Mycobacterium tuberculosis prosthetic joint infections: A case series and literature review

Diagnostic Role of Metagenomic Next-Generation Sequencing in Tubercular Orthopedic Implant-Associated Infection

Objective

The diagnosis of tubercular orthopedic implant-associated infection (TB-IAI) is challenging. This study evaluated the value of metagenomic next-generation sequencing (mNGS) for the diagnosis of TB-IAI and developed a standardized diagnostic procedure for TB-IAI.

Methods

The records of all patients with TB-IAI diagnosed and treated at our institution between December 2018 and September 2022 were retrospectively reviewed. Patient demographic characteristics, medical history, laboratory test, microbial culture, histopathology, and mNGS results, and time to diagnosis were recorded. The diagnostic efficiency of mNGS for TB-IAI was assessed by comparing the results and diagnostic time with that of other diagnostic modalities.

Results

Ten patients were included in the analysis, including eight with prosthetic joint infections and two with fracture-related infections. The mNGS positivity rate was 100% (10/10), which was higher than that of TB-antibody (11%, 1/9), real-time quantitative polymerase chain reaction (22%, 2/9), T-SPOT.TB (25%, 2/8), purified protein derivative (50%, 4/8), microbial culture (50%, 5/10), and histopathology (20%, 2/10). mNGS shortened the time to diagnosis of TB-IAI. A standardized diagnostic procedure for TB-IAI was developed based on the findings.

Conclusion

mNGS is useful for the diagnosis of TB-IAI. mNGS is recommended in cases where it is difficult to identify a pathogen using routine diagnostic tests. The standardized diagnostic procedure might improve TB-IAI diagnosis.

Importance

TB-IAI is a rare infection, which occurs after orthopedic surgery and hard to diagnose microbiologically. mNGS is a new detection technique not yet discussed in current literature as a means for TB-IAI diagnostics. Here we describe a cohort of patients with TB-IAI diagnosed by mNGS show high efficiency of mNGS for detection of this pathology and present a clinical algorithm supplementing conventional methods for TB-IAI assessment.

Prosthetic Joint Infections Caused by Mycobacterium tuberculosis Complex-An ESGIAI-ESGMYC Multicenter, Retrospective Study and Literature Review

PURPOSE

While tuberculosis remains a significant global health concern, prosthetic joint infections (PJIs) caused by members of the Mycobacterium tuberculosis complex are exceptionally rare. Our objective is to perform a retrospective search of new cases of this disease and analyze all cases available in the literature of tuberculous PJIs, aiming to detect factors that may influence patient outcomes.

METHODS

The ESGIAI and ESGMYC study groups were used to collect information on non-published cases of tuberculous prosthetic joint infections (PJIs). Additionally, a literature review of all published cases of tuberculous PJIs was conducted. All identified cases in the retrospective study and in the literature review were merged and included in the statistical analysis, involving both univariate and multivariate analyses.

RESULTS

Fifteen previously unreported cases of tuberculous prosthetic joint infections (PJIs) from four countries were detailed. Among them, ten patients were female, with a median age of 76 years. The hip was affected in 13 cases. Seven patients experienced co-infection with another microorganism. Treatment approaches varied, with 13 patients undergoing implant removal, one treated with DAIR (debridement, antibiotics, and implant retention), and one case was treated with an unknown treatment method. All patients received antibiotic therapy and achieved a cure. The literature review that was conducted detected 155 published cases. Univariate analysis revealed a statistical significance for previous tuberculosis, joint, and no importance of surgery for cure.

CONCLUSIONS

Tuberculous prosthetic joint infection (PJI) is a rare condition, typically presenting as a localized chronic infection. Antibiotic treatment is essential for the management of these patients, but neither surgical treatment nor duration of treatment seems to have importance in the outcome.

Two-stage revision for treatment of tuberculous prosthetic hip infection: an outcome analysis

OBJECTIVES

Prosthetic joint infections (PJI) and especially tuberculosis (TB) PJI are rare diseases and hard to cure. The effectiveness of treatments for tuberculous PJI still remains a problem. The objective of this research was to indicate the success of two-stage revision replacement and also giving the associated criteria.

METHODS

From 2015 to 2020, five patients with tuberculous PJI were treated with two-stage revision at Cho Ray hospital, Vietnam. We collected the dataset which included demographic data, the interval from the time of joint replacement to reported infection, records of tuberculous PJI, administration of anti-TB medications (duration, months), history of operation(s), duration of follow-up, and specific type(s) of antibiotics loaded in bone cement. The approval for this study was made by the institutional review board from Cho Ray Hospital, Vietnam. We conducted a literature review based on the keywords "PJI" and "TB" on PubMed.

RESULTS

Five patients [median age 66 years (range 35-84)] had found tuberculous PJI. The median time from arthroplasty to diagnosis was 19 months (range 4-48). The diagnosis was confirmed by joint aspirates or synovial tissue. Positive PCR was also reported in all cases. The average duration of anti-tuberculosis polytherapy administration was 14.4 months. The operative techniques on five patients included debridement and using spacer loaded with 2 g streptomycin (and 2 g vancomycin if they got a coinfection) for 1 pack of bone cement, and revision arthroplasty. In most cases, the outcome of treatment using two-stage revision replacement was 80%. Overall, the auxiliary bacterial infections were recognized in three patients with tuberculous PJI and Staphylococcus aureus. Streptomycin and vancomycin were loaded in a cement spacer to increase the success rate, and tuberculous PJI was controlled for all patients.

CONCLUSION

Tuberculous PJI can be controlled with two-stage revision replacement with an antibiotic-loaded cement spacer that is molded intraoperatively with custom mold and prolonged anti-tuberculosis treatment in all cases.

LEVEL OF EVIDENCE

IV.

A case of prosthetic joint infection caused by Mycobacterium tuberculosis complicated secondary bacterial infection after knee joint replacement surgery

Mycobacterium tuberculosis (M. tuberculosis) is a rare cause of prosthetic joint infection (PJI). Previous studies have reported that many cases of PJI caused by M. tuberculosis have no medical history of active tuberculosis (TB) or other localization, which contributes to diagnostic difficulties. Furthermore, owing to the limited number of studies on treatment, appropriate treatment strategies, such as the duration of anti-tuberculosis (anti-TB) drugs and surgical indications, remain unclear. We report a case of PJI caused by M. tuberculosis and secondary pyogenic arthritis caused by Staphylococcus aureus and Streptococcus dysgalactiae in a 67-year-old man after knee joint replacement surgery in Japan, which was a moderately endemic country until 2020 and a low endemic country since 2021. Although he had no past medical history or close contact with TB, he was diagnosed with PJI caused by M. tuberculosis, following the culture of a synovectomy specimen. He underwent two-stage surgery and was treated with anti-TB drugs for a total of 12 months and recovered without recurrence. Based on our case and previous studies, there are three points of clinical significance for PJI caused by M. tuberculosis. First, about one year of anti-TB drugs with two staged joint revision resulted in a good course of treatment. Second, surgical treatment might be considered in cases complicated by secondary bacterial infection. Third, because the diagnosis of PJI caused by M. tuberculosis is difficult, TB should be considered in the differential diagnosis of routine bacterial culture-negative PJI, especially in endemic areas.

Mycobacterium biofilms

The genus Mycobacterium includes some of the deadliest pathogens of History (Mycobacterium tuberculosis, Mycobacterium leprae), but most of the species within the genus are environmental microorganisms. Because some of these nontuberculous mycobacteria (NTM) species can be human pathogens, the study of these mycobacterial biofilms has increased during the last decades, and the interest in this issue increased as well as the growing number of patients with diseases caused by NTM. Different molecular mechanisms have been described, being especially well known the importance of glycopeptidolipids. Moreover, the knowledge of the extracellular matrix has shown important differences with other microorganisms, especially because of the presence of lipidic molecules as a key component of this structure. The clinical importance of mycobacterial biofilms has been described for many chronic diseases, especially lung diseases and implant-related ones, both in vitro and in vivo, and even in patients. Moreover, the biofilm-producing capacity has been proven also in M. tuberculosis, while its importance is not well understood. Biofilm studies have also shown the increasing resistance of mycobacteria in sessile form, and the importance of this resistance in the management of the patients is beyond doubt, being surgery necessary in some cases to cure the patients. Diagnosis of mycobacterial diseases is still based on culture-based techniques designed for the detection of M. tuberculosis. Molecular biology-based methods are also broadly used but again designed for tuberculosis diagnosis. Antimicrobial susceptibility testing is also well developed for tuberculosis, but only some species of NTM have standardized techniques for this purpose. New tools or approaches are necessary to treat these patients, whose importance is increasing, as the number of potential hosts is also increasing throughout the world.

Do Changes in Hemoglobin and C-Reactive Protein Levels in Patients With Hip Tuberculosis After Two Months of Treatment Predict Tubercle Bacilli Deletion?

Background and objective Tuberculosis (TB) of the hip refers to the hip infection caused by tubercle bacilli. Treatment for hip TB includes anti-TB medications, surgery to remove joint abscesses, and orthopedic surgery. It is necessary to conduct tests to confirm that the tubercle bacilli have been eradicated following the treatments. In this study, we aimed to assess the change in hemoglobin and C-reactive protein (CRP) serum levels in patients with hip TB before and two months after receiving specific treatments. We sought to determine whether they are significant tests for the treatment prognosis of hip TB. Methods We employed a prospective cohort design for this study. It was conducted at National Lung Hospital, Hanoi, and involved 24 hip TB patients with intra-articular abscesses who were treated at the center during the period from October 2016 to October 2021. Blood hemoglobin, CRP serum level, and abscesses on hip MRI were assessed before and two months after treatments. Hemoglobin was examined by spectrophotometry, and CRP serum was measured using the immunoturbidimetric method. Results Before treatments, the average hemoglobin level in the patients was 11.48 ± 1.85 g/dl; the average CRP serum level was 63.53 ± 36.47 mg/l. After two months of treatments, the average hemoglobin level increased significantly to 13.22 ± 1.36 g/dl, while the average CRP level reduced significantly to 12.55 ± 11.34 mg/l. However, five cases displayed abnormal findings. These five individuals continued to have intra-articular abscesses. Conclusion In individuals who reacted well to the therapy, blood hemoglobin and CRP serum levels improved. Blood hemoglobin and serum CRP assays can be utilized to monitor outcomes in hip TB therapy.

Clinical Features and Outcome of Multidrug-Resistant Osteoarticular Tuberculosis: A 12-Year Case Series from France

The optimal treatment for osteoarticular infection due to multidrug-resistant tuberculosis strains (MDR-OATB) remains unclear. This study aims to evaluate the diagnosis, management and outcome of MDR-OATB in France. We present a case series of MDR-OATB patients reviewed at the French National Reference Center for Mycobacteria between 2007 and 2018. Medical history and clinical, microbiological, treatment and outcome data were collected. Twenty-three MDR-OATB cases were reported, representing 3% of all concurrent MDR-TB cases in France. Overall, 17 were male, and the median age was 32 years. Six patients were previously treated for TB, including four with first-line drugs. The most frequently affected site was the spine (n = 16). Bone and joint surgery were required in 12 patients. Twenty-one patients (91%) successfully completed the treatment with a regimen containing a mean of four drugs (range, 2-6) for a mean duration of 20 months (range, 13-27). Overall, high rates of treatment success were achieved following WHO MDR-TB treatment guidelines and individualized patient management recommendations by the French National TB Consilium. However, the optimal combination of drugs, duration of treatment and role of surgery in the management of MDR-OATB remains to be determined.

Prosthetic joint infection of the hip and knee due to Mycobacterium species: A systematic review

BACKGROUND

Mycobacterium species (Mycobacterium sp) is an emerging cause of hip and knee prosthetic joint infection (PJI), and different species of this organism may be responsible for the same.

AIM

To evaluate the profile of hip and knee Mycobacterium PJI cases as published in the past 30 years.

METHODS

A literature search was performed in PubMed using the MeSH terms “Prosthesis joint infection” AND “Mycobacterium” for studies with publication dates from January 1, 1990, to May 30, 2021. To avoid missing any study, another search was performed with the terms “Arthroplasty infection” AND “Mycobacterium” in the same period as the previous search. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart was used to evaluate the included studies for further review. In total, 51 studies were included for further evaluation of the cases, type of pathogen, and treatment of PJI caused by Mycobacterium sp.

RESULTS

Seventeen identified Mycobacterium sp were reportedly responsible for hip/knee PJI in 115 hip/knee PJI cases, whereas in two cases there was no mention of any specific Mycobacterium sp. Mycobacterium tuberculosis (M. tuberculosis) was detected in 50/115 (43.3%) of the cases. Nontuberculous mycobacteria (NTM) included M. fortuitum (26/115, 22.6%), M. abscessus (10/115, 8.6%), M. chelonae (8/115, 6.9%), and M. bovis (8/115, 6.9%). Majority of the cases (82/114, 71.9%) had an onset of infection > 3 mo after the index surgery, while in 24.6% (28/114) the disease had an onset in ≤ 3 mo. Incidental intraoperative PJI diagnosis was made in 4 cases (3.5%). Overall, prosthesis removal was needed in 77.8% (84/108) of the cases to treat the infection. Overall infection rate was controlled in 88/102 (86.3%) patients with Mycobacterium PJI. Persistent infection occurred in 10/108 (9.8%) patients, while 4/108 (3.9%) patients died due to the infection.

CONCLUSION

At least 17 Mycobacterium sp can be responsible for hip/knee PJI. Although M. tuberculosis is the most common causal pathogen, NTM should be considered as an emerging cause of hip/knee PJI.

Management of Mycobacterium tuberculosis Prosthetic Joint Infection: 2 Cases and Literature Review

Prosthetic joint infection caused by Mycobacterium tuberculosis (TBPJI) is uncommon but can be encountered in immunocompromised patients or those from tuberculosis-endemic regions. A lack of clinical suspicion and experience with TBPJI often leads to a delay in diagnosis. We report 2 cases of TBPJI in a Hungarian-Canadian and Iranian-Canadian immigrant, respectively. Both were treated with concurrent surgical and medical therapy. We also performed a literature review on TBPJI case reports, outlining their diagnosis and management.

Elbow arthroplasty complicated by Mycobacterium tuberculosis infection: A case report

INTRODUCTION

Total elbow arthroplasty (TEA) is an orthopedic procedure that is relatively infrequently performed, but its use has been increasing over time. Infection remains one of the most concerning complications after TEA, although Mycobacterium tuberculosis (TB) as a microbial etiology, is extremely rare. Here, we present a case of M. tuberculosis infection after TEA.

PATIENT CONCERNS

A 45-year-old woman underwent TEA for severe traumatic arthritis of the elbow following failure of conservative treatment. Four months after TEA, the patient experienced progressive elbow pain and swelling, without other external signs of infection such as a sensation of local heating and erythematous alterations.

DIAGNOSIS

Pulmonary computed tomography showed stable pulmonary TB in the right upper lobe. The T-SPOT, TB, and purified protein derivative test results were positive, and M. tuberculosis exhibited growth on cultures. The final diagnosis was periprosthetic infection of M. tuberculosis.

INTERVENTIONS

The patient was treated with debridement with submission of deep tissue cultures. According to these cultures and suggestions of a bacteriologist, anti-TB treatment was administered for 12 months.

OUTCOMES

The symptoms of the infection were controlled, and the prosthesis was retained. At the time of writing this case report, the elbow prosthesis had survived for more than 2 years, and no recurrent infection had been observed.

CONCLUSION

The diagnosis of TB infection after TEA is difficult to confirm due to its nonspecific signs and symptoms. Despite the extremely low incidence, failure to consider this possibility for diagnosis can lead to delayed treatment. Proper diagnosis allows for antitubercular therapy with retention of a prosthesis.

Acute Periprosthetic Hip Joint Infection Caused by Multidrug-Resistant Acinetobacter Baumannii: Is Debridement, Antibiotics, Irrigation, and Implant Retention a Viable Treatment Option?

In this study, we aimed to investigate the effectiveness of debridement, antibiotics, irrigation, and implant retention (DAIR) in periprosthetic hip joint infection caused by multidrug-resistant (MDR) Acinetobacter baumannii (A. baumannii).

From July 2019 to June 2020, we retrospectively reviewed all patients treated for periprosthetic hip joint infections caused by MDR A. baumannii at our institution. The diagnosis of periprosthetic joint infection (PJI) was established based on the Musculoskeletal Infection Society (MSIS) 2018 criteria. The Charlson Comorbidity Index (CCI) was used to estimate the risk of mortality. The patients were followed up for over a year, until their death, or loss to follow-up.

Four patients (three females and one male), with a mean age of 68 years, were included in the study. A. baumannii exhibited resistance to fluoroquinolones in all cases. All patients were treated with the DAIR procedure followed by intravenous tigecycline and colistin combination treatment. Prosthesis retention with good functional results was achieved in two patients. One patient required resection arthroplasty and one patient died two months after the initial surgical treatment, yielding a success rate of 50% for the DAIR procedure.

Periprosthetic hip joint infection caused by MDR A. baumannii is one of the most demanding and challenging complications in orthopaedic practice. This case series suggests that the outcome of the DAIR is affected by a number of factors that are in a complex interplay. Our results indicate a limited success rate for the DAIR procedure in the treatment of a periprosthetic hip joint infection caused by MDR A. baumannii.

Total Knee Arthroplasty in Patients with Unsuspected Tuberculosis of the Joint: A Report of Four Cases and a Systematic Review of the Literature

OBJECTIVES

To provide a case series and systematic review that explores the clinical manifestations, treatments, and methods for defining tuberculosis diagnoses in patients who have undergone total knee arthroplasty (TKA).

METHODS

Four patients (three women, one man; average age, 59.5 ± 8.89 years; range, 48-69 years) underwent TKA and were subsequently treated for previously unsuspected knee tuberculosis between January 2013 and December 2019. We also reviewed published cases of tuberculous periprosthetic joint infections (TBPJIs) following TKA through databases of MEDLINE/PubMed, the Cochrane Library, and EMBASE. We reviewed studies that were published between January 1980 and December 2019.

RESULTS

In our four cases, the preoperative diagnoses were osteoarthritis (n = 2), rheumatoid arthritis (one case), and Charcot's arthropathy (one case). The main clinical manifestations were knee swelling and pain, without fever, weakness, or weight loss. Comorbidities included multiple joints with rheumatoid arthritis or Charcot's arthropathy, diabetes mellitus, and uremia. One patient had a history of lumbar tuberculosis treated with debridement and intervertebral fusion. Preoperative elevated erythrocyte sedimentation rates (ESRs) were detected in all cases, and elevated C-reactive protein (CRP) levels were observed in three cases. The tuberculosis diagnoses were confirmed via histopathologic analysis (three cases) and second-generation sequencing (one case). Three patients received antituberculosis therapy for 1 year, without surgical intervention. Two-stage exchange arthroplasty was performed in one patient because of prosthesis loosening. Within an average follow-up period of 24.75 months, tuberculosis reactivation was not observed and overall functional improvement was demonstrated. Forty-four TBPJI cases were reported in the literature between January 1980 and December 2019. Most (59.09%) occurred within the first year after the index arthroplasty, and the diagnoses were confirmed by culturing Mycobacterium tuberculosis in 88.64% of cases. Favorable outcomes were achieved in 90.91% of the patients who did not undergo surgery, 71.43% of those treated with debridement, 93.33% undergoing revision arthroplasty, and in 90.91% of those undergoing resection and arthrodesis.

CONCLUSIONS

Clinical manifestations of knee tuberculosis and TBPJI are atypical. Thus, attention should be paid to finding the causes of increased ESRs and CRP levels, particularly in patients with weakened immune functioning, before performing TKA. Pathological examination is an effective method for diagnosing tuberculosis, although sending multiple specimens for pathological examination is necessary.