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Septic polyarthritis and its relation to systemic disease processes
Septic Polyarthritis and Its Relation to Systemic Disease Processes A Report of Three Cases
R o b e r t E. Lins, M D , F r e d M . H a n k i n , M D , H e r b e r t K a u f e r , M D , a n d J e f f r e y F. G r a n g e r , M D
Abstract: In the case of a postoperative joint infection, the orthopaedic surgeon is frequently blamed. Certain intrinsic disease processes, however, make a joint more susceptible to infection. In these three reports of septic polyarthritis, all patients had underlying systemic disorders, including rheumatoid arthritis, diabetes mellitus, and hemophilia A. Two of the three patients had had no recent surgical procedures. This suggests that the development of a pyarthrosis may depend at least as much on the patient's underlying systemic condition as on the surgeon and his or her technique. Key words: pyarthrosis, systemic disease, arthroplasty, complication.
Case Reports
In the practice of most orthopaedic surgeons pyarthrosis is uncommon. W h e n it does occur, it frequently follows penetrating trauma or a joint operation, such as implant arthroplasty (1, 4, 5, 7). Certain populations are at an increased risk for septic arthritis. Rheumatoid arthritis patients, intravenous substance abusers, and patients with impaired imm u n e responses are representative of this subgroup (1, 3 - 5 , 7). Pyarthrosis involving multiple joints is a very infrequent event. We discuss three patients with this clinical presentation (Table 1).
Case 1 A 63-year-old w o m a n with a 20-year history of seropositive and nodular deforming rheumatoid arthrifts was admitted in November 1985 for evaluation of fever to 103°1:, diffuse arthralgias, nausea, and malaise of 2 days' duration. Current medications included prednisone (9 mg/day) and a topical steroid preparation for psoriasis. Her past medical history was remarkable for an incidental splenectomy in February 1984 during peptic ulcer surgery. A left total knee arthroplasty performed in April 1985 had benign clinical and radiographic postoperative courses. In August 1985, she had a perforated diverticulum and required a partial small bowel resection. On admission to our hospital, 3 months after her last surgical intervention, her temperature was 98°F,
From the Section of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.
Reprint requests: Herbert Kaufer, MD, Section of Orthopaedic Surgery,UniversityHospitals(TC2912), 1500EastMedicalCenter Drive, Ann Arbor, MI 48109-0328.
359
360
The Journal of Arthroplasty Vol. 3 No. 4 December 1988 Table l. Patient Data
Age (years) Weight (kg) Postsurgical history Past medical history
Immunosuppressive medications Admission laboratory studies WBC and differential
Case 1
Case 2
Case 3
63 52.7 Left TKA 4/85 Splenectomy 2/84 Perforated diverticulum 8/85 Rheumatoid arthritis Psoriasis treated with topical steroids
52 64.0
36 43.8
Prednisone 9 mg/day 30,300 63 segs 34 bands 113
Sedimentation rate (mm/hr) Albumin (serum (g/dl) Blood culture Joints involved
1.8 S. pneumoniae
Joint cultures
Alpha hemolytic Streptococcus
Both knees, both ankles, both elbows
her blood pressure 104170 mm Hg, and her pulse 88 beats/minute. Physical examination revealed an alert, elderly woman with multiple musculoskeletal deformities consistent with rheumatoid arthritis. Numerous joints were tender and swollen. Joint fluid cultures from both knees, both ankles, and her left elbow grew alpha hemolytic Streptococcus. Two blood cultures were positive for Streptococcus pneumoniae. Aspiration of both hips was negative. Surgical incision and drainage of both ankles, knees, and elbows was performed the following day, as was aspiration of both shoulders (cultures demonstrated no growth) and arthrocentesis of both hips (no purulent material recovered and sterile on culture). A gallium-67 scan revealed no extraarticular source of infection. Intravenous antibiotic treatment consisted of penicillin-G, 3 million units every 4 hours, for 42 days. The patient also received physical therapy during her 10-week hospital stay, and by discharge (January 1986) was able to stand and transfer to a chair with assistance. Due to her multiple rheumatoid joint involvement, she used a wheelchair for ambulation. At discharge, she was placed on penicillin V potassium, 250 mg p.o.q.i.d., until June 1986. The infected left total knee returned to its preinfection symptomatic and functional state. At follow-up evaluation, by phone call, In June 1988, the patient reported no recurrence of her infections.
None
None
Insulin dependent DM Hemophilia A Peripheral vascular occlusive disease None
Rheumatoid arthritis
20,000 60 segs 12 bands 138 2.4 Negative Both ankles, R knee, R wrist, L elbow
S. aureus S. epidennidis
None 9,200 62 segs 22 bands 114 1.6 S, aur¢ld$
Both hips, both knees, both ankles, both SC joints, both elbows, R shoulder, PiP joints, R index and small fingers, IP joinL L thumb S. aureus
Case 2
A 52-year-old man with hemophilia A and type II insulin-dependent diabetes mellitus was admitted to an outside hospital with nausea, vomiting, fever, multiple painful joints, and cellulitis over the lateral aspect of the left ankle. The patient's temperature rose to 105°F despite administration of an intravenous cephalosporin antibiotic, and he was transferred to another institution. Right wrist aspiration and left ankle aspiration grew both Staphylococcus aureus and Staphylococcus epidennidis. Right knee aspirate and blood cultures were negative. The patient was started on intravenous trimethoprim-sulfamethoxazole and vancomycin hydrochloride and subsequently transferred to our institution 2 weeks after the onset of symptoms. His vital signs upon admission (May 1986) were: temperature, 99.4°F; blood pressure, 130/70 mm Hg; and pulse, 88 beats/minute. The right wrist and knee were swollen and warm. Both elbows were mildly swollen and erythematous, with l-cm diameter fullthickness ulcerations present over both olecranon processes. Both ankles were swollen and erythematous, with purulent drainage present over the lateral malleolus of the left ankle. Incision and drainage of both ankles, right knee, right wrist, and left elbow were performed, and frank
Septic Polyarthritis
•
Lins et al.
361
Case 3
Fig. l. Pyarthrosis of the wrist was treated with an open drainage procedure.
pus was obtained from all joints (Figs. 1, 2). All gram stains and cultures were negative, except for a Proprionibacterium species from the left ankle. The patient was begun on tobramycin sulfate, imipenemcilastatin sodium, and vancomycin hydrochloride. The skin over the left ankle became necrotic with progressive cellulitis and required a left below-knee amputation 17 days following admission. The patient was treated with physical therapy, whirlpool, and multiple dressing changes. He was discharged after 6 weeks of hospitalization with all arthrotomy sites granulating well and with a healed left leg stump. Follow-up evaluation, by phone call, 1 year later revealed complaints of pain in the right knee and right ankle. The patient remains confined to a wheelchair due to his multiple joint arthropathy.
Fig. 2. Arthrotomy was performed for this knee pyarthrosis.
A 36-year-old woman had a 16-year history of rheumatoid arthritis previously treated with gold. She had contractures involving all four extremities and progressive malnutrition. In May 1986, the patient declined admission to our hospital for further evaluation and treatment. In June 1986, she developed increased joint pain, fever, diaphoresis, and inability to get out of bed. Three days later, on admission to our hospital, she was obtunded but responsive to deep pain with a temperature of 104°F, blood pressure of 112/Doppler mm Hg, respiratory rate of 24 breaths/minute, and pulse of 116 beats/minute. Physical examination revealed extremely poor oral hygiene, two trochanteric decubitus ulcers, and multiple chronic musculoskeletal changes consistent with rheumatoid arthritis. Multiple joints were noted to be tender, warm, erythematous, and with effusions. Aspiration of both shoulders, sternoclavicularjoints, hips, and knees revealed frank pus. The patient had incision and drainage of both hips, knees, ankles, sternoclavicular joints, elbows, her right shoulder, the proximal interphatangeal joints of the index and small finger of the right hand, and the interphalangeal joint of the left thumb. The wounds were left open, treated with multiple dressing changes, and healed by secondary intention after several months. Joint cultures revealed methicillin-resistant S. aureus, which was treated with vancomycin hydrochloride. Ventilatory support for 2 weeks and hyperalimentation were also required. A technetium-99m bone scan revealed increased uptake in the left sacroiliac joint and both hips consistent with osteomyelitis. Subsequently, both hipswere again aspirated; no pus was obtained, but cultures of the material recovered from the right hip revealed S. epidermidis. Six weeks of additional antibiotics were then initiated with vancomycin hydrochloride and later changed to trimethoprim-sulfamethoxazide. Bedside physical therapy was used to help maintain joint posture. Discharge physical examination after 6 months of hospitalization revealed severe rigidity and contractures of the patient's shoulders, hips, and knees bilaterally, consistent with her severe rheumatoid arthritis. Follow-up evaluation, by phone call, 18 months after discharge revealed no recurrence of the infections. A feeding tube had been used to facilitate nutritional support. The patient was restricted to a wheelchair for ambulation and was totally dependent on others for her daily personal care. She sub-
362
The Journal of Arthroplasty Vol. 3 No. 4 December 1988
sequently died, following an upper gastrointestinal bleed.
Discussion While the management of pyarthroses remains controversial, all authors would agree that rapid therapeutic intervention is desirable (1-3). Regimens including repeated aspirations and intravenous antibiotics, arthroscopic lavage, and open drainage each has its advocates. The etiology of the septic process can include surgical manipulation, a remote infected site with subsequent bacteremia, and underly.ing immune deficiency syndromes (1, 3, 4, 6). Often the underlying systemic problem must be treated to control the local pyarthrosis problem. The orthopaedic surgeon becomes involved with pyarthroses most frequently following surgical intervention, and frequently the responsibility for the septic process is attributed to the operating physician. In these three case reports, individuals with underlying systemic disorders, including rheumatoid atthrifts, hemophilia, and diabetes mellitus, had multiple septic joints. Two of the three patients had not had recent surgery. The remaining patient had had a total knee arthroplasty 7 months prior to her presentation with sepsis. This patient's benign postoperative course would speak against a late wound infection; perhaps her previous splenectomy and underlying rheumatoid arthritis predisposed her to developing the multiple pyarthroses. The underlying systemic diseases of our patients increased their susceptibility to potential bacteremic insults from remote sources, including poor dentition, skin ulceration, and abdominal surgery, capable of seeding multiple joints. The poor nutrition of this patient group undoubtably also contributed to their impaired immune responses and the development of septic episodes.
Meticulous care and sterile technique are required when performing an arthroplasty on any individual. Postoperative complications such as infection will occur, and may be attributable in part to the patient's underlying disease process, rather than to the surgeon or the surgeon's technique. The spontaneous occurrence of multiple septic joints in our three patients serves to support the contention that pyarthrosis is not solely an iatrogenic problem.
Acknowledgments The authors acknowledge the excellent technical assistance provided by Ms. Caroline Waterbury.
References 1. Goldenberg DL, Reed JI: Bacterial arthritis. N Engl J ivied 312:764, 1985 2. Kelly PJ, Martin WJ, Coventry MB: Bacterial (suppurative) arthritis in the adult. J Bone Joint Surg 52A:1595, 1970 3. Myers AR: Septic arthritis caused by.bacteria, p. 1507. In Kelly WN, Harris ED, Ruddy S, Sledge CB (eds): Textbook of Rheumatology. WB Saunders, Philadelphia, 1985 4. Rosenthal J, Bole GG, Robinson WD: Acute nongonococcat infectious arthritis. Arthritis Rheum 23:889, 1980 5. Slama TG: Treatment of septic arthritis: diagnostic approach and rational use of antibiotics. Orthop Rev 16:67, 1987 6. Watkins MB, Samilson RL, Winters DM: Acute suppurative arthritis. J Bone Joint Surg 38A:1313, 1956 7. Wigren A, Kaflstrom G, Kaufer H: Hematogenous infection of total joint implants: a report of multiple joint infections in three patients. Clin Orthop 152:288, 1980
R o b e r t E. Lins, M D , F r e d M . H a n k i n , M D , H e r b e r t K a u f e r , M D , a n d J e f f r e y F. G r a n g e r , M D
Abstract: In the case of a postoperative joint infection, the orthopaedic surgeon is frequently blamed. Certain intrinsic disease processes, however, make a joint more susceptible to infection. In these three reports of septic polyarthritis, all patients had underlying systemic disorders, including rheumatoid arthritis, diabetes mellitus, and hemophilia A. Two of the three patients had had no recent surgical procedures. This suggests that the development of a pyarthrosis may depend at least as much on the patient's underlying systemic condition as on the surgeon and his or her technique. Key words: pyarthrosis, systemic disease, arthroplasty, complication.
Case Reports
In the practice of most orthopaedic surgeons pyarthrosis is uncommon. W h e n it does occur, it frequently follows penetrating trauma or a joint operation, such as implant arthroplasty (1, 4, 5, 7). Certain populations are at an increased risk for septic arthritis. Rheumatoid arthritis patients, intravenous substance abusers, and patients with impaired imm u n e responses are representative of this subgroup (1, 3 - 5 , 7). Pyarthrosis involving multiple joints is a very infrequent event. We discuss three patients with this clinical presentation (Table 1).
Case 1 A 63-year-old w o m a n with a 20-year history of seropositive and nodular deforming rheumatoid arthrifts was admitted in November 1985 for evaluation of fever to 103°1:, diffuse arthralgias, nausea, and malaise of 2 days' duration. Current medications included prednisone (9 mg/day) and a topical steroid preparation for psoriasis. Her past medical history was remarkable for an incidental splenectomy in February 1984 during peptic ulcer surgery. A left total knee arthroplasty performed in April 1985 had benign clinical and radiographic postoperative courses. In August 1985, she had a perforated diverticulum and required a partial small bowel resection. On admission to our hospital, 3 months after her last surgical intervention, her temperature was 98°F,
From the Section of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.
Reprint requests: Herbert Kaufer, MD, Section of Orthopaedic Surgery,UniversityHospitals(TC2912), 1500EastMedicalCenter Drive, Ann Arbor, MI 48109-0328.
359
360
The Journal of Arthroplasty Vol. 3 No. 4 December 1988 Table l. Patient Data
Age (years) Weight (kg) Postsurgical history Past medical history
Immunosuppressive medications Admission laboratory studies WBC and differential
Case 1
Case 2
Case 3
63 52.7 Left TKA 4/85 Splenectomy 2/84 Perforated diverticulum 8/85 Rheumatoid arthritis Psoriasis treated with topical steroids
52 64.0
36 43.8
Prednisone 9 mg/day 30,300 63 segs 34 bands 113
Sedimentation rate (mm/hr) Albumin (serum (g/dl) Blood culture Joints involved
1.8 S. pneumoniae
Joint cultures
Alpha hemolytic Streptococcus
Both knees, both ankles, both elbows
her blood pressure 104170 mm Hg, and her pulse 88 beats/minute. Physical examination revealed an alert, elderly woman with multiple musculoskeletal deformities consistent with rheumatoid arthritis. Numerous joints were tender and swollen. Joint fluid cultures from both knees, both ankles, and her left elbow grew alpha hemolytic Streptococcus. Two blood cultures were positive for Streptococcus pneumoniae. Aspiration of both hips was negative. Surgical incision and drainage of both ankles, knees, and elbows was performed the following day, as was aspiration of both shoulders (cultures demonstrated no growth) and arthrocentesis of both hips (no purulent material recovered and sterile on culture). A gallium-67 scan revealed no extraarticular source of infection. Intravenous antibiotic treatment consisted of penicillin-G, 3 million units every 4 hours, for 42 days. The patient also received physical therapy during her 10-week hospital stay, and by discharge (January 1986) was able to stand and transfer to a chair with assistance. Due to her multiple rheumatoid joint involvement, she used a wheelchair for ambulation. At discharge, she was placed on penicillin V potassium, 250 mg p.o.q.i.d., until June 1986. The infected left total knee returned to its preinfection symptomatic and functional state. At follow-up evaluation, by phone call, In June 1988, the patient reported no recurrence of her infections.
None
None
Insulin dependent DM Hemophilia A Peripheral vascular occlusive disease None
Rheumatoid arthritis
20,000 60 segs 12 bands 138 2.4 Negative Both ankles, R knee, R wrist, L elbow
S. aureus S. epidennidis
None 9,200 62 segs 22 bands 114 1.6 S, aur¢ld$
Both hips, both knees, both ankles, both SC joints, both elbows, R shoulder, PiP joints, R index and small fingers, IP joinL L thumb S. aureus
Case 2
A 52-year-old man with hemophilia A and type II insulin-dependent diabetes mellitus was admitted to an outside hospital with nausea, vomiting, fever, multiple painful joints, and cellulitis over the lateral aspect of the left ankle. The patient's temperature rose to 105°F despite administration of an intravenous cephalosporin antibiotic, and he was transferred to another institution. Right wrist aspiration and left ankle aspiration grew both Staphylococcus aureus and Staphylococcus epidennidis. Right knee aspirate and blood cultures were negative. The patient was started on intravenous trimethoprim-sulfamethoxazole and vancomycin hydrochloride and subsequently transferred to our institution 2 weeks after the onset of symptoms. His vital signs upon admission (May 1986) were: temperature, 99.4°F; blood pressure, 130/70 mm Hg; and pulse, 88 beats/minute. The right wrist and knee were swollen and warm. Both elbows were mildly swollen and erythematous, with l-cm diameter fullthickness ulcerations present over both olecranon processes. Both ankles were swollen and erythematous, with purulent drainage present over the lateral malleolus of the left ankle. Incision and drainage of both ankles, right knee, right wrist, and left elbow were performed, and frank
Septic Polyarthritis
•
Lins et al.
361
Case 3
Fig. l. Pyarthrosis of the wrist was treated with an open drainage procedure.
pus was obtained from all joints (Figs. 1, 2). All gram stains and cultures were negative, except for a Proprionibacterium species from the left ankle. The patient was begun on tobramycin sulfate, imipenemcilastatin sodium, and vancomycin hydrochloride. The skin over the left ankle became necrotic with progressive cellulitis and required a left below-knee amputation 17 days following admission. The patient was treated with physical therapy, whirlpool, and multiple dressing changes. He was discharged after 6 weeks of hospitalization with all arthrotomy sites granulating well and with a healed left leg stump. Follow-up evaluation, by phone call, 1 year later revealed complaints of pain in the right knee and right ankle. The patient remains confined to a wheelchair due to his multiple joint arthropathy.
Fig. 2. Arthrotomy was performed for this knee pyarthrosis.
A 36-year-old woman had a 16-year history of rheumatoid arthritis previously treated with gold. She had contractures involving all four extremities and progressive malnutrition. In May 1986, the patient declined admission to our hospital for further evaluation and treatment. In June 1986, she developed increased joint pain, fever, diaphoresis, and inability to get out of bed. Three days later, on admission to our hospital, she was obtunded but responsive to deep pain with a temperature of 104°F, blood pressure of 112/Doppler mm Hg, respiratory rate of 24 breaths/minute, and pulse of 116 beats/minute. Physical examination revealed extremely poor oral hygiene, two trochanteric decubitus ulcers, and multiple chronic musculoskeletal changes consistent with rheumatoid arthritis. Multiple joints were noted to be tender, warm, erythematous, and with effusions. Aspiration of both shoulders, sternoclavicularjoints, hips, and knees revealed frank pus. The patient had incision and drainage of both hips, knees, ankles, sternoclavicular joints, elbows, her right shoulder, the proximal interphatangeal joints of the index and small finger of the right hand, and the interphalangeal joint of the left thumb. The wounds were left open, treated with multiple dressing changes, and healed by secondary intention after several months. Joint cultures revealed methicillin-resistant S. aureus, which was treated with vancomycin hydrochloride. Ventilatory support for 2 weeks and hyperalimentation were also required. A technetium-99m bone scan revealed increased uptake in the left sacroiliac joint and both hips consistent with osteomyelitis. Subsequently, both hipswere again aspirated; no pus was obtained, but cultures of the material recovered from the right hip revealed S. epidermidis. Six weeks of additional antibiotics were then initiated with vancomycin hydrochloride and later changed to trimethoprim-sulfamethoxazide. Bedside physical therapy was used to help maintain joint posture. Discharge physical examination after 6 months of hospitalization revealed severe rigidity and contractures of the patient's shoulders, hips, and knees bilaterally, consistent with her severe rheumatoid arthritis. Follow-up evaluation, by phone call, 18 months after discharge revealed no recurrence of the infections. A feeding tube had been used to facilitate nutritional support. The patient was restricted to a wheelchair for ambulation and was totally dependent on others for her daily personal care. She sub-
362
The Journal of Arthroplasty Vol. 3 No. 4 December 1988
sequently died, following an upper gastrointestinal bleed.
Discussion While the management of pyarthroses remains controversial, all authors would agree that rapid therapeutic intervention is desirable (1-3). Regimens including repeated aspirations and intravenous antibiotics, arthroscopic lavage, and open drainage each has its advocates. The etiology of the septic process can include surgical manipulation, a remote infected site with subsequent bacteremia, and underly.ing immune deficiency syndromes (1, 3, 4, 6). Often the underlying systemic problem must be treated to control the local pyarthrosis problem. The orthopaedic surgeon becomes involved with pyarthroses most frequently following surgical intervention, and frequently the responsibility for the septic process is attributed to the operating physician. In these three case reports, individuals with underlying systemic disorders, including rheumatoid atthrifts, hemophilia, and diabetes mellitus, had multiple septic joints. Two of the three patients had not had recent surgery. The remaining patient had had a total knee arthroplasty 7 months prior to her presentation with sepsis. This patient's benign postoperative course would speak against a late wound infection; perhaps her previous splenectomy and underlying rheumatoid arthritis predisposed her to developing the multiple pyarthroses. The underlying systemic diseases of our patients increased their susceptibility to potential bacteremic insults from remote sources, including poor dentition, skin ulceration, and abdominal surgery, capable of seeding multiple joints. The poor nutrition of this patient group undoubtably also contributed to their impaired immune responses and the development of septic episodes.
Meticulous care and sterile technique are required when performing an arthroplasty on any individual. Postoperative complications such as infection will occur, and may be attributable in part to the patient's underlying disease process, rather than to the surgeon or the surgeon's technique. The spontaneous occurrence of multiple septic joints in our three patients serves to support the contention that pyarthrosis is not solely an iatrogenic problem.
Acknowledgments The authors acknowledge the excellent technical assistance provided by Ms. Caroline Waterbury.
References 1. Goldenberg DL, Reed JI: Bacterial arthritis. N Engl J ivied 312:764, 1985 2. Kelly PJ, Martin WJ, Coventry MB: Bacterial (suppurative) arthritis in the adult. J Bone Joint Surg 52A:1595, 1970 3. Myers AR: Septic arthritis caused by.bacteria, p. 1507. In Kelly WN, Harris ED, Ruddy S, Sledge CB (eds): Textbook of Rheumatology. WB Saunders, Philadelphia, 1985 4. Rosenthal J, Bole GG, Robinson WD: Acute nongonococcat infectious arthritis. Arthritis Rheum 23:889, 1980 5. Slama TG: Treatment of septic arthritis: diagnostic approach and rational use of antibiotics. Orthop Rev 16:67, 1987 6. Watkins MB, Samilson RL, Winters DM: Acute suppurative arthritis. J Bone Joint Surg 38A:1313, 1956 7. Wigren A, Kaflstrom G, Kaufer H: Hematogenous infection of total joint implants: a report of multiple joint infections in three patients. Clin Orthop 152:288, 1980