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Covert multi-focal infective arthritis
Journal of Infection (1993) 27, 297-3oo
CASE R E P O R T Covert multi-focal
infective
arthritis
A. D. P i t k i n * a n d S . J . E y k y n t
Departments of Intensive Care* and Alicrobiology,t St Thomas' Hospital, Lambeth Palace Road, London SEI 7EH, U.K. Accepted for publication 25 June 1993 Summary Six patients with pre-existing rheumatic joint disease presented with overwhelming septicaemia but without overt signs of joint inflammation. Joint aspirates demonstrated multifocal staphylococcal infective arthritis. Despite intensive care all six died from the infection or its immediate sequelae. The contrast between this clinical entity and classical infective arthritis, presenting with one or more swollen, tender joints, is discussed.
Introduction Infective arthritis is a well recognised complication of joints affected by rheumatoid arthritis, 1-3 and typically presents with a painful swollen joint. Staphylococcus aureus is the commonest causal pathogen. 4 Microscopy of joint aspirates will distinguish between this and an exacerbation of the underlying rheumatic disease. A distinct though less well known clinical entity is septicaemia with shock, acute respiratory and renal failure secondary to occult multiple joint infection in patients with rheumatic joint disease ~'6 in whom overt signs of joint inflammation are absent. 7 We report six cases of fatal staphylococcal septicaemia associated with unsuspected multifocal infective arthritis.
Patients and methods Between I97O and I992 six patients presented to St Thomas' Hospital with staphylococcal septicaemia associated with multifocal septic arthritis. T h e most recent case is described; the principal features of the others are shown in Table I.
Case report A 49-year-old domestic cleaner had a Io year history of sero-positive rheumatoid arthritis requiring long term steroids. About 3 months before admission an ulcerated toe had been amputated and the wound had not healed. She presented to hospital complaining of more pain in several joints for 2 days and 24 hours of increasing breathlessness. Her general practitioner had prescribed amoxycillin for a respiratory tract infection. On admission the patient was moribund with an unrecordable blood Address correspondence to: Dr S. J. Eykyn. oi63-4453/93/o6o297+o4 $08.00/0
© I993 The British Society for the Study of Infection
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Covert multi-focal infective arthritis
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pressure, cyanosis and extreme respiratory distress. She had marked peripheral oedema, p u r p u r i c lesions on her hands and feet and large rheumatoid nodules on both elbows. Examination of her joints showed no abnormalities other than those typical of long standing rheumatoid arthritis. T h e liver and spleen were enlarged. Initial investigations showed a leucopenia (2"3 × IO9/1) with toxic granulation of neutrophils. Blood cultures grew penicillin-resistant S. aureus and closer examination revealed a modest effusion in the left knee joint. Needle aspiration p r o d u c e d frank pus, as did aspiration of the right knee, both hips, both shoulders, both wrists, two metacarpophalangeal joints and one interphalangeal joint in the right hand. S. aureus was isolated from all specimens. T h e patient was treated with vancomycin but continued to deteriorate with worsening of renal failure, p u l m o n a r y oedema and lactic acidosis. Surgical irrigation of her knees, ankles and hip was carried out, with debridement of the infected amputation site. Although some clinical i m p r o v e m e n t followed, blood cultures remained persistently positive despite therapeutic blood levels of vancomycin. Joint irrigation was repeated b u t she died Io days after admission. Post mortem examination confirmed multiple pyarthroses with acute tubular necrosis and fatty infiltration of the liver. A large, previously unsuspected, abscess in the anterior chest wall in continuity with the right sternoclavicular joint was found. Discussion
Staphylococcal septicaemia with multiple pyarthroses is a rare but well recognised complication of severe rheumatic joint disease. 5'7 Of 2oI cases of c o m m u n i t y acquired S. aureus bacteraemia at St T h o m a s ' Hospital in the period I97o to I992, only six (3 %) were associated with multiple joint sepsis. It occurs most c o m m o n l y in rheumatoid arthritis but also in systemic lupus erythematosus 8 and other rheumatic diseases. 9 Although there may be a history of increasing arthralgia, the infected joints often appear quiescent on examination with no erythema, swelling or tenderness, and the presence of joint infection is sometimes discovered by chance. In one of our cases pus was obtained from the left hip joint during attempted femoral artery puncture. Fever is almost always present, but with joint pain could be attributed to an exacerbation of the underlying rheumatic disorder. T h e causative pathogen is readily isolated from blood cultures and from joint aspirates. T h e s e may be frankly purulent even from joints that appear unaffected. R h e u m a t o i d joints are prone to haematogenous infection and i m p a i r m e n t of neutrophil function by corticosteroids may further increase the susceptibility to infection. T h e joints most likely to be involved are knee, hip, elbow, shoulder and wrist. T h e likely portal of entry of the staphylococcus in the case described was an infected toe amputation site, but S. aureus bacteraemia is known to occur without a predisposing skin lesion. Toxic granulation of neutrophils indicative of overwhelming sepsis, was noted in two patients who were leucopenic. T r e a t m e n t consists of appropriate systemic antibiotics with drainage of the affected joints, 1° which usually necessitates open arthrotomy and irrigation. 3' 1~
300
A. D. PITKIN AND S. J. EYKYN
R e p e a t e d isolation o f staphylococci f r o m blood cultures despite appropriate antibiotics suggests a c o n t i n u i n g focus of infection and this is m o s t likely to be a joint. I n the case described, the sternoclavicular joint was discovered to be such a focus only at post m o r t e m examination. M o r t a l i t y o f m u l t i p l e staphylococcal septic arthritis is very high and m a y be related to the d u r a t i o n o f s y m p t o m s before t r e a t m e n t is started. O n l y one o f our six patients survived the acute septicaemic episode, b u t died soon afterwards with severe disability f r o m the sequelae. T h e lack o f joint signs and the p r o m i n e n t systemic features m a y contribute to the delay in diagnosis. A high index of suspicion o f joint sepsis should be m a i n t a i n e d in any acute systemic illness in a patient with pre-existing rheumatic joint disease. References I. Karten I. Septic arthritis complicating rheumatoid arthritis. Ann Int Med 1969; 70(6): II47-II58. 2. Russell AS, Ansell BM. Septic arthritis. Ann Rheum Dis 1972; 3I: 40-44. 3. Gristina AG, Rovere GD, Shoji H. Spontaneous septic arthritis complicating rheumatoid arthritis. J Bone Joint Surg I974; 56A(6): I iSo-i I84. 4. Goldenberg DL. Infectious arthritis complicating rheumatoid arthritis and other chronic rheumatic disorders. Arthritis Rheum 1989; 32(4): 496-5o2. 5- De Andrade JR, Tribe CR. Staphylococcal septicaemia with pyoarthrosis in rheumatoid arthritis. Br M e d J I962 ; i: I516-I518. 6. Mitchell WS, Brooks PM, Stevenson RD, Buchanan WW. Septic arthritis in patients with rheumatoid disease: a still underdiagnosed complication. J Rheum I976; 3(2): 124-I33. 7- Kraft SM, Panush RS, Longley S. Unrecognized staphylococcal pyarthrosis with rheumatoid arthritis. Semin Arth Rheum I985; I4(3): I96-2oi. 8. Quismorio FP, Dubois EL. Septic arthritis in systemic lupus erythematosus. J Rheum I975; 2: 73-82. 9. Epstein JH, Zimmerman B, Ho G. Polyarticular septic arthritis. J Rheum 1986; I3: 1105--1107. I0. HO G, Su GY. Therapy for septic arthritis. J A M A 1982; 247(6): 797-8oo. I I. Myers AR. Pyarthrosis complicating rheumatoid arthritis. Lancet 1969; 2: 714-716.
CASE R E P O R T Covert multi-focal
infective
arthritis
A. D. P i t k i n * a n d S . J . E y k y n t
Departments of Intensive Care* and Alicrobiology,t St Thomas' Hospital, Lambeth Palace Road, London SEI 7EH, U.K. Accepted for publication 25 June 1993 Summary Six patients with pre-existing rheumatic joint disease presented with overwhelming septicaemia but without overt signs of joint inflammation. Joint aspirates demonstrated multifocal staphylococcal infective arthritis. Despite intensive care all six died from the infection or its immediate sequelae. The contrast between this clinical entity and classical infective arthritis, presenting with one or more swollen, tender joints, is discussed.
Introduction Infective arthritis is a well recognised complication of joints affected by rheumatoid arthritis, 1-3 and typically presents with a painful swollen joint. Staphylococcus aureus is the commonest causal pathogen. 4 Microscopy of joint aspirates will distinguish between this and an exacerbation of the underlying rheumatic disease. A distinct though less well known clinical entity is septicaemia with shock, acute respiratory and renal failure secondary to occult multiple joint infection in patients with rheumatic joint disease ~'6 in whom overt signs of joint inflammation are absent. 7 We report six cases of fatal staphylococcal septicaemia associated with unsuspected multifocal infective arthritis.
Patients and methods Between I97O and I992 six patients presented to St Thomas' Hospital with staphylococcal septicaemia associated with multifocal septic arthritis. T h e most recent case is described; the principal features of the others are shown in Table I.
Case report A 49-year-old domestic cleaner had a Io year history of sero-positive rheumatoid arthritis requiring long term steroids. About 3 months before admission an ulcerated toe had been amputated and the wound had not healed. She presented to hospital complaining of more pain in several joints for 2 days and 24 hours of increasing breathlessness. Her general practitioner had prescribed amoxycillin for a respiratory tract infection. On admission the patient was moribund with an unrecordable blood Address correspondence to: Dr S. J. Eykyn. oi63-4453/93/o6o297+o4 $08.00/0
© I993 The British Society for the Study of Infection
298
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Covert multi-focal infective arthritis
299
pressure, cyanosis and extreme respiratory distress. She had marked peripheral oedema, p u r p u r i c lesions on her hands and feet and large rheumatoid nodules on both elbows. Examination of her joints showed no abnormalities other than those typical of long standing rheumatoid arthritis. T h e liver and spleen were enlarged. Initial investigations showed a leucopenia (2"3 × IO9/1) with toxic granulation of neutrophils. Blood cultures grew penicillin-resistant S. aureus and closer examination revealed a modest effusion in the left knee joint. Needle aspiration p r o d u c e d frank pus, as did aspiration of the right knee, both hips, both shoulders, both wrists, two metacarpophalangeal joints and one interphalangeal joint in the right hand. S. aureus was isolated from all specimens. T h e patient was treated with vancomycin but continued to deteriorate with worsening of renal failure, p u l m o n a r y oedema and lactic acidosis. Surgical irrigation of her knees, ankles and hip was carried out, with debridement of the infected amputation site. Although some clinical i m p r o v e m e n t followed, blood cultures remained persistently positive despite therapeutic blood levels of vancomycin. Joint irrigation was repeated b u t she died Io days after admission. Post mortem examination confirmed multiple pyarthroses with acute tubular necrosis and fatty infiltration of the liver. A large, previously unsuspected, abscess in the anterior chest wall in continuity with the right sternoclavicular joint was found. Discussion
Staphylococcal septicaemia with multiple pyarthroses is a rare but well recognised complication of severe rheumatic joint disease. 5'7 Of 2oI cases of c o m m u n i t y acquired S. aureus bacteraemia at St T h o m a s ' Hospital in the period I97o to I992, only six (3 %) were associated with multiple joint sepsis. It occurs most c o m m o n l y in rheumatoid arthritis but also in systemic lupus erythematosus 8 and other rheumatic diseases. 9 Although there may be a history of increasing arthralgia, the infected joints often appear quiescent on examination with no erythema, swelling or tenderness, and the presence of joint infection is sometimes discovered by chance. In one of our cases pus was obtained from the left hip joint during attempted femoral artery puncture. Fever is almost always present, but with joint pain could be attributed to an exacerbation of the underlying rheumatic disorder. T h e causative pathogen is readily isolated from blood cultures and from joint aspirates. T h e s e may be frankly purulent even from joints that appear unaffected. R h e u m a t o i d joints are prone to haematogenous infection and i m p a i r m e n t of neutrophil function by corticosteroids may further increase the susceptibility to infection. T h e joints most likely to be involved are knee, hip, elbow, shoulder and wrist. T h e likely portal of entry of the staphylococcus in the case described was an infected toe amputation site, but S. aureus bacteraemia is known to occur without a predisposing skin lesion. Toxic granulation of neutrophils indicative of overwhelming sepsis, was noted in two patients who were leucopenic. T r e a t m e n t consists of appropriate systemic antibiotics with drainage of the affected joints, 1° which usually necessitates open arthrotomy and irrigation. 3' 1~
300
A. D. PITKIN AND S. J. EYKYN
R e p e a t e d isolation o f staphylococci f r o m blood cultures despite appropriate antibiotics suggests a c o n t i n u i n g focus of infection and this is m o s t likely to be a joint. I n the case described, the sternoclavicular joint was discovered to be such a focus only at post m o r t e m examination. M o r t a l i t y o f m u l t i p l e staphylococcal septic arthritis is very high and m a y be related to the d u r a t i o n o f s y m p t o m s before t r e a t m e n t is started. O n l y one o f our six patients survived the acute septicaemic episode, b u t died soon afterwards with severe disability f r o m the sequelae. T h e lack o f joint signs and the p r o m i n e n t systemic features m a y contribute to the delay in diagnosis. A high index of suspicion o f joint sepsis should be m a i n t a i n e d in any acute systemic illness in a patient with pre-existing rheumatic joint disease. References I. Karten I. Septic arthritis complicating rheumatoid arthritis. Ann Int Med 1969; 70(6): II47-II58. 2. Russell AS, Ansell BM. Septic arthritis. Ann Rheum Dis 1972; 3I: 40-44. 3. Gristina AG, Rovere GD, Shoji H. Spontaneous septic arthritis complicating rheumatoid arthritis. J Bone Joint Surg I974; 56A(6): I iSo-i I84. 4. Goldenberg DL. Infectious arthritis complicating rheumatoid arthritis and other chronic rheumatic disorders. Arthritis Rheum 1989; 32(4): 496-5o2. 5- De Andrade JR, Tribe CR. Staphylococcal septicaemia with pyoarthrosis in rheumatoid arthritis. Br M e d J I962 ; i: I516-I518. 6. Mitchell WS, Brooks PM, Stevenson RD, Buchanan WW. Septic arthritis in patients with rheumatoid disease: a still underdiagnosed complication. J Rheum I976; 3(2): 124-I33. 7- Kraft SM, Panush RS, Longley S. Unrecognized staphylococcal pyarthrosis with rheumatoid arthritis. Semin Arth Rheum I985; I4(3): I96-2oi. 8. Quismorio FP, Dubois EL. Septic arthritis in systemic lupus erythematosus. J Rheum I975; 2: 73-82. 9. Epstein JH, Zimmerman B, Ho G. Polyarticular septic arthritis. J Rheum 1986; I3: 1105--1107. I0. HO G, Su GY. Therapy for septic arthritis. J A M A 1982; 247(6): 797-8oo. I I. Myers AR. Pyarthrosis complicating rheumatoid arthritis. Lancet 1969; 2: 714-716.