Mycobacterium avium Complex Septic Arthritis Presenting as Osteonecrosis of the Femoral Head in a Patient With Systemic Lupus Erythematosus

Mycobacterium avium complex prosthetic joint infection: A systematic review of the literature and pooled analysis

BACKGROUND

Mycobacterium avium complex (MAC) prosthetic joint infection (PJI) has been rarely reported.

METHODS

This study aimed to investigate the epidemiology and outcomes of MAC PJI. A systematic review of the literature regarding the MAC infection following total joint arthroplasty including hip and knee joint was performed. Multiple databases were searched for published English-written articles up to May 2023. Studies that reported cases of PJI by MAC were reviewed.

RESULTS

A total of 17 patients were identified and analyzed from 11 published studies. All patients presented with joint symptom of pain or swelling prior to the diagnosis and MAC was confirmed by culture. The most of the patients (16/17 patients, 94.1%) were noted to have underlying medical condition(s) that might have affected immunity. Treatment consisted of anti-MAC medication therapy only in two patients and anti-MAC medication therapy plus surgery in 15 patients. Among the patients who underwent surgery, 14 patients (82.3%) had removal of the prosthesis including seven patients who had two-stage surgery to have reimplantation of the prosthesis. No relapse of MAC infection was reported despite of one case of relapse of infection caused by different pyogenic bacteria. The rate of overall mortality was 29.4%, however, identified attributable mortality due to MAC infection was low (5.9%).

CONCLUSION

PJI by MAC is a rare disease. However, MAC needs to be considered in the differential diagnosis in immunocompromised patients presenting with symptoms of PJI. Two-stage exchange arthroplasty may result in successful treatment outcomes without higher risks of relapse of infection if undertaken in association with appropriate active anti-MAC antibiotic therapy.

Clinical evaluation of total hip arthroplasty for osteoarthropathy secondary to septic hip arthritis

To investigate the clinical efficacy and prognosis of total hip arthroplasty (THA) in patients with osteoarthropathy secondary to septic hip arthritis. A total of 100 patients with osteoarthropathy secondary to septic hip arthritis who underwent surgery in our hospital from December 2010 to December 2021 were selected. Operative data were summarized. Moreover, preoperative and postoperative differences in Harris score, Western Ontario and McMaster Universities Osteoarthritis Index score, Visual Analogue Scale score, hip mobility were compared. Due to hospital transfer, the epidemic of COVID-2019 and other reasons, 10 patients were lost to follow-up and finally 90 patients were recorded. According to the results, the mean operation time (OT) was 1.78 ± 0.32 (hour), the mean intraoperative blood loss (BL) was 586.62 ± 31.66 (mL), the mean red blood cell (RBC) transfusion was 3.84 ± 0.75 (U), and 2 cases were positive, and 88 cases were negative for Trendelenburg sign. Postoperatively, the unequal length of the lower limbs and the Visual Analogue Scale score were significantly lower than that of the preoperative, while the Western Ontario and McMaster Universities Osteoarthritis Index score, Harris score, and hip joint range of motion were significantly higher than those of the preoperative (P < .05). At the last follow-up, all the incisions healed with no deep infections, 1 case suffered from transient sciatic nerve palsy, 2 cases had intermuscular venous thrombosis, and 2 cases who occurred hip dislocation recovered after treatment. THA surgery for osteoarthropathy secondary to septic hip arthritis has a good effect, relieving the patient's pain effectively, improving prognosis and joint mobility. For osteoarthropathy secondary to septic hip arthritis, THA may be meaningful in terms of prognosis.

Septic arthritis of native joints due to Mycobacterium avium complex: A systematic review of case reports

INTRODUCTION

While MAC native joint septic arthritis is historically considered a rare entity, the number of reported cases have increased in recent decades. However, no comprehensive review of this topic has been conducted.

OBJECTIVES

To conduct a systematic review of cases of MAC native joint septic arthritis reported in the literature and summarize the presentations, baseline characteristics, risk factors, diagnosis, treatment, and treatment outcomes.

METHODS

A systematic review was conducted by performing an extensive literature search through Medline, Google Scholar, and Web of Science, starting from their inception. Screening of articles, assessment of eligibility, and data synthesis from eligible articles were independently performed by two reviewers with input from a third reviewer to achieve consensus. Inclusion criteria to determine eligibility included articles in English, case reports/case series, adult patients who presented with MAC/MA/MI septic arthritis of a native joint. Statistical analyses were performed using Statistical Package for the Social Sciences.

RESULTS

Thirty-three cases of MAC native joint septic arthritis were reported since 1976. MAC septic arthritis affects immunocompetent and immunocompromised patients, most frequently as a monoarthritis involving the knees and wrist. MAC septic arthritis may present in the context of disseminated MAC infection and primary MAC septic arthritis. The average time to diagnosis from onset of symptoms was 20 months, where the majority of cases were initially misdiagnosed. Although arthrocentesis can be used to make the diagnosis, a synovial biopsy is necessary in many cases to confirm the diagnosis. A combination of surgery and antimycobacterial drug treatment has the highest chance of achieving complete resolution.

CONCLUSION

The diagnosis of septic arthritis of native joints due to MAC can be challenging and/or delayed. A high level of suspicion is needed in high-risk patients and also when atypical presentations occur. Therefore, understanding the presentation, risk factors, and pitfalls in diagnosing MAC septic arthritis are essential. MAC septic arthritis literature is scarce, necessitating further research of this rare condition to increase awareness, diagnostic accuracy and determine the optimal treatment strategy to improve patient outcomes.

Atypical Mycobacterial Infections of the Upper Extremity

Atypical mycobacterial infections of upper extremity synovial-lined structures are often misdiagnosed and unrecognized. Despite an increasing incidence, lack of physician awareness of these pathogens may result in considerable delay in diagnosis and management, potentially leading to permanent disability. The authors conducted a literature review and analyzed 31 cases of penetrating atypical mycobacterial infection to better understand the clinical characteristics and to evaluate their posttreatment complication rate compared with available literature. Medical records for culture-positive cases of tenosynovial or intra-articular atypical mycobacterial infections of the upper extremity that were treated were retrospectively reviewed. Treatment outcomes were analyzed against published case reviews and case series. Thirty-one cases of penetrating atypical mycobacterial infection were identified. Mycobacterium marinum (n=11) was the most common organism and was associated with aquatic exposure. Twenty-eight cases received empiric treatment, 17 of which received contraindicated treatment. Patients saw an average of 5 physicians prior to receiving an accurate diagnosis, and the mean time to diagnosis was 10 months. All cases received antibiotic treatment in addition to surgical management. Twenty cases (68%) failed treatment outcomes. Delay in diagnosis and inappropriate management of atypical mycobacterial infections may lead to a treatment failure rate that is higher than what has been reported in the literature. Mycobacterium avium and M fortuitum had significantly higher failure rates than other organisms. A high index of suspicion is required to make a diagnosis and prevent residual disability. [Orthopedics. 2018; 41(3):e383-e388.].