Infectious arthritis in renal transplant patients

Non-tuberculous mycobacterial infections in solid organ transplant recipients: An update

Non-tuberculous mycobacteria are ubiquitous environmental organisms that are now increasingly recognized as important causes of clinical disease in solid organ transplant recipients. Risk factors of non-tuberculous mycobacteria infection are severe immunologic defects and structural abnormalities. Lung transplant recipients are at higher risk for non-tuberculous mycobacterial disease compared to recipients of other solid organs. The clinical presentation could be skin and soft tissue infection, osteoarticular disease, pleuropulmonary infection, bloodstream (including catheter-associated) infection, lymphadenitis, and disseminated or multi-organ disease. Management of non-tuberculous mycobacteria infection is complex due to the prolonged treatment course with multi-drug regimens that are anticipated to interact with immunosuppressive medications. This review article provides an update on infections due to non-tuberculous mycobacteria after solid organ transplantation, and discusses the epidemiology, risk factors, clinical presentation, and management.

Severe Osteomyelitis and Septic Arthritis due to Serratia marcescens in an Immunocompetent Patient

Septic arthritis and osteomyelitis due to Serratia marcescens in immunocompetent patients without risk factors are extremely rare. Here, we report a case of septic arthritis and severe adjacent osteomyelitis of the tibia due to Serratia marcescens in a diabetic community-dweller patient. The patient had no contact with healthcare workers or facilities and had no chronic disease except for poorly controlled diabetes. Without predisposing risk factors, this type of infection is extremely rare, even in diabetics.

Septic arthritis due to extended spectrum beta lactamase producing Klebsiella pneumoniae

CASE REPORT

Septic arthritis due to Klebsiella species is a rare but serious infection that may destroy a joint and cause serious immobility. This is a report of two immunocompromised adult patients presenting with acute septic arthritis due to extended spectrum beta lactamase producing Klebsiella pneumoniae. The infection was treated successfully with a course of meropenem and amikacin in combination with early arthroscopic washout of the joint. Little information has been published on the management of this infection. We are therefore presenting a systematic literature review summarizing risk factors, clinical presentation, laboratory diagnosis, treatment regimens and outcome of this condition.

DISCUSSION

On the basis of our study, we recommend an early diagnostic arthrocentesis of the joint for Gram stain microscopy, culture and antibiotic sensitivity testing to guide the appropriate use of antibiotics. In cases of hospital acquired infections where drug resistant Gram negative bacteria are suspected or prevalent, broad-spectrum antibiotics such as meropenem plus or minus amikacin may be given as the empirical treatment until the sensitivities are confirmed. In addition, adequate surgical joint lavage should be considered as the mainstay of treatment.

Mycoplasma hominis septic arthritis in a pediatric renal transplant recipient: case report and review of the literature

Septic arthritis (SA) typically occurs in young children, often from Staphylococcus. With chronic immunosuppression, however, pathogens may be atypical. A 15-year-old African-American female developed Mycoplasma hominis SA in her right hip 2 months following cadaveric renal transplant (Tx). Her presentation was subtle and indolent, without fever or leukocytosis. Although reported in adult Tx recipients, M. hominis infections have not been described in pediatric recipients. Early immunosuppression (basiliximab, prednisone, tacrolimus, mycophenolate mofetil and Thymoglobulin) may have increased her susceptibility to M. hominis. Optimal therapy for M. hominis SA is not well established and relapses occur. This patient underwent joint incision and drainage, treatment for 8 weeks with doxycycline and levofloxacin guided by in vitro sensitivities, and a reduction in immunosuppression. She has been free of ongoing infection for 3 years with stable graft function (Cr 1.1 mg/dL) on moderate immunosuppression with prednisone, tacrolimus and MMF.

Septic arthritis caused by nocardia asteroides in a renal transplant recipient

Although articular complications are common following renal transplantation, septic arthritis is not frequent. Previous bacterial infection in an another site is a consistent finding and the knee is the most often affected joint. We present a 30-year-old female renal transplant recipient with recurrent pulmonary infiltrates preceding septic arthritis of her left knee. Cultures of the aspirated synovial fluid yielded a gram-positive, rod-shaped bacterium later identified as Nocardia asteroides. The patient was treated with oral trimethoprim-sulfamethoxazole without any side effect. Nocardia is a rare but serious cause of infection in renal transplant recipients but there is no well-known predisposing factor. Recently mycophenolate mofetil has been implicated as a factor associated with Nocardia infections. Prolonged courses of treatment with sulphonamides are recommended.

Nontuberculous mycobacterial infection in hematopoietic stem cell and solid organ transplant recipients

Nontuberculous mycobacteria (NTM) are ubiquitous environmental organisms. In immunocompetent hosts, they are a rare cause of disease. In immunocompromised hosts, disease due to NTM is well documented. Reports of NTM disease have increased in hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) recipients. This increase may reflect increased numbers of transplants, intensification of immune suppressive regimens, prolonged survival of transplant recipients, and/or improved diagnostic techniques. The difficulty of diagnosis and the impact associated with infections due to NTM in HSCT and SOT recipients necessitates that, to ensure prompt diagnosis and early initiation of therapy, a high level of suspicion for NTM disease be maintained. The most common manifestations of NTM infection in SOT recipients include cutaneous and pleuropulmonary disease, and, in HSCT recipients, catheter-related infection. Skin and pulmonary lesions should be biopsied for histologic examination, special staining, and microbiologic cultures, including cultures for bacteria, Nocardia species, fungi, and mycobacteria. Mycobacterial infections associated with catheters may be documented by tunnel or blood (isolator) cultures. Susceptibility testing of mycobacterial isolates is an essential component of optimal care. The frequent isolation of NTM other than Mycobacterium avium complex (MAC) from transplant recipients limits the extrapolation of therapeutic data from human immunodeficiency virus-infected individuals to the population of transplant recipients. Issues involved in the management of NTM disease in transplant recipients are characterized by a case of disseminated infection due to Mycobacterium avium complex in a lung transplant recipient, with a review of the relevant literature.

Septic arthritis

Septic arthritis is a medical emergency that can lead to significant morbidity and mortality. Prompt recognition and treatment are critical to ensuring a good prognosis. Thus, this article reviews the clinical presentation, microbiology, diagnostic workup, and outcome of nonprosthetic joint infections.

Dialysis arthropathy: outcome after renal transplantation

PURPOSE

Patients treated by long-term maintenance hemodialysis frequently develop a form of chronic arthropathy that is strongly associated with beta 2-microglobulin amyloid deposition and related, at least in part, to beta 2-microglobulin retention. Successful renal transplantation is followed by a rapid fall in serum beta 2-microglobulin levels and might allow dissolution of amyloid deposits. The purpose of this work was to investigate the effects of renal transplantation on dialysis arthropathy.

PATIENTS AND METHODS

Fourteen renal transplant recipients were selected on the basis of previous hemodialysis treatment for at least 10 years (mean 16) and a history of chronic joint pain prior to transplantation. They all received 10 to 17.5 mg/d of prednisone. Posttransplant rheumatologic manifestations were studied prospectively and compared to pretransplant rheumatologic manifestations recorded in medical charts and reported during patient interviews. Pretransplant and posttransplant articular roentgenograms were separately analyzed by three observers who were blinded to timing of the films. Beta 2-microglobulin amyloid was identified by Congo red staining and immunohistology.

RESULTS

After a mean posttransplant interval of 54 months (range 12 to 121), the articular condition was improved in 10 patients, unchanged in 1, and worsened in 3, according to patients' assessments. The number of painful joints decreased significantly (P < 0.05) as compared to the pretransplant period. However, the number and size of subchondral bone erosions remained unchanged, destructive arthropathies generally worsened, and articular beta 2-microglobulin amyloid deposits were identified in 2 patients, 2 and 10 years after renal transplantation, respectively.

CONCLUSION

Renal transplantation appeared to arrest progression of beta 2-microglobulin amyloid in dialysis patients, but it neither led to dissolution of deposits nor prevented progression of destructive arthropathies. Most articular symptoms were improved, probably as a result of corticosteroid therapy.