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Septic erosive mono arthritis and osteomyelitis of the wrist caused by Mycobacterium intracellulare in an immunocompetent patient
G Model
ARTICLE IN PRESS Med Clin (Barc). 2017;xxx(xx):xxx–xxx
www.elsevier.es/medicinaclinica
Letter to the Editor
Septic erosive mono arthritis and osteomyelitis of the wrist caused by Mycobacterium intracellulare in an immunocompetent patient夽 ˜ Monoartritis séptica erosiva y osteomielitis de la muneca por Mycobacterium intracellulare en un paciente inmunocompetente Dear Editor, Non-tuberculous mycobacteria, considered opportunistic pathogens, are an uncommon cause of osteoarticular infection. Mycobacterium avium complex, which includes Mycobacterium intracellulare (M. intracellulare) and M. avium, is made up of the most frequently involved causal species. M. intracellulare is an extremely rare cause of arthritis and osteomyelitis, which in recent years has seen an increase in its incidence as a result of increased iatrogenic immunosuppression or HIV infection. However, isolated cases have been described in immunocompetent patients.1 We report the case of an immunocompetent patient with infectious arthritis and osteomyelitis of the wrist caused by M. intracellulare. 81-Year-old male with a history of chondrocalcinosis at the right radiocarpal joint and carpal tunnel surgery 8 years earlier. For 7 years, he had pain in the right wrist, associated with inflammation in the previous 6 months, reason why he came to the emergency department. An arthrocentesis was performed at the emergency department, obtaining abundant purulent matter that was sent for a microbiology culture. While waiting for the results, the patient was discharged under empirical antibiotic treatment and follow-up by the outpatient’s trauma service. After 2 weeks, the patient returned to the emergency department for persistent pain and purulent drainage through the area where the puncture was performed. Physical examination revealed significant right wrist oedema and inflammation, with drainage fistula in dorsal area. Following a suspected diagnosis of septic arthritis associated with fistulated osteomyelitis, a study was initiated. A Gallium scintigraphy was performed, which reports a right radioulnar carpal pathological radiotracer uptake, with greater activity in the distal ulna, compatible with septic arthritis of the wrist. The X-ray of the right wrist showed destruction of the right distal radioulnar and radiocarpal joint, and the CT scan shows bone destruction and subchondral geodes, affecting the radioulnar carpal, carpal and carpometacarpal joints (Fig. 1).
夽 Please cite this article as: Antón Vázquez V, Coloma Conde A, Corominas ˜ por MycobacH. Monoartritis séptica erosiva y osteomielitis de la muneca terium intracellulare en un paciente inmunocompetente. Med Clin (Barc). 2017. http://dx.doi.org/10.1016/j.medcli.2017.01.010
The synovial fluid bacteriological/microbiological study was negative. The Ziehl–Neelsen method and cultures for mycobacteria and fungi were negative. Laboratory results revealed a white blood cell count of 15 × 109 , ESR 45, polymerase chain reaction 220, ANA, negative RF and anti-CCP, negative HIV serology and positive gamma interferon. Surgical debridement was performed in the operating room, under right axillary block, with sampling from the affected tissue and right wrist fistulectomy. The tissue obtained was analysed by microbiology and anatomical pathology. The Ziehl–Neelsen study, polymerase chain reaction for mycobacteria and fungal cultures were negative. Histology of the lesion reported chronic granulomatous inflammation with necrosis and calcifications. Finally, mycobacterial cultures were positive for M. intracellulare, after 9 weeks. Once the diagnosis was established, the patient received treatment with 3 tuberculostatic drugs: rifampicin (600 mg/day), ethambutol (1200 mg/day) and clarithromycin (1000 mg/day) for a total of 12 months. 2 months after surgery and antibiotic treatment initiation, the patient showed complete resolution of the inflammatory signs and cure of the fistula, without adverse reactions or complications from the treatment. At the 6-month follow-up visit, after treatment completion, there was no recurrence of the inflammatory process. Diagnostic suspicion of septic arthritis should be greater when several risk factors are identified, such as an underlying inflammatory or degenerative arthritis, a joint prosthesis, intraarticular injection of corticosteroids, cutaneous ulcers, injecting drug addicts, diabetics, alcoholism, iatrogenic immunosuppression or HIV infection.2 Patients with rheumatoid arthritis who have a symmetric polyarthritis are more likely to develop septic arthritis due to the underlying process itself and to the immunosuppressive effect of the medication they receive. Likewise, in patients with crystal deposition arthropathy, the frequency of septic arthritis increases, mainly those of pyogenic origin.3 The characteristic symptoms of the underlying inflammatory arthropathy makes the diagnosis of an infectious aetiology more difficult and, therefore, the establishment of a correct therapy is sometimes delayed. The foundation in the diagnosis of septic arthritis consists of establishing clinical suspicion, added to a microscopic analysis and culture of the joint’s synovial fluid or tissue by open surgical biopsy. Since gram-staining and microscopy in synovial fluid only gives a positive result in 50% of septic arthritis, it is vital to perform aerobic and anaerobic cultures for mycobacteria and fungus. The proposed route of spread is haematogenous due to surgery, penetrating wound or joint steroid injection, as is the case of our patient, with carpal tunnel surgery some years earlier. The treatment consists of the combination of wide debridement of the infected tissue and administration of the indicated antibiotic treatment. Sporadic cases of arthritis due to M. intracellulare
˜ S.L.U. All rights reserved. 2387-0206/© 2017 Elsevier Espana,
MEDCLE-3947; No. of Pages 2
G Model 2
ARTICLE IN PRESS Letter to the Editor / Med Clin (Barc). 2017;xxx(xx):xxx–xxx
Fig. 1. X-ray of the wrist in anteroposterior projection and CT scan showing arthrodesis of the radiocarpal and carpometacarpal joints with fusion of the carpal bones. Bone erosion and destruction are observed in distal radius.
have recently been reported in immunocompetent patients without prior manipulation or trauma.4,5 Our case illustrates how non-tuberculous mycobacterial infections, although infrequent, should be included in the differential diagnosis of osteoarticular infections in immunocompetent patients with inflammatory or degenerative arthritis who have a torpid clinical course. References 1. Kozin SH, Bishop AT. Atypical Mycobacterium infections of the upper extremity. J Hand Surg Am. 1994;19:480–7. 2. Murdoch DM, McDonald JR. Mycobacterium avium-intracellulare cellulitis occurring with septic arthritis after joint injection: a case report. BMC Infect Dis. 2007;7:9–10. 3. Atkins BL, Gottlieb T. Skin and soft tissue infections caused by nontuberculous mycobacteria. Curr Opin Infect Dis. 2014;27:137–45.
4. Kanik KS, Greenwald DP. Mycobacterium avium/Mycobacterium intracellulare complex-associated arthritis masquerading as a seronegative rheumatoid arthritis. J Clin Rheumatol. 2000;6:154–7. 5. Yano K, Kazuki K, Ikeda M, Yoneda M. Osteomyelitis and arthritis of the wrist caused by Mycobacterium intracellulare in an immunocompetent patient: a case report and literature review. Remittal Port. 2014;39:176–81.
Vanesa Antón Vázquez a,∗ , Ana Coloma Conde a , Hèctor Corominas b a
Servicio de Medicina Interna, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain b Servicio de Reumatología, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain ∗ Corresponding author. E-mail address: [email protected] (V. Antón Vázquez).
ARTICLE IN PRESS Med Clin (Barc). 2017;xxx(xx):xxx–xxx
www.elsevier.es/medicinaclinica
Letter to the Editor
Septic erosive mono arthritis and osteomyelitis of the wrist caused by Mycobacterium intracellulare in an immunocompetent patient夽 ˜ Monoartritis séptica erosiva y osteomielitis de la muneca por Mycobacterium intracellulare en un paciente inmunocompetente Dear Editor, Non-tuberculous mycobacteria, considered opportunistic pathogens, are an uncommon cause of osteoarticular infection. Mycobacterium avium complex, which includes Mycobacterium intracellulare (M. intracellulare) and M. avium, is made up of the most frequently involved causal species. M. intracellulare is an extremely rare cause of arthritis and osteomyelitis, which in recent years has seen an increase in its incidence as a result of increased iatrogenic immunosuppression or HIV infection. However, isolated cases have been described in immunocompetent patients.1 We report the case of an immunocompetent patient with infectious arthritis and osteomyelitis of the wrist caused by M. intracellulare. 81-Year-old male with a history of chondrocalcinosis at the right radiocarpal joint and carpal tunnel surgery 8 years earlier. For 7 years, he had pain in the right wrist, associated with inflammation in the previous 6 months, reason why he came to the emergency department. An arthrocentesis was performed at the emergency department, obtaining abundant purulent matter that was sent for a microbiology culture. While waiting for the results, the patient was discharged under empirical antibiotic treatment and follow-up by the outpatient’s trauma service. After 2 weeks, the patient returned to the emergency department for persistent pain and purulent drainage through the area where the puncture was performed. Physical examination revealed significant right wrist oedema and inflammation, with drainage fistula in dorsal area. Following a suspected diagnosis of septic arthritis associated with fistulated osteomyelitis, a study was initiated. A Gallium scintigraphy was performed, which reports a right radioulnar carpal pathological radiotracer uptake, with greater activity in the distal ulna, compatible with septic arthritis of the wrist. The X-ray of the right wrist showed destruction of the right distal radioulnar and radiocarpal joint, and the CT scan shows bone destruction and subchondral geodes, affecting the radioulnar carpal, carpal and carpometacarpal joints (Fig. 1).
夽 Please cite this article as: Antón Vázquez V, Coloma Conde A, Corominas ˜ por MycobacH. Monoartritis séptica erosiva y osteomielitis de la muneca terium intracellulare en un paciente inmunocompetente. Med Clin (Barc). 2017. http://dx.doi.org/10.1016/j.medcli.2017.01.010
The synovial fluid bacteriological/microbiological study was negative. The Ziehl–Neelsen method and cultures for mycobacteria and fungi were negative. Laboratory results revealed a white blood cell count of 15 × 109 , ESR 45, polymerase chain reaction 220, ANA, negative RF and anti-CCP, negative HIV serology and positive gamma interferon. Surgical debridement was performed in the operating room, under right axillary block, with sampling from the affected tissue and right wrist fistulectomy. The tissue obtained was analysed by microbiology and anatomical pathology. The Ziehl–Neelsen study, polymerase chain reaction for mycobacteria and fungal cultures were negative. Histology of the lesion reported chronic granulomatous inflammation with necrosis and calcifications. Finally, mycobacterial cultures were positive for M. intracellulare, after 9 weeks. Once the diagnosis was established, the patient received treatment with 3 tuberculostatic drugs: rifampicin (600 mg/day), ethambutol (1200 mg/day) and clarithromycin (1000 mg/day) for a total of 12 months. 2 months after surgery and antibiotic treatment initiation, the patient showed complete resolution of the inflammatory signs and cure of the fistula, without adverse reactions or complications from the treatment. At the 6-month follow-up visit, after treatment completion, there was no recurrence of the inflammatory process. Diagnostic suspicion of septic arthritis should be greater when several risk factors are identified, such as an underlying inflammatory or degenerative arthritis, a joint prosthesis, intraarticular injection of corticosteroids, cutaneous ulcers, injecting drug addicts, diabetics, alcoholism, iatrogenic immunosuppression or HIV infection.2 Patients with rheumatoid arthritis who have a symmetric polyarthritis are more likely to develop septic arthritis due to the underlying process itself and to the immunosuppressive effect of the medication they receive. Likewise, in patients with crystal deposition arthropathy, the frequency of septic arthritis increases, mainly those of pyogenic origin.3 The characteristic symptoms of the underlying inflammatory arthropathy makes the diagnosis of an infectious aetiology more difficult and, therefore, the establishment of a correct therapy is sometimes delayed. The foundation in the diagnosis of septic arthritis consists of establishing clinical suspicion, added to a microscopic analysis and culture of the joint’s synovial fluid or tissue by open surgical biopsy. Since gram-staining and microscopy in synovial fluid only gives a positive result in 50% of septic arthritis, it is vital to perform aerobic and anaerobic cultures for mycobacteria and fungus. The proposed route of spread is haematogenous due to surgery, penetrating wound or joint steroid injection, as is the case of our patient, with carpal tunnel surgery some years earlier. The treatment consists of the combination of wide debridement of the infected tissue and administration of the indicated antibiotic treatment. Sporadic cases of arthritis due to M. intracellulare
˜ S.L.U. All rights reserved. 2387-0206/© 2017 Elsevier Espana,
MEDCLE-3947; No. of Pages 2
G Model 2
ARTICLE IN PRESS Letter to the Editor / Med Clin (Barc). 2017;xxx(xx):xxx–xxx
Fig. 1. X-ray of the wrist in anteroposterior projection and CT scan showing arthrodesis of the radiocarpal and carpometacarpal joints with fusion of the carpal bones. Bone erosion and destruction are observed in distal radius.
have recently been reported in immunocompetent patients without prior manipulation or trauma.4,5 Our case illustrates how non-tuberculous mycobacterial infections, although infrequent, should be included in the differential diagnosis of osteoarticular infections in immunocompetent patients with inflammatory or degenerative arthritis who have a torpid clinical course. References 1. Kozin SH, Bishop AT. Atypical Mycobacterium infections of the upper extremity. J Hand Surg Am. 1994;19:480–7. 2. Murdoch DM, McDonald JR. Mycobacterium avium-intracellulare cellulitis occurring with septic arthritis after joint injection: a case report. BMC Infect Dis. 2007;7:9–10. 3. Atkins BL, Gottlieb T. Skin and soft tissue infections caused by nontuberculous mycobacteria. Curr Opin Infect Dis. 2014;27:137–45.
4. Kanik KS, Greenwald DP. Mycobacterium avium/Mycobacterium intracellulare complex-associated arthritis masquerading as a seronegative rheumatoid arthritis. J Clin Rheumatol. 2000;6:154–7. 5. Yano K, Kazuki K, Ikeda M, Yoneda M. Osteomyelitis and arthritis of the wrist caused by Mycobacterium intracellulare in an immunocompetent patient: a case report and literature review. Remittal Port. 2014;39:176–81.
Vanesa Antón Vázquez a,∗ , Ana Coloma Conde a , Hèctor Corominas b a
Servicio de Medicina Interna, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain b Servicio de Reumatología, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain ∗ Corresponding author. E-mail address: [email protected] (V. Antón Vázquez).