- Email: [email protected]
Streptococcus gallolyticus infection after knee arthroplasty: A case report
APME-403; No. of Pages 4 apollo medicine xxx (2017) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
Streptococcus gallolyticus infection after knee arthroplasty: A case report Yashwant Singh Tanwar e,*, Anindya Debnath a, Leena Mehndiratta b, Yatinder Kharbanda c, Raman Sardana d a
Registrar, Department of Orthopedics, Apollo Hospital, Sarita Vihar, Delhi 110076, India Consultant Microbiology, Indraprastha Apollo Hospital, Sarita Vihar, Delhi 110076, India c Senior Consultant, Department of Orthopedics, Apollo Hospital, Sarita Vihar, Delhi 110076, India d Senior Consultant Microbiology, Indraprastha Apollo Hospital, Sarita Vihar, Delhi 110076, India e Consultant, Department of Orthopedics, Apollo Hospital, Sarita Vihar, Delhi 110076, India b
article info
abstract
Article history:
Infection after arthroplasty is disastrous both for the patient and surgeon. Infection by
Received 28 December 2016
certain micro-organisms have additional important systemic implications. Streptococcus
Accepted 2 February 2017
galloyticus is one such organism which has been implicated in colon carcinoma. We report
Available online xxx
a case of S. gallolyticus infection of a total knee prosthesis implant in a 72-year-old female who was managed successfully by two-stage revision. A thorough work-up did not show any
Keywords:
evidence of gastro-intestinal malignancy, but nonspecific colitis was present on biopsy.
Streptococcus gallolyticus Knee arthroplasty Colon carcinoma
1.
Introduction
Infection is a dreaded complication after any orthopedic procedure and especially so after hip and knee arthroplasty. Various studies have reported incidence of infection after total knee arthroplasty (TKA) in the range from 0.5 to 5%.1,2 The most common organisms causing post-operative infection in total knee replacement (TKR) are Staphylococcus aureus, Staphylococcus epidermidis and Streptococcus species.3 Post-TKR infection with Streptococcus gallolyticus is relatively rare, however several individual case reports and few case series have been published. S. gallolyticus has been more often isolated from the gut and has often been shown to be associated with colon carcinoma.1,2,4 An association has also been claimed between this organism and
© 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
infective endocarditis.5–7 Some studies have reported biliary tract infection, brain abscess, meningitis, peritonitis to be caused by this pathogen.8–10 Several orthopedic problems including septic arthritis, osteomyelitis have also been reported by many workers.11 We report a case of infection with S. gallolyticus in an elderly immunocompetent female patient who had undergone total knee replacement. She also had history of gastrointestinal infection and was therefore subjected to thorough diagnostic work-up to rule out any associated malignancies, especially colon carcinoma.
2.
Case report
A 72-year-old female underwent TKA of left knee in March 2015 for advanced osteoarthritis. The procedure was done
* Corresponding author. Tel.: +91 9958112912. E-mail address: [email protected] (Y.S. Tanwar). http://dx.doi.org/10.1016/j.apme.2017.02.001 0976-0016/© 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Tanwar YS, et al. Streptococcus gallolyticus infection after knee arthroplasty: A case report, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.02.001
APME-403; No. of Pages 4
2
apollo medicine xxx (2017) xxx–xxx
Fig. 1 – Anteroposterior and lateral radiographs showing osteolysis and loosening of the prostheses.
under strict aseptic conditions in an operation theater equipped with vertical laminar airflow system and air changes of more than 16 air changes per hour (ACH). Knee was exposed by midvastus approach and using standard instrumentation non restrictive geometry (NRG) knee system of StrykerTM was implanted. Post-operative recovery was uneventful with no unexpected event in the early post-operative period. Eleven months after the surgery, patient presented with pain and swelling in the operated knee. Pain was insidious in onset, gradually progressive, non-radiating, and aggravated by weight bearing, especially on climbing stairs and was associated with knee swelling. Pain was also present at rest with visual analogue scale (VAS) scores in range of 3–4. Patient also gave history of some abdominal discomfort along with gastrointestinal infection 2 months preceding the onset of knee symptoms. She had diarrhea with episodes of nausea and vomiting which persisted for 3 weeks. On examination she was febrile (temperature recorded 37.6 8C), her left knee was erythematous, warm and tender. The range of movement in the affected knee was reduced (108–808) as compared to previous record, and it was painful throughout the range. Synovial fluid was aspirated and sent for analysis and was negative for any bacterial growth. Radiographs of the knee
Fig. 2 – After the first stage revision surgery. Left knee with non-articulating antibiotic cement spacer.
showed osteolysis in all the zones and loosening of both tibial and femoral components of the prosthesis (Fig. 1). Blood investigations revealed increased white cell count (12.8 103/ mm3) and raised erythrocyte sedimentation rate (92 mm/1st hour). Based on the clinical presentation, laboratory reports and the radiographs, a diagnosis of infected total knee prosthesis with loosening of components was made. Bone scan showed increased uptake in left knee in all the three stages, suggestive of infection.
3.
Management
A two-stage revision procedure was planned. The first stage was done in February 2016, prosthesis was removed and after thorough debridement of the joint an antibiotic (Vancomycin 2 g) impregnated non-articulating spacer was packed loosely in the resulting defect (Fig. 2). Debrided tissue was sent to the laboratory for aerobic, anaerobic, fungal cultures as well as for histopathological examination. Aerobic culture and sensitivity report showed non-enterococcus Streptococcus further identified as S. gallolyticus (Fig. 3a and b) sensitive to Penicillin G, Amoxicillin + Clavulanate, Ciprofloxacin, Teicoplanin and Vancomycin, Ceftriaxone, Gentamicin, intravenous antibiotic
Fig. 3 – (a) Gram staining pattern of S. gallolyticus. (b) Colony morphology of S. gallolyticus on blood agar plate. Please cite this article in press as: Tanwar YS, et al. Streptococcus gallolyticus infection after knee arthroplasty: A case report, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.02.001
APME-403; No. of Pages 4 apollo medicine xxx (2017) xxx–xxx
Fig. 4 – After the second stage revision surgery with the final semi-constrained prostheses.
(Teicoplanin) was administered for 6 weeks and regular monitoring of renal/liver function tests, acute phase reactants, complete blood counts and coagulation profile was done. By 6 weeks, markers of infection (erythrocyte sedimentation rate (ESR), C reactive protein (CRP) total leukocyte count) had come back to normal range and patient was planned for second stage procedure. After confirmation of S. galolyticus as the offending pathogen, an extensive gastrointestinal workup was done. Colonoscopy was done, which showed few pedunculated polyps with no malignant features. Biopsy was taken and sent for histopathological examination. Report suggested colonic polyp with mild non-specific colitis with no evidence of malignancy. Positron emission tomography–magnetic resonanace imaging (PET–MRI) was also done to identify any metabolically active lesion elsewhere in the gut; which came out to be normal. The second stage surgery was done after 3 months of the first stage in May 2016. Cement spacer was removed and intraoperative tissue was sent for culture, and histopathological examination. A semi-constrained total knee prosthesis TC3 DePuyTM was implanted (Fig. 4). Following the two-stage revision surgery, patient gradually improved. Her left knee is now painless (VAS score 0–1), mobile (range of motion 08–1108) and stable. She has recovered from all the gastrointestinal complaints. The patient is on regular follow-up for last 1 year with no evidence of any unfavorable course.
4.
Discussion
S. bovis/S. equinus complex (SBSEC) is a large group of human and animal derived streptococci that are commensals, opportunistic pathogens or food fermentation associates. The classification of SBSEC has changed over time and at present there are 7 (sub) species grouped into four branches based on sequences identities: the S. gallolyticus, the S. equinus, the S. infantarius and the S. alactolyticus branch. In humans, there is a strong association between bacteraemia, infective endocarditis and colorectal cancer or gut ulcerative lesions. Especially the SBSECspecies S. gallolyticus subsp. gallolyticus is an emerging pathogen for endocarditis and prosthetic joint infections. A significant association between this pathogen with colon carcinoma was shown by Klein et al. in 1977. They isolated S. gallolyticus from the fecal cultures of 11 of 105 controls, 35 of 63
3
patients with carcinoma colon, 7 of 25 with inflammatory bowel disease, 4 of 21 with non-colonic neoplasms and 5 of 37 of other gastrointestinal disorders. The association of S. gallolyticus with the colon carcinoma cases were statistically significant and not with other entities.4 Ellmerich et al.12 were able to clinically induce early pre-neoplastic lesions in the colon of rats by administering either S. gallolyticus or its toxic antigen in them. Of the various pathogens causing post-operative infection after TKA, S. gallolyticus has a special relevance. Though rarely isolated from the infected TKAs, it has significant implication toward possibility of some life-threatening underlying pathology being associated somewhere else. There have been reports of underlying colon carcinomas being diagnosed at an early stage after S. galolyticus induced TKA infection. Vince et al. in 2003 reported S. gallolyticus infected TKR in a 76 years old man. Further diagnostic work-up helped in the diagnosis of a carcinoma in the ascending colon with extension into the adrenal gland.13 Apsingi et al. in 2007 reported a case of TKR which was found to be infected with S. gallolyticus 40 months after the replacement surgery. Carcinoma of the sigmoid colon was diagnosed by subjecting the patient to colonoscopy and was surgically resected.14 Hernandez-Vaquero et al. in 2008 reported a case of 75 years old male patient who had undergone TKR, but got infected 2 years later. S. gallolyticus was the pathogen isolated. Apart from management of the infected TKR in the form of debridement and prosthesis removal and spacer insertion, he was subjected to colonoscopy and radiological study of the intestine, which detected a polyp. Excision biopsy of the polyp confirmed villous adenoma of colon. Following this left partial colectomy was done, histopathological study of which revealed infiltrating adenocarcinoma extending to the muscular plane. Patient refused implantation of any new prosthesis in the knee and hence arthrodesis was done. Follow-up of 2 years revealed no recurrence of carcinoma.1 We in the present case conducted a thorough diagnostic work up to exclude any malignant lesion in the gastrointestinal tract including colonoscopy and PET–MRI. However no associated malignant lesion was found. However there was history of gastrointestinal infection preceding the knee infection, which probably lead to S. gallolyticus bacteremia followed by secondary seeding in the knee joint. This also emphasizes on the already well-established fact that patients who have undergone an arthroplasty procedure should not ignore any infective foci and should consult their respective physician at the earliest. The threshold for starting antibiotic treatment or prophylaxis in arthroplasty patients should be low. Empirical therapy should cover all the likely pathogens. Most Group D Streptococci are sensitive to Penicillin/Ceftriaoxne. The latter has an advantage of once daily administration. Nagy et al. in 2013 reported a 73-year-old immunocompetent male patient who presented with late septic arthritis 3 years after TKR. He also had infective endocarditis with aortic valve insufficiency. S. gallolyticus was the pathogen isolated. Diagnostic work-up for the intestinal lesion was done which revealed non-malignant colonic ulcers. The authors postulated that initially the patient had colonic ulcers that lead to bacteremia causing acute septic arthritis and endocarditis. But septic arthritis was the presenting symptom in this patient.2
Please cite this article in press as: Tanwar YS, et al. Streptococcus gallolyticus infection after knee arthroplasty: A case report, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.02.001
APME-403; No. of Pages 4
4
apollo medicine xxx (2017) xxx–xxx
Our patient is a 71-year-old female whose TKR got infected with S. gallolyticus 8 months after the index surgery. This is similar to the other reported cases where the age of the patient is in 70 s and the infection was detected 4–40 months after the replacement surgery. Also, our patient developed gastrointestinal disorders. Hence, in view of the association of the pathogen with colon malignancies in available literature, we subjected her to further investigations. But unlike many of the reported cases, there was no evidence of any malignancy in our case. The patient is on regular follow up for last 1 year. A long-term follow up is needed for earlier detection of any malignant transformation in future.
2.
3.
4.
5. 6.
5.
Conclusion 7.
S. gallolyticus is an infrequent pathogen causing peri-prosthetic infections. There is a clear association between infection caused by S. gallolyticus and other disorders like colon carcinoma and infective endocarditis and gastrointestinal ulcerative lesions. Therefore the clinician must be aware of such an association, which may lead to early detection of an underlying malignancy. However this may not be the case always, as has been seen in this case report and S. gallolyticus peri-prosthetic infection may result from a simple transmigration from the gut in certain individuals leading to bacteraemia with the organism, the probability of which may get enhanced by any disruptive lesion of the G.I. tract even a gastroenteritis. A well-planned long-term follow-up is advocated to diagnose any adverse event at the earliest.
Conflicts of interest
8.
9. 10.
11.
12.
13.
The authors have none to declare.
references
14.
in total knee replacement with large intestine carcinoma. Orthopedics. 2008;31(1). Nagy MT, Hla SM, Keys GW. Late Streptococcus bovis infection of total knee replacement complicated by infective endocarditis and associated with colonic ulcers. BMJ Case Rep. 2013;2013:. bcr2013008709. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;392:15–23. Klein RS, Recco RA, Catalano MT, Edberg SC, Casey JI, Steigbigel NH. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med. 1977;297(15):800–802. Watanakunakorn C. Streptococcus bovis endocarditis. Am J Med. 1974;56(2):256–260. Haldane EV, Haldane JH, Digout G, West A, Van Rooyen CE. Streptococcus bovis endocarditis. Can Med Assoc J. 1974;111 (7):678. Ballet M, Gevigney G, Gare JP, Delahaye F, Etienne J, Delahaye JP. Infective endocarditis due to Streptococcus bovis. A report of 53 cases. Eur Heart J. 1995;16(12):1975–1980. Corredoira J, Alonso MP, García-Garrote F, et al. Streptococcus bovis group and biliary tract infections: an analysis of 51 cases. Clin Microbiol Infect. 2014;20(5):405–409. Lerner PI. Meningitis caused by Streptococcus in adults. J Infect Dis. 1975;131(suppl):S9–S16. Vilaichone RK, Mahachai V, Kullavanijaya P, Nunthapisud P. Spontaneous bacterial peritonitis caused by Streptococcus bovis: case series and review of the literature. Am J Gastroenterol. 2002;97(6):1476–1479. García-País MJ, Rabuñal R, Armesto V, et al. Streptococcus bovis septic arthritis and osteomyelitis: a report of 21 cases and a literature review. Semin Arthritis Rheum. 2016;45(June (6)):738–746. Ellmerich S, Schöller M, Duranton B, et al. Promotion of intestinal carcinogenesis by Streptococcus bovis. Carcinogenesis. 2000;21(4):753–756. Vince KG, Kantor SR, Descalzi J. Late infection of a total knee arthroplasty with Streptococcus bovis in association with carcinoma of the large intestine. J Arthroplasty. 2003;18 (6):813–815. Apsingi S, Kulkarni A, Gould KF, McCaskie AW. Late Streptococcus bovis infection of knee arthroplasty and its association with carcinoma of the colon: a case report. Knee Surg Sports Traumatol Arthrosc. 2007;15(6):761–762.
1. Hernandez-Vaquero D, Cuervo-Olay MC, Suarez-Vazquez A. Association of Streptococcus bovis haematolgenous infection
Please cite this article in press as: Tanwar YS, et al. Streptococcus gallolyticus infection after knee arthroplasty: A case report, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.02.001
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
Streptococcus gallolyticus infection after knee arthroplasty: A case report Yashwant Singh Tanwar e,*, Anindya Debnath a, Leena Mehndiratta b, Yatinder Kharbanda c, Raman Sardana d a
Registrar, Department of Orthopedics, Apollo Hospital, Sarita Vihar, Delhi 110076, India Consultant Microbiology, Indraprastha Apollo Hospital, Sarita Vihar, Delhi 110076, India c Senior Consultant, Department of Orthopedics, Apollo Hospital, Sarita Vihar, Delhi 110076, India d Senior Consultant Microbiology, Indraprastha Apollo Hospital, Sarita Vihar, Delhi 110076, India e Consultant, Department of Orthopedics, Apollo Hospital, Sarita Vihar, Delhi 110076, India b
article info
abstract
Article history:
Infection after arthroplasty is disastrous both for the patient and surgeon. Infection by
Received 28 December 2016
certain micro-organisms have additional important systemic implications. Streptococcus
Accepted 2 February 2017
galloyticus is one such organism which has been implicated in colon carcinoma. We report
Available online xxx
a case of S. gallolyticus infection of a total knee prosthesis implant in a 72-year-old female who was managed successfully by two-stage revision. A thorough work-up did not show any
Keywords:
evidence of gastro-intestinal malignancy, but nonspecific colitis was present on biopsy.
Streptococcus gallolyticus Knee arthroplasty Colon carcinoma
1.
Introduction
Infection is a dreaded complication after any orthopedic procedure and especially so after hip and knee arthroplasty. Various studies have reported incidence of infection after total knee arthroplasty (TKA) in the range from 0.5 to 5%.1,2 The most common organisms causing post-operative infection in total knee replacement (TKR) are Staphylococcus aureus, Staphylococcus epidermidis and Streptococcus species.3 Post-TKR infection with Streptococcus gallolyticus is relatively rare, however several individual case reports and few case series have been published. S. gallolyticus has been more often isolated from the gut and has often been shown to be associated with colon carcinoma.1,2,4 An association has also been claimed between this organism and
© 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
infective endocarditis.5–7 Some studies have reported biliary tract infection, brain abscess, meningitis, peritonitis to be caused by this pathogen.8–10 Several orthopedic problems including septic arthritis, osteomyelitis have also been reported by many workers.11 We report a case of infection with S. gallolyticus in an elderly immunocompetent female patient who had undergone total knee replacement. She also had history of gastrointestinal infection and was therefore subjected to thorough diagnostic work-up to rule out any associated malignancies, especially colon carcinoma.
2.
Case report
A 72-year-old female underwent TKA of left knee in March 2015 for advanced osteoarthritis. The procedure was done
* Corresponding author. Tel.: +91 9958112912. E-mail address: [email protected] (Y.S. Tanwar). http://dx.doi.org/10.1016/j.apme.2017.02.001 0976-0016/© 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Tanwar YS, et al. Streptococcus gallolyticus infection after knee arthroplasty: A case report, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.02.001
APME-403; No. of Pages 4
2
apollo medicine xxx (2017) xxx–xxx
Fig. 1 – Anteroposterior and lateral radiographs showing osteolysis and loosening of the prostheses.
under strict aseptic conditions in an operation theater equipped with vertical laminar airflow system and air changes of more than 16 air changes per hour (ACH). Knee was exposed by midvastus approach and using standard instrumentation non restrictive geometry (NRG) knee system of StrykerTM was implanted. Post-operative recovery was uneventful with no unexpected event in the early post-operative period. Eleven months after the surgery, patient presented with pain and swelling in the operated knee. Pain was insidious in onset, gradually progressive, non-radiating, and aggravated by weight bearing, especially on climbing stairs and was associated with knee swelling. Pain was also present at rest with visual analogue scale (VAS) scores in range of 3–4. Patient also gave history of some abdominal discomfort along with gastrointestinal infection 2 months preceding the onset of knee symptoms. She had diarrhea with episodes of nausea and vomiting which persisted for 3 weeks. On examination she was febrile (temperature recorded 37.6 8C), her left knee was erythematous, warm and tender. The range of movement in the affected knee was reduced (108–808) as compared to previous record, and it was painful throughout the range. Synovial fluid was aspirated and sent for analysis and was negative for any bacterial growth. Radiographs of the knee
Fig. 2 – After the first stage revision surgery. Left knee with non-articulating antibiotic cement spacer.
showed osteolysis in all the zones and loosening of both tibial and femoral components of the prosthesis (Fig. 1). Blood investigations revealed increased white cell count (12.8 103/ mm3) and raised erythrocyte sedimentation rate (92 mm/1st hour). Based on the clinical presentation, laboratory reports and the radiographs, a diagnosis of infected total knee prosthesis with loosening of components was made. Bone scan showed increased uptake in left knee in all the three stages, suggestive of infection.
3.
Management
A two-stage revision procedure was planned. The first stage was done in February 2016, prosthesis was removed and after thorough debridement of the joint an antibiotic (Vancomycin 2 g) impregnated non-articulating spacer was packed loosely in the resulting defect (Fig. 2). Debrided tissue was sent to the laboratory for aerobic, anaerobic, fungal cultures as well as for histopathological examination. Aerobic culture and sensitivity report showed non-enterococcus Streptococcus further identified as S. gallolyticus (Fig. 3a and b) sensitive to Penicillin G, Amoxicillin + Clavulanate, Ciprofloxacin, Teicoplanin and Vancomycin, Ceftriaxone, Gentamicin, intravenous antibiotic
Fig. 3 – (a) Gram staining pattern of S. gallolyticus. (b) Colony morphology of S. gallolyticus on blood agar plate. Please cite this article in press as: Tanwar YS, et al. Streptococcus gallolyticus infection after knee arthroplasty: A case report, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.02.001
APME-403; No. of Pages 4 apollo medicine xxx (2017) xxx–xxx
Fig. 4 – After the second stage revision surgery with the final semi-constrained prostheses.
(Teicoplanin) was administered for 6 weeks and regular monitoring of renal/liver function tests, acute phase reactants, complete blood counts and coagulation profile was done. By 6 weeks, markers of infection (erythrocyte sedimentation rate (ESR), C reactive protein (CRP) total leukocyte count) had come back to normal range and patient was planned for second stage procedure. After confirmation of S. galolyticus as the offending pathogen, an extensive gastrointestinal workup was done. Colonoscopy was done, which showed few pedunculated polyps with no malignant features. Biopsy was taken and sent for histopathological examination. Report suggested colonic polyp with mild non-specific colitis with no evidence of malignancy. Positron emission tomography–magnetic resonanace imaging (PET–MRI) was also done to identify any metabolically active lesion elsewhere in the gut; which came out to be normal. The second stage surgery was done after 3 months of the first stage in May 2016. Cement spacer was removed and intraoperative tissue was sent for culture, and histopathological examination. A semi-constrained total knee prosthesis TC3 DePuyTM was implanted (Fig. 4). Following the two-stage revision surgery, patient gradually improved. Her left knee is now painless (VAS score 0–1), mobile (range of motion 08–1108) and stable. She has recovered from all the gastrointestinal complaints. The patient is on regular follow-up for last 1 year with no evidence of any unfavorable course.
4.
Discussion
S. bovis/S. equinus complex (SBSEC) is a large group of human and animal derived streptococci that are commensals, opportunistic pathogens or food fermentation associates. The classification of SBSEC has changed over time and at present there are 7 (sub) species grouped into four branches based on sequences identities: the S. gallolyticus, the S. equinus, the S. infantarius and the S. alactolyticus branch. In humans, there is a strong association between bacteraemia, infective endocarditis and colorectal cancer or gut ulcerative lesions. Especially the SBSECspecies S. gallolyticus subsp. gallolyticus is an emerging pathogen for endocarditis and prosthetic joint infections. A significant association between this pathogen with colon carcinoma was shown by Klein et al. in 1977. They isolated S. gallolyticus from the fecal cultures of 11 of 105 controls, 35 of 63
3
patients with carcinoma colon, 7 of 25 with inflammatory bowel disease, 4 of 21 with non-colonic neoplasms and 5 of 37 of other gastrointestinal disorders. The association of S. gallolyticus with the colon carcinoma cases were statistically significant and not with other entities.4 Ellmerich et al.12 were able to clinically induce early pre-neoplastic lesions in the colon of rats by administering either S. gallolyticus or its toxic antigen in them. Of the various pathogens causing post-operative infection after TKA, S. gallolyticus has a special relevance. Though rarely isolated from the infected TKAs, it has significant implication toward possibility of some life-threatening underlying pathology being associated somewhere else. There have been reports of underlying colon carcinomas being diagnosed at an early stage after S. galolyticus induced TKA infection. Vince et al. in 2003 reported S. gallolyticus infected TKR in a 76 years old man. Further diagnostic work-up helped in the diagnosis of a carcinoma in the ascending colon with extension into the adrenal gland.13 Apsingi et al. in 2007 reported a case of TKR which was found to be infected with S. gallolyticus 40 months after the replacement surgery. Carcinoma of the sigmoid colon was diagnosed by subjecting the patient to colonoscopy and was surgically resected.14 Hernandez-Vaquero et al. in 2008 reported a case of 75 years old male patient who had undergone TKR, but got infected 2 years later. S. gallolyticus was the pathogen isolated. Apart from management of the infected TKR in the form of debridement and prosthesis removal and spacer insertion, he was subjected to colonoscopy and radiological study of the intestine, which detected a polyp. Excision biopsy of the polyp confirmed villous adenoma of colon. Following this left partial colectomy was done, histopathological study of which revealed infiltrating adenocarcinoma extending to the muscular plane. Patient refused implantation of any new prosthesis in the knee and hence arthrodesis was done. Follow-up of 2 years revealed no recurrence of carcinoma.1 We in the present case conducted a thorough diagnostic work up to exclude any malignant lesion in the gastrointestinal tract including colonoscopy and PET–MRI. However no associated malignant lesion was found. However there was history of gastrointestinal infection preceding the knee infection, which probably lead to S. gallolyticus bacteremia followed by secondary seeding in the knee joint. This also emphasizes on the already well-established fact that patients who have undergone an arthroplasty procedure should not ignore any infective foci and should consult their respective physician at the earliest. The threshold for starting antibiotic treatment or prophylaxis in arthroplasty patients should be low. Empirical therapy should cover all the likely pathogens. Most Group D Streptococci are sensitive to Penicillin/Ceftriaoxne. The latter has an advantage of once daily administration. Nagy et al. in 2013 reported a 73-year-old immunocompetent male patient who presented with late septic arthritis 3 years after TKR. He also had infective endocarditis with aortic valve insufficiency. S. gallolyticus was the pathogen isolated. Diagnostic work-up for the intestinal lesion was done which revealed non-malignant colonic ulcers. The authors postulated that initially the patient had colonic ulcers that lead to bacteremia causing acute septic arthritis and endocarditis. But septic arthritis was the presenting symptom in this patient.2
Please cite this article in press as: Tanwar YS, et al. Streptococcus gallolyticus infection after knee arthroplasty: A case report, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.02.001
APME-403; No. of Pages 4
4
apollo medicine xxx (2017) xxx–xxx
Our patient is a 71-year-old female whose TKR got infected with S. gallolyticus 8 months after the index surgery. This is similar to the other reported cases where the age of the patient is in 70 s and the infection was detected 4–40 months after the replacement surgery. Also, our patient developed gastrointestinal disorders. Hence, in view of the association of the pathogen with colon malignancies in available literature, we subjected her to further investigations. But unlike many of the reported cases, there was no evidence of any malignancy in our case. The patient is on regular follow up for last 1 year. A long-term follow up is needed for earlier detection of any malignant transformation in future.
2.
3.
4.
5. 6.
5.
Conclusion 7.
S. gallolyticus is an infrequent pathogen causing peri-prosthetic infections. There is a clear association between infection caused by S. gallolyticus and other disorders like colon carcinoma and infective endocarditis and gastrointestinal ulcerative lesions. Therefore the clinician must be aware of such an association, which may lead to early detection of an underlying malignancy. However this may not be the case always, as has been seen in this case report and S. gallolyticus peri-prosthetic infection may result from a simple transmigration from the gut in certain individuals leading to bacteraemia with the organism, the probability of which may get enhanced by any disruptive lesion of the G.I. tract even a gastroenteritis. A well-planned long-term follow-up is advocated to diagnose any adverse event at the earliest.
Conflicts of interest
8.
9. 10.
11.
12.
13.
The authors have none to declare.
references
14.
in total knee replacement with large intestine carcinoma. Orthopedics. 2008;31(1). Nagy MT, Hla SM, Keys GW. Late Streptococcus bovis infection of total knee replacement complicated by infective endocarditis and associated with colonic ulcers. BMJ Case Rep. 2013;2013:. bcr2013008709. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;392:15–23. Klein RS, Recco RA, Catalano MT, Edberg SC, Casey JI, Steigbigel NH. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med. 1977;297(15):800–802. Watanakunakorn C. Streptococcus bovis endocarditis. Am J Med. 1974;56(2):256–260. Haldane EV, Haldane JH, Digout G, West A, Van Rooyen CE. Streptococcus bovis endocarditis. Can Med Assoc J. 1974;111 (7):678. Ballet M, Gevigney G, Gare JP, Delahaye F, Etienne J, Delahaye JP. Infective endocarditis due to Streptococcus bovis. A report of 53 cases. Eur Heart J. 1995;16(12):1975–1980. Corredoira J, Alonso MP, García-Garrote F, et al. Streptococcus bovis group and biliary tract infections: an analysis of 51 cases. Clin Microbiol Infect. 2014;20(5):405–409. Lerner PI. Meningitis caused by Streptococcus in adults. J Infect Dis. 1975;131(suppl):S9–S16. Vilaichone RK, Mahachai V, Kullavanijaya P, Nunthapisud P. Spontaneous bacterial peritonitis caused by Streptococcus bovis: case series and review of the literature. Am J Gastroenterol. 2002;97(6):1476–1479. García-País MJ, Rabuñal R, Armesto V, et al. Streptococcus bovis septic arthritis and osteomyelitis: a report of 21 cases and a literature review. Semin Arthritis Rheum. 2016;45(June (6)):738–746. Ellmerich S, Schöller M, Duranton B, et al. Promotion of intestinal carcinogenesis by Streptococcus bovis. Carcinogenesis. 2000;21(4):753–756. Vince KG, Kantor SR, Descalzi J. Late infection of a total knee arthroplasty with Streptococcus bovis in association with carcinoma of the large intestine. J Arthroplasty. 2003;18 (6):813–815. Apsingi S, Kulkarni A, Gould KF, McCaskie AW. Late Streptococcus bovis infection of knee arthroplasty and its association with carcinoma of the colon: a case report. Knee Surg Sports Traumatol Arthrosc. 2007;15(6):761–762.
1. Hernandez-Vaquero D, Cuervo-Olay MC, Suarez-Vazquez A. Association of Streptococcus bovis haematolgenous infection
Please cite this article in press as: Tanwar YS, et al. Streptococcus gallolyticus infection after knee arthroplasty: A case report, Apollo Med. (2017), http://dx.doi.org/10.1016/j.apme.2017.02.001