatoid arthritis, disease modifying agents, and periprosthetic joint infection: What does a joint surgeon need to know?: J Arthroplasty, 2018; 33(4); 1258-64

5.. Rosteius T, Jansen O, Fehmer T, Evaluating the microbial pattern of periprosthetic joint infections of the hip and knee: J Med Microbiol, 2018; 67(11); 1608-13

6.. Steckel H, Baums MH, Tennstedt-Schenk C, Klinger HM, Necrotizing fasciitis of the knee following primary total knee arthroplasty: Knee Surg Sports Traumatol Arthrosc, 2011; 19(12); 2076-79

7.. Goodman SM, Springer B, Guyatt G, 2017 American College of Rheumatology/American Association of hip and knee surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty: J Arthroplasty, 2017; 32(9); 2628-38

8.. Lee DK, Kim HJ, Cho IY, Lee DH, Infection and revision rates following primary total knee arthroplasty in patients with rheumatoid arthritis versus osteoarthritis: A meta-analysis: Knee Surg Sports Traumatol Arthrosc, 2017; 25(12); 3800-7

9.. Cordtz RL, Zobbe K, Højgaard P, Predictors of revision, prosthetic joint infection and mortality following total hip or total knee arthroplasty in patients with rheumatoid arthritis: A nationwide cohort study using Danish healthcare registers: Ann Rheum Dis, 2018; 77(2); 281-88

10.. Hayashi S, Hashimoto S, Takayama K, Risk factors for late deep infection after total hip arthroplasty in patients with rheumatoid arthritis: Acta Reumatol Port, 2017; 42(2); 150-54

11.. Cunningham DJ, Kavolus JJ, Bolognesi MP, Specific infectious organisms associated with poor outcomes in treatment for hip periprosthetic infection: J Arthroplasty, 2017; 32(6); 1984-90 e5

12.. Stefánsdóttir A, Johansson D, Knutson K, Microbiology of the infected knee arthroplasty: Report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases: Scand J Infect Dis, 2009; 41(11–12); 831-40

13.. Zappe B, Graf S, Ochsner PE, Propionibacterium spp. in prosthetic joint infections: A diagnostic challenge: Arch Orthop Trauma Surg, 2008; 128(10); 1039-46

14.. Rantala S: Eur J Clin Microbiol Infect Dis, 2014; 33(8); 1303-10

15.. Takahashi T, Sunaoshi K, Sunakawa K: Clin Microbiol Infect, 2010; 16(8); 1097-103

16.. Wong CH, Khin LW, Heng KS, The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections: Crit Care Med, 2004; 32(7); 1535-41

17.. Neeki MM, Dong F, Au C, Evaluating the laboratory risk indicator to differentiate cellulitis from necrotizing fasciitis in the Emergency Department: West J Emerg Med, 2017; 18(4); 684-89

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923