Spontaneous bacterial arthritis in a cirrhotic patient

Risk factors for septic arthritis and multiple arthroscopic washouts: minimum 2-year follow-up at a major trauma centre

Background

Septic arthritis (SA) is a dangerous condition that requires emergency treatment. Managed by culture-specific antibiotics, irrigation, and debridement (I&D), some patients require repeat surgical treatment. The objectives were to determine the risk factors for SA and risk factors for repeat arthroscopic I&D in SA patients. We hypothesized that variables which directly or indirectly contributed to a larger infection burden would be associated with the development of SA and the need for repeat arthroscopic I&D.

Methods

All patients ≥ 18 years old presenting to the emergency department, orthopaedic and rheumatology clinics at our major trauma centre between January 2018 and January 2020 with a hot, swollen joint were retrospectively evaluated. Patients with previous trauma and metalwork in the affected joint, periprosthetic joint infection, previous joint arthroplasty surgery, soft tissue infection, missing data, transferred to another centre, diagnosis not concerning the joint, and < 24-month follow-up were excluded. Two hundred eleven patients were included (SA: 28; pseudogout: 32; gout: 50; others: 101). Variables of interest in the 3-month period preceding the diagnosis of SA were compared between SA and non-SA patients using univariable analysis. A multivariable logistic regression model was formed using covariates with corresponding univariable tests of p < 0.200. Similar analyses were performed to compare SA patients with multiple washouts/procedures with those with one washout/procedure.

Results

Multivariable analysis showed multiple risk factors for SA, namely rheumatoid arthritis (RA) (OR: 3.4; 95% CI: 1.2–10.0; p = 0.023); skin infection (OR: 3.3; 95% CI: 1.2–9.0; p = 0.017), liver disease (OR: 9.9; 95% CI: 2.2–43.9; p = 0.003), knee joint involvement (OR: 3.5; 95% CI: 1.3–9.4; p = 0.014), and use of immunosuppressive medication (OR: 3.5; 95% CI: 1.2–10.6; p = 0.027). Risk factors for multiple washouts included synovial WBC levels > 10.5 × 10⁹ cells/L (OR: 3.0; 95% CI: 2.3–38.8; p = 0.009) and RA (OR: 3.5; 95% CI: 1.9–66.3; p = 0.017).

Conclusions

These findings suggest that prophylactic actions against septic arthritis should be targeted at patients with liver disease, RA, or skin infection. Repeat arthroscopic I&D of septic joints may be needed, especially in patients with synovial WBC levels > 10.5 × 10⁹ cells/L and RA.

Key Points • The risk factors for septic arthritis determined in this study are rheumatoid arthritis, skin infection, liver disease, knee joint involvement, and immunosuppressant usage. • Some septic arthritis patients need multiple rounds of arthroscopic irrigation and debridement. The risk factors for this are a synovial WBC count > 10.5 × 109 cells/L and rheumatoid arthritis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10067-022-06151-w.

Common musculoskeletal disorders in chronic liver disease patients

Chronic liver disease (CLD) is the commonest ailment affecting the hepatobiliary system. Six significant pathologies related to CLD include hepatic osteodystrophy (HO), increased infection susceptibility, sarcopenia, osteonecrosis of the femoral head (OFH), increased risk of periprosthetic complications and fracture. Hepatic osteodystrophy, which comprises osteopenia, osteoporosis, and osteomalacia, refers to alterations in bone mineral metabolism found in patients with CLD. The HO prevalence ranges from 13 to 95%. Low complement levels, poor opsonization capacity, portosystemic shunting, decreased albumin levels, and impaired reticuloendothelial system make the cirrhotic patients more susceptible to developing infectious diseases. Septic arthritis, osteomyelitis, prosthetic joint infection, and cellulitis were common types of CLD-associated infectious conditions. The incidence of septic arthritis is 1.5 to 2-fold higher in patients with cirrhosis. Sarcopenia, also known as muscle wasting, is one of the frequently overlooked manifestations of CLD. Sarcopenia has been shown to be independent predictor of longer mechanical ventilation, hospital stay, and 12-month mortality of post-transplantation. Alcohol and steroid abuse commonly associated with CLD are the two most important contributory factors for non-traumatic osteonecrosis. However, many studies have identified cirrhosis alone to be an independent cause of atraumatic osteonecrosis. The risk of developing OFH in cirrhosis patients increases by 2.4 folds and the need for total hip arthroplasty increases by 10 folds. Liver disease has been associated with worse outcomes and higher costs after arthroplasty. Cirrhosis is a risk factor for arthroplasty complications and is associated with a prolonged hospital stay, higher costs, readmission rates, and increased mortality after arthroplasty. Greater physician awareness of risk factors associated with musculoskeletal complications of CLD patients would yield earlier interventions, lower healthcare costs, and better overall clinical outcomes for this group of patients.

A Case of Septic Arthritis of Shoulder Presenting as Stiffness of the Shoulder

Introduction:

Septic arthritis of the shoulder is uncommon in adults. It is a surgical emergency as joint destruction occurs rapidly and can lead to significant morbidity and mortality. Accurate diagnosis can be particularly challenging in patients with underlying liver disease. MRI is a useful adjunct in early detection of atypical causes of shoulder pain.

Case report:

A 43 years old male came to our outpatient department with complaints of pain and stiffness of his left shoulder. On examination, his shoulder movements were severely restricted. Further evaluation with MRI revealed septic arthritis of left gleno-humeral joint for which emergency arthroscopic debridement was done.

Conclusion:

Septic arthritis of shoulder may not present with classical clinical features. Hence, a through clinical and radiological evaluation will help us prognosticate and treat accordingly thereby preventing complications like septic shock, osteomyelitis.

Cirrhosis-related musculoskeletal disease: radiological review

Musculoskeletal problems in patients with liver disease are common; however, they are not so well described in the literature. Therefore, there is a need to collate information on these disorders, as their incidence is on a constant rise and some of these pathologies can severely debilitate the patient's quality of life. These disorders are parietal wall varices with or without bleeding, spontaneous intramuscular haematoma (e.g. rectus sheath), abdominal wall hernia, anasarca, hepatic osteodystrophy, septic arthritis, osteomyelitis, necrotizing fasciitis, osseous metastases from hepatocellular carcinoma etc. While portal hypertension plays a key role in disorders, in others, dysregulation of the coagulation system or a compromised immune system are responsible. Imaging plays an essential role in the assessment of these complications and awareness of these musculoskeletal manifestations is vital for establishing a timely diagnosis and planning of appropriate therapy, as these disorders can significantly impact the morbidity and mortality and also influence candidacy for liver transplantation. We herein comprehensively appraise various musculoskeletal complications associated with chronic liver disease/liver cirrhosis especially from an imaging perspective which, to the best of our knowledge, have not been collectively described in English literature.

Klebsiella pneumoniae necrotizing fasciitis and septic arthritis: an appearance in the Western hemisphere

BACKGROUND

Necrotizing fasciitis caused by Klebsiella pneumoniae is rare, with 11 documented cases in the literature, all occurring in Asia and the Middle East. These reports have become more frequent in recent years in association with the emergence of the highly virulent K1 capsular serotype of Klebsiella. We report a case of Klebsiella necrotizing fasciitis and con-current septic arthritis in the Western hemisphere.

METHODS

Case report and review of the literature.

RESULTS

Our patient, a 50-year-old Cambodian man with advanced hepatitis B-associated cirrhosis, who had last visited an endemic area six months prior to presentation, was hospitalized after several days of left knee and thigh pain. He was hypotensive, tachycardic, and bacteremic with K. pneumoniae. A computed tomography scan showed gas in the tissues of the thigh and left knee joint. Despite aggressive surgical debridement and antibiotic therapy, the patient died on day three. Serotyping of blood, wound, and synovial cultures revealed K1-type K. pneumoniae.

CONCLUSIONS

Although K. pneumoniae is common, monomicrobial necrotizing fasciitis and septic arthritis caused by this pathogen has not been reported previously outside Asia, where it is rare. The appearance of this infection in the Western hemisphere may reflect geographic spread of the aggressive K1 phenotype. Physicians treating patients with symptoms and signs of necrotizing fasciitis or septic arthritis, particularly in the setting of underlying chronic illness or recent travel to Asia, should consider K. pneumoniae as a potential cause and treat accordingly.

Spontaneous bilateral ankle and midfoot sepsis in a nonimmunocompromised patient

We describe a 70-year-old nonimmunocompromised woman with spontaneous bilateral ankle and midfoot sepsis and a deep-space abscess of the right lower leg. Salvage of both limbs was achieved by aggressive bilateral soft-tissue and osseous debridement, including a four-compartment fasciotomy of the right lower leg, antibiotic-loaded polymethyl methacrylate bone cement implantation, delayed allogeneic bone grafting of the osseous defects impregnated with autologous platelet-rich plasma bilaterally, and external fixation immobilization, implantable bone growth stimulation, and split-thickness skin graft coverage of the right lower leg, ankle, and foot. Osseous incorporation of the bone grafts bilaterally occurred 8 weeks after surgery. No soft-tissue or osseous complications occurred during the postoperative period or at 18-month follow-up except for arthrofibrosis in the right ankle; there was no evidence of recurrent abscesses, sequestrum, or wound-related problems. A review of the literature regarding bilateral pedal sepsis and the techniques used for limb salvage in this patient are presented in detail.

Klebsiella pneumoniae septic arthritis in a cirrhotic patient with hepatocellular carcinoma

Despite septic arthritis is increasingly being reported in elderly patients with diabetes or alcoholism, reported cases of spontaneous bacterial arthritis in cirrhotic patients are extremely rare. We present the first reported case of K. pneumoniae septic arthritis and spontaneous bacterial peritonitis in a cirrhotic patient with hepatocellular carcinoma. K. pneumoniae, one of the most common causative organisms of spontaneous bacterial peritonitis in cirrhotic patients, was isolated from both the blood and the joint fluid, which suggests that the route of infection was hematogenous. After the treatment with cefotaxime and closed tube drainage, the condition of the patient was improved, and subsequently, the joint fluid became sterile and the blood cultures were proved negative. Therefore, this case provides further evidence for the mode of infection being bacteremia in cirrhotic patients and suggests that the enteric bacteremia in cirrhotics may cause infection in different organ systems.