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Streptococcus pneumoniae septic arthritis in adults
EDITORIAL
10.1111/j.1469-0691.2004.00968.x
Streptococcus pneumoniae septic arthritis in adults I. Baraboutis1 and A. Skoutelis2 Hellenic Centre for Infectious Diseases Control, Athens and 2Infectious Diseases Division, Department of Medicine, University Hospital of Patras, Rio ⁄ Patra, Greece
1
ABSTRACT Streptococcus pneumoniae septic arthritis is an uncommon infection. The classic clinical picture is that of concomitant pulmonary and ⁄ or meningeal and joint infections in the presence of predisposing local and systemic factors. Initial laboratory tests are usually inconclusive, and joint aspiration is required for a definitive diagnosis. Treatment options include antibiotic therapy (usually with penicillin) combined with closed or open joint drainage. Increasing reports of infections involving penicillin-resistant strains are a concern. The prognosis is usually favourable, but early recognition and aggressive management are essential to reduce the likelihood of significant joint injury. Keywords
Arthritis, pneumococcal arthritis, septic arthritis, Streptococcus pneumoniae
Clin Microbiol Infect 2004; 10: 1037–1039 Non-gonococcal bacterial infections are the most serious infections of adult joints, usually affecting large joints [1]. Most (80–90%) of these infections are monoarticular, but polyarticular involvement is seen in conditions such as rheumatoid arthritis [2]. Staphylococcus aureus and non-group A b-haemolytic streptococci are the Gram-positive organisms involved most frequently [3]. The first reported case of Streptococcus pneumoniae septic arthritis was in 1888 [4], with 285 cases being reported in the scientific literature between 1888 and 1970 [4]. More recent series have found rates of 3–5% among all patients with septic arthritis [3], while rates of 8–10% have been reported from the UK and New Zealand [5–7]. The joint affected most frequently is the knee, followed by the shoulder, the elbow and multiple joints [4,6–9]. A recent review of S. pneumoniae spinal infection in the UK included a total of 28 cases from 1970 to 1997 [10]. S. pneumoniae septic arthritis of the hip is also reported occasionally [6–9]. Middle-aged and elderly adults seem to be more vulnerable to S. pneumoniae septic arthritis [6–8,10]. Higher rates in male adults have been reported [4,5,10], but this finding has not been confirmed by others [6,8,9]. Most patients with Corresponding author and reprint requests: I. Baraboutis, Hellenic Centre for Infectious Diseases Control, 3rd September 54, 10433 Athens, Greece E-mail: [email protected]
S. pneumoniae septic arthritis have one or more underlying articular or non-articular illnesses and host factors predisposing to joint infection, including preceding upper respiratory tract infection, alcohol abuse, trauma, diabetes mellitus, rheumatoid arthritis, osteoarthritis, corticosteroid therapy, multiple myeloma and other malignancies, and cardiovascular disease and other collagen vascular diseases [4,6–10]. Patients with rheumatoid arthritis are predisposed to polyarticular septic arthritis of any aetiology (up to 25%). Four or more joints may be involved [7]. It has been suggested that S. pneumoniae may tend to involve multiple joints irrespective of the presence of rheumatoid arthritis [11]. Other risk factors noted less frequently include gout, splenectomy, HIV infection [7,12–14] and hip osteonecrosis (I. Baraboutis, unpublished data). Surprisingly, S. pneumoniae septic arthritis is an uncommon complication in adult patients with sickle cell disease [9]. Rarely, S. pneumoniae septic arthritis involves prosthetic joints, mostly knees and hips [15–17]. S. pneumoniae septic arthritis has been associated with pneumococcal pneumonia in 70–75% of patients from older series and 29–36% of patients in more recent series [4,6–8]. Other primary foci include the meninges, endocardium, pleural space, or combinations of these [6–8,10]. Absence of concomitant infection elsewhere is found in 10–50% of patients [6–8].
2004 Copyright by the European Society of Clinical Microbiology and Infectious Diseases
1038 Clinical Microbiology and Infection, Volume 10 Number 12, December 2004
Conversely, S. pneumoniae septic arthritis is an infrequent complication of pneumococcal pneumonia (c. 0.3%), even before the emergence of antibiotic resistance [9]. The clinical presentation of patients with S. pneumoniae septic arthritis may combine symptoms from the affected joint(s) and concomitant pneumococcal infection elsewhere, usually pneumonia and ⁄ or meningitis. Joint symptoms may appear before, at the same time or after the onset of the primary infection [10]. The mean duration of pain before diagnosis of spinal involvement is 5.5 weeks [10]. S. pneumoniae septic arthritis involving other sites has a much faster onset, usually 3–5 days [6], but the delay in diagnosis of S. pneumoniae septic arthritis involving prosthetic hips may be several months [16,17]. Fever of > 38C upon admission is recorded in 45–65% of cases [6,8,10], although a small series reported fever in 83% and shaking chills in 42% of cases [9]. Lack of febrile response is especially common with spinal involvement [10,18]. Local symptoms are usually intense, but there are no specific local findings [4]. Advanced infection with joint destruction and pus extension in the surroundings is rarely seen nowadays. The peripheral white blood cell count is usually elevated with a left shift (mean of > 11 · 109 cells ⁄ L, including spine cases) [6,8– 10]. A low white blood cell count is indicative of a poor prognosis. The erythrocyte sedimentation rate is usually elevated (> 90 mm ⁄ h in > 50% of cases) [6,10]. Bacteraemia occurs in 70–90% of patients who have blood cultures taken, and in 30–56% of patients with spinal involvement [6,10]. Conversely, arthritic symptoms occurring during or following pneumonia cannot be ascribed safely to S. pneumoniae septic arthritis without compatible joint fluid findings [4]. The joint fluid is usually thick, yellow–brown and purulent, but occasionally may be only slightly turbid [4,8,9]. The joint fluid white blood cell count may range from 7000 to > 100 000 cells ⁄ mm3 [4,8,9]. Gram’s stain and culture of fluid yields positive results in > 75% and 60–85% of cases, respectively [6,8,9]. Serotyping has indicated the involvement of multiple serotypes, most of which are included in the 23-valent pneumococcal vaccine [6,8]. Most isolates reported to date have been susceptible to penicillin, although reports of infections with moderately or even highly resistant strains are a concern [19].
Imaging is not essential for the diagnosis of S. pneumoniae septic arthritis, with the exception of spinal involvement and the suspicion of an epidural abscess, in which case magnetic resonance imaging is indicated [10]. Radiographic findings include those related to the underlying disease and, additionally, soft tissue swelling or effusion, joint destruction in neglected cases, adjacent osteomyelitis and, rarely, periarticular calcification [9,18]. Before the antibiotic era, treatment included multiple aspirations or open drainage [9]. Subsequently, intravenous penicillin has been the preferred drug, with third-generation cephalosporins and vancomycin being reasonable alternatives [4,6–8,10]. There is no consensus on the duration of intravenous therapy (usually for 3–4 weeks, but 6–8 weeks for spinal infections) and the role of subsequent oral therapy [7–10]. Intra-articular antibiotics are not necessary [6]. Many cases of S. pneumoniae septic arthritis have been treated successfully with antimicrobial agents, together with one or more closed-needle aspirations [6,8]. Some centres use routine surgical lavage, either arthroscopic or open [6–8]. Surgical drainage may be more important with hip involvement, especially in children and when the joint fluid is very thick and loculated [4,9,20]. Early surgery is advised for spinal S. pneumoniae septic arthritis with significant spine instability and suspicion of epidural abscess [10]. Several cases of S. pneumoniae septic arthritis involving prosthetic joints have been managed adequately with long courses of antibiotics and open drainage [6,8]. The prognosis for S. pneumoniae septic arthritis was favourable even in the pre-antibiotic era. With appropriate antibiotic therapy and surgical intervention, residual morbidity is usually minimal [7–10]. The short-term prognosis depends also on underlying host factors, accounting for the long duration of hospitalisation and high mortality (up to 32%) in some series [6,7,9]. In a large review, mortality was predicted only by positive blood culture [8]. Most published reviews have not provided data on previous pneumococcal vaccination. In summary, S. pneumoniae septic arthritis remains an uncommon infection. However, it should be considered in cases of concomitant pulmonary and ⁄ or meningeal and joint infection, especially in the presence of predisposing factors. The prognosis is usually favourable. Neverthe-
2004 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 10, 1037–1039
Baraboutis and Skoutelis Streptococcus pneumoniae septic arthritis 1039
less, early recognition and aggressive management are imperative to reduce the likelihood of significant joint injury. Since experience with antimicrobial agents other than penicillin is very limited, and reports of infections involving penicillin-resistant strains are increasing, improved awareness of this syndrome is essential. REFERENCES 1. Baker DG, Schumacher RH. Current concepts: acute monoarthritis. N Engl J Med 1993; 329: 1013–1020. 2. Goldenberg DL, Cohen AS. Acute infectious arthritis: a review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med 1976; 60: 369–377. 3. Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med 1985; 312: 764–771. 4. Torres J, Rathbun HK, Greenough WB. Pneumococcal arthritis: report of a case and review of the literature. Johns Hopkins Med J 1973; 132: 234–241. 5. Ryan MJ, Kavanagh R, Wall PG, Hazleman BL. Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period. Br J Rheum 1997; 36: 370– 373. 6. Ispahani P, Weston VC, Turner DPJ, Donald FE. Septic arthritis due to Streptococcus pneumoniae in Nottingham, United Kingdom, 1985–1998. Clin Infect Dis 1999; 29: 1450– 1454. 7. James PA, Thomas MG. Streptococcus pneumoniae septic arthritis in adults. Scand J Infect Dis 2000; 32: 491–494. 8. Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis 2003; 36: 319–327.
9. Kauffman CA, Watanakunakorn C, Phair JP. Pneumococcal arthritis. J Rheumatol 1976; 3: 409–419. 10. Turner DPJ, Weston VC, Ispahani P. Streptococcus pneumoniae spinal infection in Nottingham, United Kingdom: not a rare event. Clin Infect Dis 1999; 28: 873–881. 11. Epstein JH, Zimmermann B, Ho G. Polyarticular septic arthritis. J Rheumatol 1986; 13: 1105–1107. 12. Edwards GS, Russell IJ. Pneumococcal arthritis complicating gout. J Rheumatol 1980; 7: 907–910. 13. Merle-Melet M, Tortuyaux JM, Condette S et al. Early postsplenectomy arthritis caused by penicillin-resistant Streptococcus pneumoniae. Eur J Clin Microbiol Infect Dis 1996; 15: 159–160. 14. Saraux A, Taelman H, Blanche P et al. HIV infection as a risk factor for septic arthritis. Br J Rheumatol 1997; 36: 333– 337. 15. Sublett KL, Katz AL. Medical management of pneumococcal arthritis involving a knee prosthesis. Arthritis Rheum 1987; 30: 940–942. 16. Sanzen L. Spread of Streptococcus pneumoniae between artificial joints in a rheumatoid patient. Acta Orthop Scand 1991; 62: 597–598. 17. Maniloff G, Greenwald R, Laskin R, Singer C. Delayed postbacteremic prosthetic joint infection. Clin Orthop 1987; 223: 194–197. 18. Babinchak TJ, Riley DK, Rotheram EB. Pyogenic vertebral osteomyelitis of the posterior elements. Clin Infect Dis 1997; 25: 221–224. 19. Naktin J, DeSimone J. Lumbar vertebral osteomyelitis with mycotic abdominal aortic aneurysm caused by highly penicillin-resistant Streptococcus pneumoniae. J Clin Microbiol 1999; 37: 4198–4200. 20. Rosenthal J, Bole GG, Robinson WD. Acute nongonococcal infectious arthritis: evaluation of risk factors, therapy and outcome. Arthritis Rheum 1980; 23: 889–897.
2004 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 10, 1037–1039
10.1111/j.1469-0691.2004.00968.x
Streptococcus pneumoniae septic arthritis in adults I. Baraboutis1 and A. Skoutelis2 Hellenic Centre for Infectious Diseases Control, Athens and 2Infectious Diseases Division, Department of Medicine, University Hospital of Patras, Rio ⁄ Patra, Greece
1
ABSTRACT Streptococcus pneumoniae septic arthritis is an uncommon infection. The classic clinical picture is that of concomitant pulmonary and ⁄ or meningeal and joint infections in the presence of predisposing local and systemic factors. Initial laboratory tests are usually inconclusive, and joint aspiration is required for a definitive diagnosis. Treatment options include antibiotic therapy (usually with penicillin) combined with closed or open joint drainage. Increasing reports of infections involving penicillin-resistant strains are a concern. The prognosis is usually favourable, but early recognition and aggressive management are essential to reduce the likelihood of significant joint injury. Keywords
Arthritis, pneumococcal arthritis, septic arthritis, Streptococcus pneumoniae
Clin Microbiol Infect 2004; 10: 1037–1039 Non-gonococcal bacterial infections are the most serious infections of adult joints, usually affecting large joints [1]. Most (80–90%) of these infections are monoarticular, but polyarticular involvement is seen in conditions such as rheumatoid arthritis [2]. Staphylococcus aureus and non-group A b-haemolytic streptococci are the Gram-positive organisms involved most frequently [3]. The first reported case of Streptococcus pneumoniae septic arthritis was in 1888 [4], with 285 cases being reported in the scientific literature between 1888 and 1970 [4]. More recent series have found rates of 3–5% among all patients with septic arthritis [3], while rates of 8–10% have been reported from the UK and New Zealand [5–7]. The joint affected most frequently is the knee, followed by the shoulder, the elbow and multiple joints [4,6–9]. A recent review of S. pneumoniae spinal infection in the UK included a total of 28 cases from 1970 to 1997 [10]. S. pneumoniae septic arthritis of the hip is also reported occasionally [6–9]. Middle-aged and elderly adults seem to be more vulnerable to S. pneumoniae septic arthritis [6–8,10]. Higher rates in male adults have been reported [4,5,10], but this finding has not been confirmed by others [6,8,9]. Most patients with Corresponding author and reprint requests: I. Baraboutis, Hellenic Centre for Infectious Diseases Control, 3rd September 54, 10433 Athens, Greece E-mail: [email protected]
S. pneumoniae septic arthritis have one or more underlying articular or non-articular illnesses and host factors predisposing to joint infection, including preceding upper respiratory tract infection, alcohol abuse, trauma, diabetes mellitus, rheumatoid arthritis, osteoarthritis, corticosteroid therapy, multiple myeloma and other malignancies, and cardiovascular disease and other collagen vascular diseases [4,6–10]. Patients with rheumatoid arthritis are predisposed to polyarticular septic arthritis of any aetiology (up to 25%). Four or more joints may be involved [7]. It has been suggested that S. pneumoniae may tend to involve multiple joints irrespective of the presence of rheumatoid arthritis [11]. Other risk factors noted less frequently include gout, splenectomy, HIV infection [7,12–14] and hip osteonecrosis (I. Baraboutis, unpublished data). Surprisingly, S. pneumoniae septic arthritis is an uncommon complication in adult patients with sickle cell disease [9]. Rarely, S. pneumoniae septic arthritis involves prosthetic joints, mostly knees and hips [15–17]. S. pneumoniae septic arthritis has been associated with pneumococcal pneumonia in 70–75% of patients from older series and 29–36% of patients in more recent series [4,6–8]. Other primary foci include the meninges, endocardium, pleural space, or combinations of these [6–8,10]. Absence of concomitant infection elsewhere is found in 10–50% of patients [6–8].
2004 Copyright by the European Society of Clinical Microbiology and Infectious Diseases
1038 Clinical Microbiology and Infection, Volume 10 Number 12, December 2004
Conversely, S. pneumoniae septic arthritis is an infrequent complication of pneumococcal pneumonia (c. 0.3%), even before the emergence of antibiotic resistance [9]. The clinical presentation of patients with S. pneumoniae septic arthritis may combine symptoms from the affected joint(s) and concomitant pneumococcal infection elsewhere, usually pneumonia and ⁄ or meningitis. Joint symptoms may appear before, at the same time or after the onset of the primary infection [10]. The mean duration of pain before diagnosis of spinal involvement is 5.5 weeks [10]. S. pneumoniae septic arthritis involving other sites has a much faster onset, usually 3–5 days [6], but the delay in diagnosis of S. pneumoniae septic arthritis involving prosthetic hips may be several months [16,17]. Fever of > 38C upon admission is recorded in 45–65% of cases [6,8,10], although a small series reported fever in 83% and shaking chills in 42% of cases [9]. Lack of febrile response is especially common with spinal involvement [10,18]. Local symptoms are usually intense, but there are no specific local findings [4]. Advanced infection with joint destruction and pus extension in the surroundings is rarely seen nowadays. The peripheral white blood cell count is usually elevated with a left shift (mean of > 11 · 109 cells ⁄ L, including spine cases) [6,8– 10]. A low white blood cell count is indicative of a poor prognosis. The erythrocyte sedimentation rate is usually elevated (> 90 mm ⁄ h in > 50% of cases) [6,10]. Bacteraemia occurs in 70–90% of patients who have blood cultures taken, and in 30–56% of patients with spinal involvement [6,10]. Conversely, arthritic symptoms occurring during or following pneumonia cannot be ascribed safely to S. pneumoniae septic arthritis without compatible joint fluid findings [4]. The joint fluid is usually thick, yellow–brown and purulent, but occasionally may be only slightly turbid [4,8,9]. The joint fluid white blood cell count may range from 7000 to > 100 000 cells ⁄ mm3 [4,8,9]. Gram’s stain and culture of fluid yields positive results in > 75% and 60–85% of cases, respectively [6,8,9]. Serotyping has indicated the involvement of multiple serotypes, most of which are included in the 23-valent pneumococcal vaccine [6,8]. Most isolates reported to date have been susceptible to penicillin, although reports of infections with moderately or even highly resistant strains are a concern [19].
Imaging is not essential for the diagnosis of S. pneumoniae septic arthritis, with the exception of spinal involvement and the suspicion of an epidural abscess, in which case magnetic resonance imaging is indicated [10]. Radiographic findings include those related to the underlying disease and, additionally, soft tissue swelling or effusion, joint destruction in neglected cases, adjacent osteomyelitis and, rarely, periarticular calcification [9,18]. Before the antibiotic era, treatment included multiple aspirations or open drainage [9]. Subsequently, intravenous penicillin has been the preferred drug, with third-generation cephalosporins and vancomycin being reasonable alternatives [4,6–8,10]. There is no consensus on the duration of intravenous therapy (usually for 3–4 weeks, but 6–8 weeks for spinal infections) and the role of subsequent oral therapy [7–10]. Intra-articular antibiotics are not necessary [6]. Many cases of S. pneumoniae septic arthritis have been treated successfully with antimicrobial agents, together with one or more closed-needle aspirations [6,8]. Some centres use routine surgical lavage, either arthroscopic or open [6–8]. Surgical drainage may be more important with hip involvement, especially in children and when the joint fluid is very thick and loculated [4,9,20]. Early surgery is advised for spinal S. pneumoniae septic arthritis with significant spine instability and suspicion of epidural abscess [10]. Several cases of S. pneumoniae septic arthritis involving prosthetic joints have been managed adequately with long courses of antibiotics and open drainage [6,8]. The prognosis for S. pneumoniae septic arthritis was favourable even in the pre-antibiotic era. With appropriate antibiotic therapy and surgical intervention, residual morbidity is usually minimal [7–10]. The short-term prognosis depends also on underlying host factors, accounting for the long duration of hospitalisation and high mortality (up to 32%) in some series [6,7,9]. In a large review, mortality was predicted only by positive blood culture [8]. Most published reviews have not provided data on previous pneumococcal vaccination. In summary, S. pneumoniae septic arthritis remains an uncommon infection. However, it should be considered in cases of concomitant pulmonary and ⁄ or meningeal and joint infection, especially in the presence of predisposing factors. The prognosis is usually favourable. Neverthe-
2004 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 10, 1037–1039
Baraboutis and Skoutelis Streptococcus pneumoniae septic arthritis 1039
less, early recognition and aggressive management are imperative to reduce the likelihood of significant joint injury. Since experience with antimicrobial agents other than penicillin is very limited, and reports of infections involving penicillin-resistant strains are increasing, improved awareness of this syndrome is essential. REFERENCES 1. Baker DG, Schumacher RH. Current concepts: acute monoarthritis. N Engl J Med 1993; 329: 1013–1020. 2. Goldenberg DL, Cohen AS. Acute infectious arthritis: a review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med 1976; 60: 369–377. 3. Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med 1985; 312: 764–771. 4. Torres J, Rathbun HK, Greenough WB. Pneumococcal arthritis: report of a case and review of the literature. Johns Hopkins Med J 1973; 132: 234–241. 5. Ryan MJ, Kavanagh R, Wall PG, Hazleman BL. Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period. Br J Rheum 1997; 36: 370– 373. 6. Ispahani P, Weston VC, Turner DPJ, Donald FE. Septic arthritis due to Streptococcus pneumoniae in Nottingham, United Kingdom, 1985–1998. Clin Infect Dis 1999; 29: 1450– 1454. 7. James PA, Thomas MG. Streptococcus pneumoniae septic arthritis in adults. Scand J Infect Dis 2000; 32: 491–494. 8. Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis 2003; 36: 319–327.
9. Kauffman CA, Watanakunakorn C, Phair JP. Pneumococcal arthritis. J Rheumatol 1976; 3: 409–419. 10. Turner DPJ, Weston VC, Ispahani P. Streptococcus pneumoniae spinal infection in Nottingham, United Kingdom: not a rare event. Clin Infect Dis 1999; 28: 873–881. 11. Epstein JH, Zimmermann B, Ho G. Polyarticular septic arthritis. J Rheumatol 1986; 13: 1105–1107. 12. Edwards GS, Russell IJ. Pneumococcal arthritis complicating gout. J Rheumatol 1980; 7: 907–910. 13. Merle-Melet M, Tortuyaux JM, Condette S et al. Early postsplenectomy arthritis caused by penicillin-resistant Streptococcus pneumoniae. Eur J Clin Microbiol Infect Dis 1996; 15: 159–160. 14. Saraux A, Taelman H, Blanche P et al. HIV infection as a risk factor for septic arthritis. Br J Rheumatol 1997; 36: 333– 337. 15. Sublett KL, Katz AL. Medical management of pneumococcal arthritis involving a knee prosthesis. Arthritis Rheum 1987; 30: 940–942. 16. Sanzen L. Spread of Streptococcus pneumoniae between artificial joints in a rheumatoid patient. Acta Orthop Scand 1991; 62: 597–598. 17. Maniloff G, Greenwald R, Laskin R, Singer C. Delayed postbacteremic prosthetic joint infection. Clin Orthop 1987; 223: 194–197. 18. Babinchak TJ, Riley DK, Rotheram EB. Pyogenic vertebral osteomyelitis of the posterior elements. Clin Infect Dis 1997; 25: 221–224. 19. Naktin J, DeSimone J. Lumbar vertebral osteomyelitis with mycotic abdominal aortic aneurysm caused by highly penicillin-resistant Streptococcus pneumoniae. J Clin Microbiol 1999; 37: 4198–4200. 20. Rosenthal J, Bole GG, Robinson WD. Acute nongonococcal infectious arthritis: evaluation of risk factors, therapy and outcome. Arthritis Rheum 1980; 23: 889–897.
2004 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 10, 1037–1039