Reactive Legionella pneumophila arthritis diagnosed by polymerase chain reaction

Legionella longbeachae wound infection: case report and review of reported Legionella wound infections

Extrapulmonary manifestations of infection with Legionella species, of which 24 may cause disease in humans, are very rare. Here, we describe a case of a 61-year-old woman with no history of immunosuppression presenting with pain and swelling of her index finger after a prick by rose thorns during gardening. Clinical examination showed fusiform swelling of the finger with mild redness, warmth, and fever. The blood sample revealed a normal white blood cell count and a slight increase in C-reactive protein. Intraoperative observation showed extensive infectious destruction of the tendon sheath, while the flexor tendons were spared. Conventional cultures were negative, while 16S rRNA PCR analysis identified Legionella longbeachae that also could be isolated on buffered charcoal yeast extract media. The patient was treated with oral levofloxacin for 13 days, and the infection healed quickly. The present case report, with a review of the literature, indicates that Legionella species wound infections may be underdiagnosed due to the requirement for specific media and diagnostic methods. It emphasizes the need for heightened awareness of these infections during history taking and clinical examination of patients presenting with cutaneous infections.

Case report of arthritis caused by Legionella anisa and review of the literature

BACKGROUND

Legionella spp. is recognized as a common cause of community acquired pneumonia, with Legionella pneumophila serogroup 1 being the most prevalent. At least 70 species are described so far but few are identified in pathogenic conditions. Data on extrapulmonary infections are scarce.

CASE PRESENTATION

A 73-yar-old male with chronic lymphoid leukemia was hospitalized for an insidious wrist arthritis. Ultrasound of the wrist showed a carpal and radiocarpal fluid effusion with positive Doppler signal. While routine bacterial cultures remained sterile, 16S rRNA PCR identified Legionella anisa. Ciprofloxacin 500 mg twice a day for a period of six weeks improved arthritis with full recovery at the end of the treatment.

CONCLUSION

Legionella non pneumophila are a rare cause of septic arthritis especially found in immunosuppressed patients and identification of species could help clinician to adapt antibiotherapy.

The clinical presentation of Legionella arthritis reveals the mode of infection and the bacterial species: case report and literature review

BACKGROUND

While Legionella is a common cause of pneumonia, extrapulmonary infections like arthritis are scarce. Here, we describe a case of monoarthritis due to Legionella bozemanii, with no history of pneumonia. We provide a literature review of the 9 previously published Legionella arthritis and highlight a dichotomous epidemiology suggesting different physiopathological pathways leading to joint infection.

CASE PRESENTATION

A 56-year old woman under immunosuppressive treatment by oral and intra-articular corticosteroids, methotrexate, and tocilizumab for an anti-synthetase syndrome was hospitalized for worsening pain and swelling of the left wrist for 3 days. Clinical examination showed left wrist synovitis and no fever. The arthritis occurred a few days after an accidental fall on wet asphalt responsible for a cutaneous wound followed by a corticosteroid intra-articular injection. Due to both the negativity of conventional culture of articular fluid and suspicion of infection, 16S rRNA and specific PCRs were performed leading to the identification of L. bozemanii. Legionella-specific culture of the articular fluid was performed retrospectively and isolated L. bozemanii. The empiric antibiotic therapy was switched for oral levofloxacin and rifampin and the patient recovered after a 12-week treatment.

CONCLUSION

We report a case of L. bozemanii monoarthritis in an immunosuppressed woman, following a fall on wet asphalt and intra-articular corticosteroid injection. The review of the literature found that the clinical presentation reveals the mode of infection and the bacterial species. Monoarthritis more likely occurred after inoculation in patients under immunosuppressive therapy and were associated with non-Legionella pneumophila serogroup 1 (Lp1) strains that predominate in the environment. Polyarthritis were more likely secondary legionellosis localizations after blood spread of Lp1, the most frequently found in pneumonia. In both settings, 16S rRNA and Legionella-specific PCR were key factors for the diagnosis.

Arthritis caused by Legionella micdadei and Staphylococcus aureus: metagenomic next-generation sequencing provides a rapid and accurate access to diagnosis and surveillance

Legionella spp. is an important pulmonary pathogen but rarely causes extra-pulmonary infections. We report a case of joint infection caused by Legionella micdadei and Staphylococcus aureus in a 54-year-old male with medication history of oral steroid for systemic lupus erythematosus (SLE). He developed arthritis in his right metacarpophalangeal (MCP) joints without precursor pneumonia. In the joint aspirate, S. aureus was detected through culture. The existence of L. micdadei and S. aureus were indicated by metagenomic next-generation sequencing (mNGS) and confirmed by 16S rRNA sequence analysis. After oral levofloxacin treatment for 54 days, the patient's symptoms ameliorated and blood test results improved, which were consistent with the dynamic trend of reads numbers in mNGS data. Our case included, arthritis caused by Legionella spp. have been reported in 11 patients. However, our case is the first to report septic arthritis caused by L. micdadei in native joints and monitored by mNGS. This case demonstrated an application of mNGS for etiological diagnosis and semi-quantification in joint aspirate. mNGS may serve as a promising tool for rapid and accurate etiological diagnosis and surveillance, contributing to appropriate antimicrobial drug applications and timely medication adjustments when necessary.

Septic arthritis due to Legionella cincinnatiensis: case report and review of the literature

Legionella spp. are an important cause of pulmonary and rarely extrapulmonary infections. L. cincinnatiensis has only been implicated in five cases to date. We herein report the first case of L. cincinnatiensis septic arthritis in a 90-year old lady with a past medical history of chronic kidney disease. She developed septic arthritis of her left wrist after having received intraarticular corticosteroid injections and oral corticosteroids administered for presumed chondrocalcinosis. Appropriate antimicrobial treatment of L. cincinnatiensis septic arthritis was delayed until identification of this organism in joint biopsies by broad-range bacterial PCR targeting the 16S rRNA gene with subsequent rDNA sequence analysis and by culture on special media. Reviewing all reported cases of septic arthritis caused by Legionella spp. other than L. cincinnatiensis it is notable that diagnosis was established by PCR in the majority of cases and only subsequently confirmed by special culture. Although most patients were immunosuppressed, outcome was favourable. Treatment consisted of a fluoroquinolone alone or in combination with rifampicin or a macrolide. Our case highlights the need for a high index of suspicion for infections with unusual/fastidious organisms when symptoms are suggestive of septic arthritis but conventional methods fail to identify a causative organism.

Detection of Legionella bozemanae, a new cause of septic arthritis, by PCR followed by specific culture

Legionella bozemanae is a rare isolate in clinical specimens. We describe a case of joint infection due to L. bozemanae in an immunocompromised patient with dermatomyositis. Without the use of PCR screening or culture on specialized medium, the organism would not have been detected.

Legionella micdadei, a new cause of prosthetic joint infection

Extrapulmonary infections caused by Legionella spp. other than Legionella pneumophila are rare. We report what is, to our knowledge, the first description of a prosthetic joint infection due to Legionella spp. Systematic testing of samples with suspected prosthetic infection by molecular biology techniques was essential. Legionella micdadei should be added to the list of microorganisms causing prosthetic joint infection.

Septic arthritis caused by Legionella dumoffii in a patient with systemic lupus erythematosus-like disease

We describe a patient with systemic lupus erythematosus (SLE)-like disease on immunosuppressive treatment who developed septic arthritis of the knee involving Legionella dumoffii. Cultures initially remained negative. A broad-range 16S PCR using synovial fluid revealed L. dumoffii rRNA genes, a finding that was subsequently confirmed by positive Legionella culture results.