Der rheumatische Fuß als Focus bakterieller Infektionen

Staphylococcus aureus bacteremia in patients with rheumatoid arthritis - Data from the prospective INSTINCT cohort

OBJECTIVES

Patients with rheumatoid arthritis (RA) are considered to be at increased risk of severe infections. We here describe the clinical characteristics, course and outcome of RA patients with Staphylococcus aureus bacteremia (SAB).

METHODS

We conducted a post hoc analysis of data from a German bi-center prospective SAB cohort study (period 2006-2014). Patients were followed-up for one year. Primary and secondary outcomes were survival time and osteoarticular infection (OAI).

RESULTS

A total of 1069 patients with SAB were analyzed, with 31 patients suffering from RA. RA patients showed significantly more often OAI (15/31 patients, 48% vs. 152/1038, 15%), disseminated infection (12/31, 39% vs. 164/1038, 16%) and severe sepsis/septic shock (12/31, 39% vs. 235/1038, 23%). Day-30 mortality in RA patients was 36% (vs. 19% in non-RA patients, p = 0.034), and day 90 mortality was 58% (vs. 32%, p = 0.003). Multivariate analyses confirmed RA to be an independent risk factor for death (HR 2.3, 95% CI 1.4-3.7) and OAI (OR 4.2, 95% CI 1.8-9.8).

CONCLUSIONS

Patients with RA exhibit a complicated SAB course and a high mortality, their management is challenging. Adequate antibiotic treatment, prompt invasive diagnostic and therapeutic procedures like joint lavage or surgery are of pivotal importance. Joint damage due to RA may confer a higher risk of acquiring OAI than immunosuppression.

Assay of Blood and Synovial Fluid of Patients With Rheumatoid Arthritis for Staphylococcus aureus Enterotoxin D: Absence of Bacteria But Presence of Its Toxin

Background:

Rheumatoid arthritis (RA) is the most common chronic inflammatory disease. The staphylococcal superantigens are considered as the causative agent of RA disease.

Objectives:

This study aimed to assess the presence of staphylococcal enterotoxin D in synovial fluid and blood of patients with RA.

Patients and Methods:

A total of 120 blood and SF samples of patients with RA were studied. Bacterial culture, primer pairs design, polymerase chain reaction (PCR), and enzyme-linked immunosorbent assay (ELISA) methods have been used to assess of the staphylococcal enterotoxin D. The data were analyzed through descriptive statistics.

Results:

During this study and after sequential subcultures, only 5 bacterial strains were isolated. The results of PCR showed the presence of staphylococcal enterotoxin D gene in almost 50% of SF and also in 48.4% of blood samples of patients with RA. Similarly, the ELISA method detected staphylococcal enterotoxin D in 36.16% of SF and in 33.33% of blood of patients with RA.

Conclusions:

The result of this study showed that a high percentage of patients with RA have shown staphylococcal enterotoxin D (superantigen D) or entD gene in SF and in blood. However, the origin of this superantigen was not clarified and no Staphylococcus aureus enterotoxin D producer was isolated. This finding indicates other role of this superantigen besides its intoxication. Therefore, staphylococcal enterotoxin D as a biomarker may provide a good model for the diagnosis and treatment of patients with RA.

[Rheumatic forefoot deformities]

The frequency and extent of rheumatic forefoot deformities have been greatly reduced since the introduction of disease-modifying antirheumatic drugs (DMARD). The accompanying reduction in arthritic destruction of joints opens up new treatment options whereby priority is given to joint preservation. This is true for the first middle foot ray as well as for the small toe rays. Whereas resection arthroplasty of the metatarsophalangeal joints II-V was previously considered the gold standard treatment, joint-preserving operative procedures (e.g. metatarsal osteotomy and periarticular soft tissue interventions) are now being increasingly more propagated. Resection arthroplasty of the first midfoot ray has major biomechanical disadvantages so that it is not surprising that reconstructive procedures are given priority. In patients with severe arthritic destruction of the first metatarsophalangeal joint, arthrodesis has substantial biomechanical advantages compared to resection arthroplasty. Nevertheless, it has not yet been confirmed that fusion leads to superior clinical results.

[Insufficiency fractures of the feet and lower limbs in rheumatoid arthritis]

BACKGROUND

Insufficiency fractures are generally a rare event, especially of the hindfoot. These are often overlooked in the initial stage, however, they must be regarded as a differential diagnosis in the range of possible causes in patients with rheumatoid arthritis and unclear complaints.

MATERIAL AND METHODS

Outpatients in an arthritis care unit from 2009-2011 were analyzed for fractures of the hindfoot and distal tibia.

RESULTS

A total of six patients with seven fractures without adequate trauma were found in the cohort. All patients had received disease modifying therapy and corticosteroids. All fractures could be successfully treated without surgery.

CONCLUSION

Insufficiency fractures in patients with rheumatoid arthritis are a typical finding after several years of the disease. They are directly related to the disease and medication and can usually be successfully treated conservatively.