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Septic prepatellar bursitis due to erysipelas.

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LETTERS
Septic prepatellar bursitis due to erysipelas
To the Editor:
Prepatellar bursitis is a relatively common disorder in rheumatologic practice. In most cases it is
caused by mechanical irritation, and develops frequently in people who have to kneel for long periods of
time such as housemaids, nuns, and miners (1). The
bursa may be infected either through the skin or by hematogeneous spread (2).
Although erysipelas is common, it is of interest
that no case of streptococcal bursitis due to erysipelas
has been reported. Balboni is the only author to mention that arthralgia, acute arthritis, and (rarely) suppurative arthritis may be associated with erysipelas, but
he fails to give any case report or reference (3).
We report here an unusual case of erysipelas
complicated by a septic bursitis. EZ, a 66-year-old white
man, was first treated in May 1978 in our department
for osteoarthrosis of the right knee. Treatment consisted
of indomethacin and physiotherapy. No intraarticular
injections were given. The patient became better and
was discharged, but a few days later he developed a fever of 39.2"C and chills and noticed a rash above his
right knee.
Physical examination revealed a typical erysipelas rash above the right knee. The prepatellar bursa
was swollen, full of fluid, and very tender to palpation.
There was no swelling or tenderness of the joint itself
and no limitation of movement was noticed.
The bursa was aspirated and 10 ml of bloody,
purulent fluid was obtained. The total synovial white
cell count was 50,000/mm3, with 60% polymorphonuclear leukocytes. Hemolytic streptococci were cultured
from the fluid. Other laboratory findings included a
Westergren sedimentation rate of 25 mm/hour, total
white cell count 9600/mm3, and an antistreptolysin titer
of 1/200.
Penicillin therapy was begun at 1,600,000 units
intramuscularly daily. The bursa was aspirated and
washed out every day with 0.9% saline solution, and
penicillin was injected locally into the bursa. Within a
few days the patient's fever ceased, the inflammatory
symptoms of the skin subsided, and the bursa1 fluid remained sterile after repeated cultures. The patient recovered completely in another 2 weeks, and the bursa
did not require surgical removal.
In 1916 Fullerton (4) described the relationship
between the knee joint and several of its adjacent bursae with emphasis on their importance in spreading infections. The prepatellar bursa, however, is usually not
1213
adjacent to the knee joint. Thus, inflammation of the
prepatellar bursa does not imply involvement of the
joint, and vice versa.
Some local and systemic factors predispose to infection of the prepatellar bursa (5). Local factors include chronic mechanical irritation, extremely large fat
pads around the knee joint, and puncture wounds of the
skin. Systemic factors include alcoholism, diabetes,
gout, rheumatoid arthritis, prolonged corticosteroid or
immunosuppressive therapy, and recurrent staphylococcal or streptococcal infections. Prepatellar or olecranon
bursitis has also been described due to Mycobacterium
marinum (6), Sporothrix schenkii (7), and Achloric algae
(8). None of these predisposing factors occurred in our
patient, who appeared to develop his prepatellar bursitis
as a result of direct infection from streptococcal erysipelas.
EVABORBAS,MD
G Y ~ R GGENTI,
Y
MD
GBZABALINT,MD
National Institute of Rheumatology
and Physiotherapy Budapest 11
Frankel Leo u. 17-19
152.5 Budapest, 114
PostaJibk 54, Hungary
1. Sharrard WJW: Aetiology and pathology of beat knee. Br J
Intern Med 20:24-3 1, 1963
2. Goldenberg DL, Cohen AS: Acute infectious arthritis: a review of patients with nongonococcal joint infections. Am J
Med 60:369-377, 1976
3. Balboni VG: cit. Hollander JL: Arthritis and Allied Conditions, Philadelphia, Lea and Febiger, 1967, p 1052
4. Fullerton A: The surgical anatomy of the synovial membrane of the knee joint. Br J Surg 4:191-200, 1916
5. Ho G, Tice AD, Kaplan SR: Septic bursitis in the prepatellar and olecranon bursae. Ann Intern Med 89:2 1-27,
1978
6. Winter FE, Runyon EH: Prepatellar bursitis caused by
Mycobacterium marinum. J Bone Joint Surg 47A (No
2):375-379, 1965
7. Levinsky WJ: Sporotrichial arthritis: report of a case mimicking gout. Arch Intern Med 129:118-119, 1972
X. Nosanchuk JS, Greenberg DD: Protothecosis ofthe olecranon bursa caused by achloric algae. Am J Clin Pathol
591567-573, 1973
Subcorneal pustular dermatosis and
rheumatoid arthritis
To the Editor:
Subcorneal pustular dermatosis (SPD)is a rare
blistering disease that primarily affects women over 40
years of age. The hallmark is a pustule that seems to sit
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