Septic arthritis in immunocompetent and immunosuppressed hosts

Devastating Pneumococcal Arthritis of the Shoulder After Two Corticosteroid Injections

A 36-year-old man was treated with two intraarticular corticoid injections for intense pain and severely decreased range of motion of his left shoulder. After the second injection, he came back with fulminant arthritis. Microbiological examination revealed streptococcus pneumoniae. Open debridement, long-term antibiotics, and total shoulder replacement were necessary to restore acceptable shoulder function. The fulminant course with rapid destruction of the joint illustrates the risks of intraarticular corticoid injections. This case also shows that the diagnosis should be accurately made and risk factors excluded before considering injection as a treatment.

A Pain in the Foot: Delayed Diagnosis of Primary Septic Arthritis of Naviculocuneiform and Second/Third Tarsometatarsal Joints

Patient: Male, 65-year-old

Final Diagnosis: Septic arthritis of midfoot

Symptoms: Foot pain

Medication: —

Clinical Procedure: Debridement • drainage

Specialty: Family Medicine • General and Internal Medicine • Orthopedics • Emergency Medicine

Immune Deficiency Does Not Increase Inflatable Penile Prosthesis Reoperation Rates

INTRODUCTION

Immunocompromised patients are postulated to have higher rates of post-operative infection. We sought to determine if inflatable penile prosthesis (IPP) reoperation rates (due to infection, erosion, device malfunction or patient dissatisfaction) are higher among immunocompromised men.

METHODS

We analyzed men who underwent initial IPP insertion from 2000 to 2016 in the New York Statewide Planning and Research Cooperative System database. Immunocompromised patients were propensity-score matched in a 1:3 fashion with immunocompetent patients. We estimated and compared reoperation rates (including removal, reoperation due to infection, revision, or replacement of an IPP after an index procedure) at 30 days, 90 days, 1 year and 3 years of follow up between immunocompromised men and controls by performing a Kaplan Meier analysis and Log-rank tests. Cox proportional hazards models were built to examine the overall association between immune deficient status and the risk of reoperation.

MAIN OUTCOME MEASURE

Reoperation rate and time to reoperation after index IPP placement.

RESULTS

A total of 245 immunocompromised patients who received an initial IPP between 2000 and 2016 were identified. After propensity score matching, we analyzed 235 immunocompromised men and 705 controls. There was no difference in overall reoperation rates between immunocompromised men and controls within any time period assessed (30 days, 90 days, 1 year, or 3 years). In our Cox proportional hazards model, the hazards of overall reoperation, removal, or revision/replacement (HR 1.11 [95% CI 0.74-1.67], HR 1.58 [95% CI 0.90-2.79)], and HR 0.83 [95% CI 0.47-1.45], respectively) were not significant different between immunocompromised men and controls. Reoperation due to infection was also not significantly different between immunocompromised and immunocompetent men (HR 2.06 [95% CI 0.97-4.40]).

STRENGTHS & LIMITATIONS

This study is strengthened by its size as the largest cohort of immunocompromised men treated with IPP to date in the literature, but is limited by the retrospective nature of the database which may introduce selection bias and by the low event rate for IPP reoperation.

CONCLUSIONS

Reoperation rates, including those due to infection, are not significantly different between immunocompromised men and immunocompetent controls. Therefore, immune status in appropriately selected candidates does not appear to place patients at substantially higher risk of explant or revision. Gaffney CD, Fainberg J, Aboukhshaba A, et al. Immune Deficiency Does Not Increase Inflatable Penile Prosthesis Reoperation Rates. J Sex Med 2021;18:1427-1433.

Diagnostic values of HNP 1-3 and procalcitonin levels in synovial fluid aspirates in the differential diagnosis between septic arthritis and noninfectious arthritis

INTRODUCTION

Although early diagnosis of septic arthritis may reduce mortality rates, and limit unnecessary surgical interventions, clinical parameters alone are not adequate for making the diagnosis of septic arthritis. Therefore, relevant laboratory parameters are used to enhance diagnostic sensitivity. The aim of our study was to assist in making the diagnosis of septic arthritis, and prevent delays in the diagnosis. For this purpose; we aimed to determine the diagnostic values of human neutrophil peptides 1-3 (HNP 1-3) and procalcitonin (PCT) in synovial fluids of patients with arthritis. By comparing the HNP 1-3 and procalcitonin levels, as well as CRP, in synovial fluid aspirates, we evaluated the significance of these data in the differential diagnosis of septic arthritis from noninfectious arthritis.

METHODS

A total of 67 adults consisting of 37 septic arthritis and 30 noninfectious arthritis patients were included in our study. As bioindicators; levels of HNP 1-3, PCT, synovial and serum CRP levels were found to have significant ROC areas in discriminating septic arthritis patients from noninfectious arthritis patients.

RESULTS

As a result, synovial fluid HNP 1-3 levels were significantly higher in septic arthritis patients compared to noninfectious arthritis patients (p < 0.001). The sensitivity, specificity, and accuracy of HNP 1-3 levels in the diagnosis of septic and noninfectious arthritis were found as 86%, 87%, and 87%, respectively (AUC of the ROC curve = 0.828).

CONCLUSIONS

It was decided that the level of HNP 1-3 in the synovial fluid can be used as an alternative indicator in the diagnosis of septic arthritis.

Effects of Antibiotics on α-Toxin Levels during Staphylococcus aureus Culture: Implications for the Protection of Chondrocytes in a Model of Septic Arthritis

OBJECTIVE

Septic arthritis results from joint infection by Staphylococcus aureus, which produces potent α-toxin causing cell death, potentially leading to permanent cartilage damage. Treatment is by joint irrigation and antibiotics, although it is unclear if, following treatment with antibiotics which cause bacterial lysis, there is release of additional stored α-toxin.

DESIGN

A rabbit erythrocyte hemolysis assay was optimised to assess biologically-active α-toxin from cultured S. aureus α-toxin strain DU5946. Hemoglobin release was measured spectrophotometrically following addition of a bacteriostatic antibiotic (linezolid) or a bacteriolytic antibiotic (penicillin). A bovine cartilage model of septic arthritis was used to test the protective effects of antibiotics against S. aureus infection.

RESULTS

During S. aureus culture, α-toxin levels increased rapidly but the rate of rise was quickly (within 20 minutes) suppressed by linezolid (25 μg/mL). Penicillin also reduced the increase in α-toxin levels; however, the time course was relatively slow compared to linezolid even at high concentrations (50,000 U/mL). The efficacy of penicillin (250,000 U/mL) at reducing the rise in α-toxin was approximately 8% less than that of linezolid (P < 0.05) suggesting the presence of additional toxin. This could be due to a delayed action of penicillin, and/or release of a small pool of stored α-toxin from dying bacteria. In a bovine cartilage model, however, there was no difference between the protection of in situ chondrocytes against S. aureus by penicillin or linezolid (P > 0.05).

CONCLUSION

The results suggested that equally effective protection of chondrocytes against S. aureus septic arthritis may be obtained by the bacteriostatic or bacteriolytic antibiotics tested.

Approach to a patient with monoarticular disease

PURPOSE

To reassess the diagnostic approach to a patient with a monoarticular disease in light of the up-to-date medical literature and to examine the practical utility of traditional and newer imaging tools in the setting of monoarthritis.

RESULTS

The monoarticular disease can represent a medical emergency on the one hand and be a diagnostic conundrum on the other. The management rules of patients with monoarthritis have been established long ago, but various pitfalls still lead physicians off the right diagnosis at times. Septic, pseudoseptic arthritis and hemarthrosis are the most common diagnoses made in patients with an acute presentation, and a decision not to perform a diagnostic arthrocentesis is the most prevalent cause of misdiagnosis in this setting. Many rheumatic and infectious diseases can present with more indolent monoarthritis; careful history and physical examination frequently provide clues to the straightforward diagnosis in some cases, but the extensive investigation is needed in others. Imaging methods become indispensable in individuals with the non-inflammatory monoarticular disease, with magnetic resonance imaging being the gold standard for diagnosing pigmented villonodular synovitis, lipoma arborescence, avascular necrosis, or neuropathic arthropathy.

CONCLUSIONS

A great variety of medical disorders can present as a monoarticular disease. The disease presentation dictates different diagnostic behavior, while knowing the available imaging methods' diagnostic potential should further shorten the diagnostic process.

Analysis of factors that drives arthrocentesis for suspected septic joint

Introduction:

This study aims to develop a simple diagnostic criterion that could be used to justify arthrocentesis in adults with suspected septic arthritis. Our hypothesis is that no single factor will be predictive for a decision to aspirate a questionable septic joint.

Methods:

A prospective observational cohort study was performed at a Level 1 Trauma institution including all patients over the age of 18 years referred to Orthopaedics through the Emergency Department or inpatient orthopaedic consultations for a suspected septic joint. Patient information recorded was age, laboratory markers (white blood cell count, erythrocyte sedimentation rate, C-reactive protein, physical exam findings (fever, pain with range-of-motion), and presence of smoking, diabetes, end-stage renal disease (ESRD) on dialysis, and body mass index > 30. Continuous data was analyzed using logistic regression, and nominal data was analyzed using a two-tailed Fisher’s exact test.

Results:

A total of 128 patients met inclusion criteria for this study; 71 patients underwent arthrocentesis for suspected septic joint. On analysis of risk factors, the demographics, laboratory markers, physical exam and comorbidities were not significant between the two groups. On subset analysis of the septic joints, we found the only risk factor to be significantly predictive of whether a joint was septic was the presence of ESRD on dialysis (p = 0.042).

Conclusion:

Past data have looked solely at predictive risk factors for septic arthritis; however, this study aims to predict what drives physicians towards aspirating a joint even before it is determined to be septic. We found no single factor was predictive of joint aspiration. Only ESRD on dialysis is predictive of whether a joint with concern for septic arthritis would ultimately be septic in our institution. The decision to aspirate continues to be best determined by clinician judgment in light of experience and available clinical information.

Post-transplant manifestation of ankylosing spondylitis: a case report and review of literature

Background

Ankylosing spondylitis (AS) is an insidiously progressive and debilitating form of arthritis involving the axial skeleton, characterized by chronic back pain and progressive spinal stiffness, and lessening of pain and stiffness with exercise. Due to subsequent manifestation in different organs, AS causes reduction in life expectancy, so early diagnosis and treatment are of great importance. No AS cases have been reported in solid-organ transplant recipients yet.

Case presentation

A 58-year-old woman with end-stage renal disease due to chronic glomerulonephritis, after allogenic kidney transplantation 25 years earlier, with stable, good graft function, treated with chronic immunosuppressive therapy based on cyclosporine A, mycophenolate mofetil, and prednisone, with no previous history of a connective tissue disease presented fever up to 39 °C accompanied by pain localized in sacroiliac region radiating to the left lower limb. Detailed diagnostic procedures and x-rays of the lumbar spine and of the targeted sacroiliac joints revealed lesions characteristic of AS. Sulphasalazine was added to standard immunosuppression regimen with good clinical results.

Conclusions

We report an adult kidney transplant recipient with a new onset of AS. The risk of relapse or new onset of inflammatory disease in transplant recipients is extremely low due to immunosuppressive therapy following transplantation. However, when it occurs, the clinical presentation is commonly atypical, often leading to delayed diagnosis.

Risk Factors, Screening, and Treatment Challenges in Staphylococcus aureus Native Septic Arthritis

Background

Staphylococcus aureus is the most common cause of native septic arthritis. Few studies have characterized this disease during the US opioid epidemic. The role of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening in this disease has not been elucidated. We sought to identify risk factors and outcomes for S. aureus native septic arthritis and to evaluate MRSA screening in this disease.

Methods

A retrospective cohort study of native septic arthritis patients (2012–2016) was performed. Demographics, risk factors, and outcomes were compared between Staphylococcus aureus and other native septic arthritis infections. Sensitivity, specificity, and predictive values of MRSA screening were assessed.

Results

Two hundred fifteen cases of native septic arthritis were included. S. aureus was cultured in 64% (138/215). MRSA was cultured in 23% (50/215). S. aureus was associated with injection drug use (odds ratio [OR], 4.33; 95% CI, 1.74–10.81; P = .002) and switching antibiotics (OR, 3.92; 95% CI, 1.01–21.38; P = .032). For every 10-year increase in age, the odds of S. aureus decreased (OR, 0.72; 95% CI, 0.60–0.87; P = .001). For 1-unit increases in Charlson comorbidity index score, the odds of S. aureus decreased (OR, 0.82; 95% CI, 0.73–0.91; P = .0004). MRSA screening during admission demonstrated a sensitivity of 0.59, specificity of 0.96, positive predictive value of 0.85, and negative predictive value of 0.84 for MRSA native septic arthritis.

Conclusions

The opioid epidemic may be contributing to a demographic shift in native septic arthritis to younger, healthier individuals. S. aureus native septic arthritis has unique risks, including injection drug use. MRSA screening may be useful to rule in MRSA native septic arthritis.

Septic arthritis post anterior cruciate ligament reconstruction due to Clostridioides difficile

Clostridioides difficile is an obligate anaerobe ubiquitous in the environment and is of particular interest in the healthcare setting as a cause of healthcare associated infection usually presenting with colitis. Extracolonic manifestations of C. difficile infection are less common with only rare reports of septic arthritis primarily in the setting of relative or overt immunocompromise. This report details the case of a 31-year-old immunocompetent male presenting with clinical features of septic arthritis, three weeks post right knee anterior cruciate ligament (ACL) reconstruction using a native hamstring tendon graft. C. difficile was isolated from two different samples of the synovial tissue from a subsequent arthroscopic washout and synovectomy. The ACL graft was retained. The isolate underwent whole genome sequencing and was found to be tcdA and tcdB gene deficient. Susceptibility testing showed susceptibility to benzylpenicillin and metronidazole. The patient received a two-week course of intravenous benzylpenicillin and four weeks of oral metronidazole. At one-year post cessation of antibiotics the patient has no clinical evidence of recurrence. This is the first known reported case of C. difficile septic arthritis in an immunocompetent patient. It demonstrates successful treatment of post-ACL septic arthritis with a graft retention strategy.

Assessing an alpha-defensin lateral flow device for diagnosing septic arthritis: reporting on a false-negative case and a false-positive case

Alpha-defensin (αD), an antimicrobial peptide released by neutrophils in response to bacterial pathogens, was proposed as a novel diagnostic biomarker in synovial fluid. Several reports have shown that αD can serve as a reliable biomarker in the diagnosis of periprosthetic joint infection (PJI). We assessed whether αD could also serve to diagnosis of septic arthritis, a similarly difficult to diagnose PJI. To our knowledge, besides PJI, few reports exist assessing the utility of αD for septic arthritis. We have attempted to diagnose several cases of suspected septic arthritis using the Synovasure^® αD detection lateral flow device. We report a false-positive case and a false-negative case. The false-negative case we experienced was caused by Staphylococcus capitis, which is coagulase-negative, and possibly represents a low virulence micro-organism infection. The false-positive case was ultimately diagnosed as seronegative rheumatoid arthritis and possessed calcium pyrophosphate depositions. False positives have been suggested to occur in conditions where neutrophils are mobilised. As for PJI, in cases where diagnosis is difficult, αD can be an additional diagnostic indicator. However, making a definitive diagnosis using the αD lateral flow device alone was found to be difficult. The utility of αD in assessing septic arthritis is inconclusive; therefore, larger prospective clinical studies should be considered for a better assessment.

Diagnosis of Culture-Negative Septic Arthritis with Polymerase Chain Reaction in an Immunosuppressed Patient: A Case Report

CASE

We present a 23-year-old woman on immunosuppressive therapy with polyarticular, culture-negative septic arthritis. She underwent irrigation and debridement with empiric antibiotic therapy but had recurrence of septic arthritis despite treatment. Polymerase chain reaction testing eventually identified Ureaplasma as the causative organism. She was successfully treated with an extended course of organism-specific antibiotics.

CONCLUSION

More patients are being treated with immune modulating therapies. Immunosuppressed patients are at risk for atypical infections and may have different presentations than immunocompetent patients. Newer diagnostic modalities can help identify causative organisms and direct treatment in the case of negative cultures.

Arthroscopic débridement has similar 30-day complications compared with open arthrotomy for the treatment of native shoulder septic arthritis: a population-based study

HYPOTHESIS

This study aimed to determine whether there are significant differences in 30-day perioperative complications between arthroscopic and open débridement (irrigation and débridement [I&D]) for septic arthritis (SA) of the shoulder using the American College of Surgeons National Surgical Quality Improvement Program database.

METHODS

Patients undergoing arthroscopic or open I&D of the native shoulder from 2006-2016 were identified in the National Surgical Quality Improvement Program database. Those with a diagnosis of SA were included in the study. Patients with a concurrent diagnosis of osteomyelitis around shoulder (n = 25) or polyarthritis (n = 2) were excluded from the study. Patient demographics, comorbidities, and complications were compared between the groups. Poisson regression, which controlled for age and American Society of Anesthesiologists (ASA) score, was used to calculate the relative risks with 95% confidence intervals for minor adverse events, serious adverse events, total adverse events, and unplanned reoperations between the 2 treatment groups, with significance set at P < .0125 after Bonferroni correction.

RESULTS

Overall, 147 and 57 patients underwent arthroscopic and open I&D, respectively, for SA of the shoulder. Patients in the open I&D group were more likely to be smokers (P = .0213), whereas patients in the arthroscopy group had higher ASA scores (P = .0008). After controlling for age and ASA score, we found no significant differences in the risk of minor adverse events (P = .0995), serious adverse events (P = .2241), total adverse events (P = .1871), or unplanned reoperations (P = .3855).

CONCLUSION

Arthroscopic débridement appears to be a safe alternative to open débridement for SA of the native shoulder. The incidence and risk of 30-day perioperative complications are similar after arthroscopic and open I&D for SA of the shoulder.

Septic Arthritis in Immunosuppressed Patients: Do Laboratory Values Help?

Previous studies have recommended synovial fluid cell count thresholds of 50,000 cells/mm^-3 to diagnose septic arthritis; however, data to support this are limited. It is also unknown if this value is valid in immunosuppressed patients.

Methods

We retrospectively reviewed 33 immunosuppressed patients treated at our institution from 2008 to 2018. We compared culture-positive patients with culture-negative patients.

Results

We found no statistically significant differences in synovial fluid cell count, percent synovial fluid neutrophils, erythrocyte sedimentation rate, or C-reactive protein between the groups (all P = 0.081). The median synovial fluid cell count in the culture-positive cohort was 29,000 cells/mm^-3, with only 31.2% having >50,000 cells/mm^-3.

Conclusion

Traditional synovial fluid cell thresholds are not a reliable method of diagnosing septic arthritis in immunosuppressed patients.

Clinical characteristics and outcomes of patients with septic arthritis treated without surgery

Septic arthritis (SA) is typically managed with antibiotic therapy with or without surgery. Little is known about how patients without surgery differ from their operatively managed counterparts. We compared SA patients who received antibiotic treatment with and without surgery. We conducted a retrospective study of patients with monoarticular septic arthritis admitted to a single tertiary care centre between 1998 and 2015. All 441 monoarticular septic arthritis patients received antibiotics; 382 were also managed operatively and 59 nonoperatively. Nonoperative patients were older (64.4 vs 58.3 years old; p = 0.02) and less likely to have prior joint pathology (44.1% vs 67.5%; p < 0.001). Nonoperative patients presented more often with sepsis (37.3% vs 31.9; p = 0.02) and were more frequently admitted to the intensive care unit (23.7% vs 16.5%; p = 0.04). Nonoperative patients were less often discharged to a rehabilitation facility (37.9% vs 55.8%; p = 0.002) and less frequently readmitted to hospital within 60 days of initial discharge (15.3% vs 18.6%; p = 0.05). However, nonoperative patients were more likely to expire within 30 days after hospital discharge (11.9% vs 3.9%; p = 0.009). Nonoperative patients were sicker at presentation; despite deferral of surgery, they had a relatively high survival rate (88%). Among survivors whose data was available, there were no significant sequelae in post-discharge imaging. These findings support the nonsurgical approach as effective for patients with septic arthritis who are not critically ill at time of presentation.

Diagnosis and treatment of mycoplasmal septic arthritis: a systematic review

PURPOSE

Septic arthritis caused by Mycoplasma is rare. The diagnosis and effective treatment of mycoplasmal septic arthritis remains a serious problem for clinicians. The aim of this systematic review was to document the available evidence on the diagnosis and treatment methods for mycoplasmal septic arthritis and to provide guidance for clinicians.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched in December 2018.The searches were limited to the English language. Article screening and data extraction and compilation were conducted by two independent reviewers. All the included studies were assessed using the Methodological Index for Non-randomized Studies (MINORS) tool.

RESULTS

There was a total of 33 articles including 34 cases of mycoplasmal septic arthritis and eight of them were periprosthetic joint infection (PJI). Twenty-four patients (70.6%) were immunocompromised, and the synovial fluid white blood cell (WBC) count was significantly lower in the immunocompromised group than in the immunocompetent group (48,527 × 10⁶/L vs. 100,640 × 10⁶/L; P = 0.009). The traditional culture method took longer, and the positivity rate was lower than that of nucleic acid testing (50% vs. 100%; P = 0.016). Only 19.2% (5/26) of patients treated with empiric antibiotics were relieved of symptoms, while 82.4% (28/34) of patients achieved satisfactory results after being treated with antibiotics against Mycoplasma.

CONCLUSION

The possibility of mycoplasmal septic arthritis should be considered if patients with joint infections have a history of immunocompromised, repeated negative cultures, and poor empiric antibiotic treatment results. The rational use of nucleic acid testing technologies can help in the clinical diagnosis and treatment of mycoplasmal septic arthritis.

Native joint septic arthritis due to Clostridium tarantellae

Clostridium is a diverse genus including more than 200 species involved in varied clinical presentations in infectious diseases. Septic arthritis caused by Clostridium sp. are however uncommon. We report here the first septic arthritis due to Clostridium tarantellae, formerly called Eubacterium tarantellae, in a patient under anti-TNF therapy.

Primary Meningococcal Type C Arthritis: A Case Report and Literature Review

Acute septic arthritis is a common clinical problem in emergency departments. Primary meningococcal arthritis (PMA) is very rare and few cases are reported in literature. D. B. M. consulted the emergency department for knee pain and fever; analysis showed that the cause was a Neisseria meningitidis type C infection. He received a treatment consisting of 2 arthroscopies and 5 weeks of antibiotics. At five weeks he returned to work and at 2 months he resumed sports (jogging and soccer) without complaints. Primary arthritis of the knee caused by Neisseria meningitidis is very rare. It has a very good response to antibiotics and arthroscopy procedure. Short-term follow-up and functional results are often good or excellent.