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Pseudomonas arthritis following puncture wounds of the foot
Volume 94 Number 3
Brief clinical and laboratory observations
pneumonia with isolation of parainfluenza type 3 virus from the lesions. Therefore, this virus must be added to the causes of giant cell pneumonia, at least in immunocompromised patients.
6.
REFERENCES I. Enders JF, McCarthy K, Mitus A, and Cheatham WJi Isolation of measles virus at autopsy in cases of giant-cell pneumonia without rash, N Engl J Med 261:875, 1959. 2. Mitus A, Enders JF, Craig JM, and Holloway A: Persistance of measles virus and depression of antibody formation in patients with giant-cell pneumonia after measles, N Engl J Med 261:882, 1959. 3. Lipsey AI, "Kahn MJ, and Bolande RP: Pathologic variants of congenital hypogammaglobuiinemia: an analysis of three patient dying of measles, Pediatrics 39:659, 1967. 4. Spencer H: Pathology of the lung, ed 3, Elmsford, N.Y., 1977, Pergamon Press, Inc. 5. Mufson MA, Krause E, Mocega HE, and Dawson FW:
7.
8.
9.
10.
429
Viruses, Mycoplasma pneumoniae and bacteria associated with lower respiratory tract disease among infants, Am J Epidemiol 91:192, 1970. Gtezen WP, Loda FA, Clyde WA, Jr, Senior RJ, Sheaffer CI, Conley WG, and Denny FW: Epidemiologic patterns Of acute lower respiratory disease of children in a pediatric practice, J PEOIATR78:397, 1971. Arrobio J: Infection with parainfluenza 3 virus: a fatal case with autopsy report, Clin Proc Chi[d Hosp (Wash) 20:298, 1964. Aheme W, Bird T, Court SDM, Gardner PS, and McQuiIlin J: Pathological changes in virus infections of the lower respiratory tract in children, J Clin Pathol 23:7, 1970. Buthala BA, and Soret MG: Parainfluenza type 3 virus infection in hamsters: virologic, serologic and pathologic studies, J Infect Dis 114:226, 1964. Liu C, Sharp E, and Collins J: Studies on the pathogenesis of parainfluenza type 3 virus infection in harosters, Arch Ges Virusforsch 24:203, 1968.
Pseudomonas arthritis following puncture wounds of the
foot Michael J. Chusid, M.D.,* William M. Jacobs, M.D., and John R. Sty, M.D., Milwaukee, Wis.
PSEUDOMONAS AERUGINOSA osteomyelitis is a wellknown complication of deep puncture wounds of the foot, but the occurrence of septic arthritis following plantar puncture wounds has not been emphasized. '-~ During the past three years, we have seen four children who developed Pseudornonas arthritis of metatarsal phalangeal joints after stepping on nails. CLINICAL MATERIAL In each instance an adolescent boy stepped on a nail which punctured his anterior foot. All patients received antibiotics orally (penicillin, ampicillin, or erythromycin) within 72 hours of injury. All were admitted to the hospital one to two weeks later because of increasing pain and swelling of the foot. Positive physical findingsupon admission were limited to the affected extremity. The dorsum of each patient's foot was edematous and minimally erythematous. Active motion of the involved joint was absent and passive From the Departments of Pediatrics and Radiology of The Medical College of Wisconsin and Milwaukee Children's Hospital *Reprint address: Department of Pediatrics, Milwaukee Children's Hospital, 1700 West WisconsinAve., Milwaukee, WI 53233.
0022-3476/79/300429+03500.30/0 9 1979 The C. V. Mosby Co.
motion was painful. Affected joints included the first MTP joint in two patients and the third and fourth MTP joints in the other two. Regional adenopathy was not present. Fever was absent throughout each patient's course. Abbreviations used MTP: metatarsal phalangeal ESR: erythrocyte sedimentation rate Peripheral WBC counts were unremarkable (range, 8,600 to 11,600/mm0 and differential counts were within normal limits. Erythrocyte sedimentation rates were abnormal upon admission (,X = 50 mm/hour, range = 27 to 84 mm/hour) and remained elevated for at least two weeks after the initiation of antimicrobial therapy. In three patients, admission radiographs revealed widening of the affected joint (Figure), and diagnostic joint aspirations were performed. In the other patient, although the joint was not widened, a radionuclide scan was compatible with joint infection. Approximately 1 ml of serosanguinous or cloudy fluid was aspirated from the affected joints. Microorganisms were not seen on Gram stain of the fluid, but cultures yielded P. aeruginosa. Blood cultures were sterile.
430
Brief clinical and laboratory observations
The Journal of Pediatrics March 1979
Figure. Left, Radiograph of affected joint upon admission, showing widening of the fourth MTP joint. Right, Ankylosis of the joint six months later. Joint pain persisted for more than one week after aspiration in all patients and resolved slowly with antimicrobial therapy. All patients were treated with a parenterally administered aminoglycoside (gentamicin or tobramycin) and a semisynthetic penicillin (carbenicillin or ticarcillin). The average length of appropriate antimicrobial therapy was 22.5 days (range 17 to 26 days). Radiographic abnormalities of bones contiguous to affected joints appeared within ten days of admission. In three patients irregularity of articular surfaces was noted; each of these patients subsequently developed radiographic evidence of permanent joint damage. In two patients, ankylosis of joints resulted in a total loss of joint mobility (Figure), In the third patient, joint deformity produced partial loss of mobility. DISCUSSION Deep infection, primarily osteomyelitis, complicates 0.06 to 0.6% of plantar puncture wounds? P. aeruginosa is the most common pathogen in such infections, accounting for 93% of the cases of osteomyelitis in the largest single series of puncture wound infections? Pseudomonas arthritis following plantar puncture wounds has not been distinguished previously from osteomyelitis. Cases of Pseudomonas osteomyelitis have been reported in which destructive changes were noted in bones contiguous with an MTP joint, and purulent material was drained from the joint area; these may represent other examples of traumatically induced Pseudomonas arthritis?, ~ The clinical presentation of Pseudomonas arthritis in our four patients was similar to that previously described
in Pseudomonas puncture wound osteomyelitis. In both
infections, there is a period of one to two weeks after injury before the infection becomes evident. Presenting symptoms are pain and swelling of the foot. The patient is usually afebrile. Laboratory data in both infections may be misleading since the WBC and differential are generally normal, although the ESR is usually elevated. Radiographs may be of use in locating the site of infection. Septic arthritis is suggested by a distended joint capsule and symmetrical destruction of all articular surfaces within the joint. Osteomyelitis is suggested by a destructive process involving the epipbysis or metaphysis. Radionuclide bone and joint scans may be of value in localizing the infection prior to the development of radiographic abnormalities. Pseudomonas aeruginosa appears to have a propensity for infecting cartilage. Each of the 11 patients described by Johanson ~ with Pseudomonas osteomyelitis h a d involvement of either an epiphyseal growth plate or an articular cartilage. Many other patients with Pseudomonas osteomyelitis have developed chondritis. ~-~ Pseudomonas is also frequently responsible for invasive bacterial infection of the external ear (perichondritis) and for infections of other cartilagenous structures including sternochondral joints and intervertebral discs. Hematogenous Pseudomonas arthritis, although rare, has been described. ~ Diagnostic aspiration of a suspected septic joint should be performed immediately. Delay in removal of purulent material from the joint increases morbidity. 7 Repeated aspirations or open surgical drainage may be necessary if there is rapid reaccumulation of fluid within the joint. Diagnostic and therapeutic aspiration was performed
Volume 94 Number 3
Brief clinical and laboratory observations
under fluoroscopic control in our patients, with the removal of all joint fluid and lavage of the joint with isotonic saline. The procedure was not repeated because of slow but progressive decrease of symptoms in all patients after the initial procedure. Open surgical drainage was avoided because of reports that this may increase long-term complications. 7,8 Each of our patients was treated with an aminoglycoside and a semisynthetic penicillin. Synergy between these two classes of drugs against E. aeruginosa has been demonstrated. Both gentamicin and carbenicillin penetrate joint fluid in bactericidal concentrations. This combination has been used successfully in the therapy of hematogenous Pseudomonas arthritis. 6 Gram-negative arthritis (nongonococcal) has been reported to produce permanent joint damage in as many as 79% of affected patients7 Prominent morbidity also appears to be associated with Pseudomonas arthritis secondary to puncture wounds. Two of our four patients developed ankylosis of their infected joints and a third had permanent epiphyseal damage and joint deformity. The use of antibiotics administered orally after puncture wounds may contribute to the development of subsequent Pseudomonas infection. Forty-six of 49 previously reported patients who developed Pseudomonas puncture wound osteomyelitis, and each of our own four patients with Pseudomonas arthritis, had received antibiotics orally following injury. In one retrospective study, Pseudomonas osteomyelitis developed in 16 of 303 (5%) patients who received oral antibiotics after puncture wound injury, compared with 0 of 584 of those who had not. The source of the microorganism remains unknown.
Penicillinase-producing
43 1
Studies of foot flora have failed to reveal the presence of P. aeruginosa on the feet of normal individuals? Pseudomonas aeruginosa arthritis, like P. aeruginosa
osteomyelitis, is a serious infection which may occur following puncture wounds of the foot. Because of its indolence, the serious nature of this infection may not be appreciated, but its morbidity makes early recognition important. REFERENCES
1. Johanson PH: Pseudomonas infections of the foot following puncture wounds, JAMA 204:170, 1968. 2. Minnefor AB, Olson MI, and Carver DH: Pseudomonas osteomyelitis following puncture wounds of the foot, Pediatrics 47:598, 1971. 3. Brand RA, and Black H: Pseudomonas osteomyelitis following puncture wounds in children, J Bone Joint Surg 56A:1637, 1974. 4. MacKinnon AE: Pseudomonas osteomyelitis following puncture wounds, Postgrad Med J 51:33, 1975. 5. Fitzgerald RH, and Cowan JDE: Puncture wounds of the foot, Orthop Clin North Am 6:965, 1975. 6. Kerstein MD, and Lee YH: Combined carbenicillin and gentamicin therapy of Pseudomonas septic arthritis, J Trauma 13:473, 1973. 7. Goldenberg DL, and Cohen AS: Acute infectious arthritis: a review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis), Am J Mud 60:369, 1976. 8. Goldenberg DL, Brandt AS, Cohen AS, et al: Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage, Arthritis Rheum 18:83, 1975. 9. Fritz RH, and Crosson FJ: Concerning the source of Pseudomonas osteomyelitis of the foot, J PEDIATR91:161, 1977.
Neisseria gonorrhoeae in a
prepubertalfemale Robert W. Rendin, Lieutenant (MSC) USN,* A. Louis Bourgeois, Lieutenant (MSC) USN, and Fang L. Lin, Lieutenant Commander (MC) USNR, Taipei, Taiwan
From the United States Naval Hospital and the Naval Medical Research Unit No. 2. Supported by the Naval Medical Research and Development Command, Navy Department for Work Unit No. MRO0. 001.01-2073. Opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy Department. *Reprint address: Publications O~ce, NAMRU-2, Box 14, APO San Francisco, CA 96263 or 7-1 Kung Yuan Rd., Taipei, Taiwan, R.O.C.
THIS REPORT describes a case of vulvovaginitis in a prepubertal female, caused by penicillinase-producing Neisseria gonorrhoeae. CASE R E P O R T
The 7-year-old daughter of a United States serviceman was brought to a United States military hospital in Taipei, Taiwan, complaining of a vaginal discharge of three days' duration. A Gram stain revealed intra- and extracellular gram-negative diplococci resembling Neisseria gonorrhoeae," a vaginal culture
Brief clinical and laboratory observations
pneumonia with isolation of parainfluenza type 3 virus from the lesions. Therefore, this virus must be added to the causes of giant cell pneumonia, at least in immunocompromised patients.
6.
REFERENCES I. Enders JF, McCarthy K, Mitus A, and Cheatham WJi Isolation of measles virus at autopsy in cases of giant-cell pneumonia without rash, N Engl J Med 261:875, 1959. 2. Mitus A, Enders JF, Craig JM, and Holloway A: Persistance of measles virus and depression of antibody formation in patients with giant-cell pneumonia after measles, N Engl J Med 261:882, 1959. 3. Lipsey AI, "Kahn MJ, and Bolande RP: Pathologic variants of congenital hypogammaglobuiinemia: an analysis of three patient dying of measles, Pediatrics 39:659, 1967. 4. Spencer H: Pathology of the lung, ed 3, Elmsford, N.Y., 1977, Pergamon Press, Inc. 5. Mufson MA, Krause E, Mocega HE, and Dawson FW:
7.
8.
9.
10.
429
Viruses, Mycoplasma pneumoniae and bacteria associated with lower respiratory tract disease among infants, Am J Epidemiol 91:192, 1970. Gtezen WP, Loda FA, Clyde WA, Jr, Senior RJ, Sheaffer CI, Conley WG, and Denny FW: Epidemiologic patterns Of acute lower respiratory disease of children in a pediatric practice, J PEOIATR78:397, 1971. Arrobio J: Infection with parainfluenza 3 virus: a fatal case with autopsy report, Clin Proc Chi[d Hosp (Wash) 20:298, 1964. Aheme W, Bird T, Court SDM, Gardner PS, and McQuiIlin J: Pathological changes in virus infections of the lower respiratory tract in children, J Clin Pathol 23:7, 1970. Buthala BA, and Soret MG: Parainfluenza type 3 virus infection in hamsters: virologic, serologic and pathologic studies, J Infect Dis 114:226, 1964. Liu C, Sharp E, and Collins J: Studies on the pathogenesis of parainfluenza type 3 virus infection in harosters, Arch Ges Virusforsch 24:203, 1968.
Pseudomonas arthritis following puncture wounds of the
foot Michael J. Chusid, M.D.,* William M. Jacobs, M.D., and John R. Sty, M.D., Milwaukee, Wis.
PSEUDOMONAS AERUGINOSA osteomyelitis is a wellknown complication of deep puncture wounds of the foot, but the occurrence of septic arthritis following plantar puncture wounds has not been emphasized. '-~ During the past three years, we have seen four children who developed Pseudornonas arthritis of metatarsal phalangeal joints after stepping on nails. CLINICAL MATERIAL In each instance an adolescent boy stepped on a nail which punctured his anterior foot. All patients received antibiotics orally (penicillin, ampicillin, or erythromycin) within 72 hours of injury. All were admitted to the hospital one to two weeks later because of increasing pain and swelling of the foot. Positive physical findingsupon admission were limited to the affected extremity. The dorsum of each patient's foot was edematous and minimally erythematous. Active motion of the involved joint was absent and passive From the Departments of Pediatrics and Radiology of The Medical College of Wisconsin and Milwaukee Children's Hospital *Reprint address: Department of Pediatrics, Milwaukee Children's Hospital, 1700 West WisconsinAve., Milwaukee, WI 53233.
0022-3476/79/300429+03500.30/0 9 1979 The C. V. Mosby Co.
motion was painful. Affected joints included the first MTP joint in two patients and the third and fourth MTP joints in the other two. Regional adenopathy was not present. Fever was absent throughout each patient's course. Abbreviations used MTP: metatarsal phalangeal ESR: erythrocyte sedimentation rate Peripheral WBC counts were unremarkable (range, 8,600 to 11,600/mm0 and differential counts were within normal limits. Erythrocyte sedimentation rates were abnormal upon admission (,X = 50 mm/hour, range = 27 to 84 mm/hour) and remained elevated for at least two weeks after the initiation of antimicrobial therapy. In three patients, admission radiographs revealed widening of the affected joint (Figure), and diagnostic joint aspirations were performed. In the other patient, although the joint was not widened, a radionuclide scan was compatible with joint infection. Approximately 1 ml of serosanguinous or cloudy fluid was aspirated from the affected joints. Microorganisms were not seen on Gram stain of the fluid, but cultures yielded P. aeruginosa. Blood cultures were sterile.
430
Brief clinical and laboratory observations
The Journal of Pediatrics March 1979
Figure. Left, Radiograph of affected joint upon admission, showing widening of the fourth MTP joint. Right, Ankylosis of the joint six months later. Joint pain persisted for more than one week after aspiration in all patients and resolved slowly with antimicrobial therapy. All patients were treated with a parenterally administered aminoglycoside (gentamicin or tobramycin) and a semisynthetic penicillin (carbenicillin or ticarcillin). The average length of appropriate antimicrobial therapy was 22.5 days (range 17 to 26 days). Radiographic abnormalities of bones contiguous to affected joints appeared within ten days of admission. In three patients irregularity of articular surfaces was noted; each of these patients subsequently developed radiographic evidence of permanent joint damage. In two patients, ankylosis of joints resulted in a total loss of joint mobility (Figure), In the third patient, joint deformity produced partial loss of mobility. DISCUSSION Deep infection, primarily osteomyelitis, complicates 0.06 to 0.6% of plantar puncture wounds? P. aeruginosa is the most common pathogen in such infections, accounting for 93% of the cases of osteomyelitis in the largest single series of puncture wound infections? Pseudomonas arthritis following plantar puncture wounds has not been distinguished previously from osteomyelitis. Cases of Pseudomonas osteomyelitis have been reported in which destructive changes were noted in bones contiguous with an MTP joint, and purulent material was drained from the joint area; these may represent other examples of traumatically induced Pseudomonas arthritis?, ~ The clinical presentation of Pseudomonas arthritis in our four patients was similar to that previously described
in Pseudomonas puncture wound osteomyelitis. In both
infections, there is a period of one to two weeks after injury before the infection becomes evident. Presenting symptoms are pain and swelling of the foot. The patient is usually afebrile. Laboratory data in both infections may be misleading since the WBC and differential are generally normal, although the ESR is usually elevated. Radiographs may be of use in locating the site of infection. Septic arthritis is suggested by a distended joint capsule and symmetrical destruction of all articular surfaces within the joint. Osteomyelitis is suggested by a destructive process involving the epipbysis or metaphysis. Radionuclide bone and joint scans may be of value in localizing the infection prior to the development of radiographic abnormalities. Pseudomonas aeruginosa appears to have a propensity for infecting cartilage. Each of the 11 patients described by Johanson ~ with Pseudomonas osteomyelitis h a d involvement of either an epiphyseal growth plate or an articular cartilage. Many other patients with Pseudomonas osteomyelitis have developed chondritis. ~-~ Pseudomonas is also frequently responsible for invasive bacterial infection of the external ear (perichondritis) and for infections of other cartilagenous structures including sternochondral joints and intervertebral discs. Hematogenous Pseudomonas arthritis, although rare, has been described. ~ Diagnostic aspiration of a suspected septic joint should be performed immediately. Delay in removal of purulent material from the joint increases morbidity. 7 Repeated aspirations or open surgical drainage may be necessary if there is rapid reaccumulation of fluid within the joint. Diagnostic and therapeutic aspiration was performed
Volume 94 Number 3
Brief clinical and laboratory observations
under fluoroscopic control in our patients, with the removal of all joint fluid and lavage of the joint with isotonic saline. The procedure was not repeated because of slow but progressive decrease of symptoms in all patients after the initial procedure. Open surgical drainage was avoided because of reports that this may increase long-term complications. 7,8 Each of our patients was treated with an aminoglycoside and a semisynthetic penicillin. Synergy between these two classes of drugs against E. aeruginosa has been demonstrated. Both gentamicin and carbenicillin penetrate joint fluid in bactericidal concentrations. This combination has been used successfully in the therapy of hematogenous Pseudomonas arthritis. 6 Gram-negative arthritis (nongonococcal) has been reported to produce permanent joint damage in as many as 79% of affected patients7 Prominent morbidity also appears to be associated with Pseudomonas arthritis secondary to puncture wounds. Two of our four patients developed ankylosis of their infected joints and a third had permanent epiphyseal damage and joint deformity. The use of antibiotics administered orally after puncture wounds may contribute to the development of subsequent Pseudomonas infection. Forty-six of 49 previously reported patients who developed Pseudomonas puncture wound osteomyelitis, and each of our own four patients with Pseudomonas arthritis, had received antibiotics orally following injury. In one retrospective study, Pseudomonas osteomyelitis developed in 16 of 303 (5%) patients who received oral antibiotics after puncture wound injury, compared with 0 of 584 of those who had not. The source of the microorganism remains unknown.
Penicillinase-producing
43 1
Studies of foot flora have failed to reveal the presence of P. aeruginosa on the feet of normal individuals? Pseudomonas aeruginosa arthritis, like P. aeruginosa
osteomyelitis, is a serious infection which may occur following puncture wounds of the foot. Because of its indolence, the serious nature of this infection may not be appreciated, but its morbidity makes early recognition important. REFERENCES
1. Johanson PH: Pseudomonas infections of the foot following puncture wounds, JAMA 204:170, 1968. 2. Minnefor AB, Olson MI, and Carver DH: Pseudomonas osteomyelitis following puncture wounds of the foot, Pediatrics 47:598, 1971. 3. Brand RA, and Black H: Pseudomonas osteomyelitis following puncture wounds in children, J Bone Joint Surg 56A:1637, 1974. 4. MacKinnon AE: Pseudomonas osteomyelitis following puncture wounds, Postgrad Med J 51:33, 1975. 5. Fitzgerald RH, and Cowan JDE: Puncture wounds of the foot, Orthop Clin North Am 6:965, 1975. 6. Kerstein MD, and Lee YH: Combined carbenicillin and gentamicin therapy of Pseudomonas septic arthritis, J Trauma 13:473, 1973. 7. Goldenberg DL, and Cohen AS: Acute infectious arthritis: a review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis), Am J Mud 60:369, 1976. 8. Goldenberg DL, Brandt AS, Cohen AS, et al: Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage, Arthritis Rheum 18:83, 1975. 9. Fritz RH, and Crosson FJ: Concerning the source of Pseudomonas osteomyelitis of the foot, J PEDIATR91:161, 1977.
Neisseria gonorrhoeae in a
prepubertalfemale Robert W. Rendin, Lieutenant (MSC) USN,* A. Louis Bourgeois, Lieutenant (MSC) USN, and Fang L. Lin, Lieutenant Commander (MC) USNR, Taipei, Taiwan
From the United States Naval Hospital and the Naval Medical Research Unit No. 2. Supported by the Naval Medical Research and Development Command, Navy Department for Work Unit No. MRO0. 001.01-2073. Opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy Department. *Reprint address: Publications O~ce, NAMRU-2, Box 14, APO San Francisco, CA 96263 or 7-1 Kung Yuan Rd., Taipei, Taiwan, R.O.C.
THIS REPORT describes a case of vulvovaginitis in a prepubertal female, caused by penicillinase-producing Neisseria gonorrhoeae. CASE R E P O R T
The 7-year-old daughter of a United States serviceman was brought to a United States military hospital in Taipei, Taiwan, complaining of a vaginal discharge of three days' duration. A Gram stain revealed intra- and extracellular gram-negative diplococci resembling Neisseria gonorrhoeae," a vaginal culture