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First reported case of infection of the suprapatellar bursa of the knee due to Streptococcus pneumoniae.

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1063
LETTERS
lence of a rare disease such as scleroderma (systemic sclerosis) either by ascertainment of cases formally diagnosed by
others in a large population or by a personal survey aimed at
detecting all cases in a small population.
Drs. Silman and Symmons should be commended for
their efforts to use multiple sources of identification to
determine the best estimate of diagnosed cases of scleroderma in the West Midlands region (their publication was not
available at the time ours was written). The differences in
prevalence rates found in the literature could be accounted
for by differences in methodology and sample size, but there
could also be a real regional variation in the prevalence of
scleroderma. We hope that this discussion will prompt other
investigators to provide estimates of the prevalence of
scleroderma in different parts of the world.
This task should be facilitated in countries that have
a national registry for reporting diseases that may include
scleroderma.
Hildegard R. Maricq. MD
Julian E. Keil. DrPH
Medical University of South Carolina
Charleston. SC
Martin C . Weinrich. PhD
University of South Carolina
Columbia, SC
First reported case of infection of the suprapatellar
bursa of the knee due to Sfreptococcuspneumoniae
To the Editor:
We read with great interest the report by Taylor
regarding the fifth reported case of infection of the deep
infrapatellar bursa of the knee ( I ) . Deep septic bursitis is
indeed infrequent and rarely attributed to bacteria other than
Staphylococcus aureus ( I ) . We present here the first reported case of infection of the suprapatellar bursa of the
knee due to Streptococcus pneumoniae.
The patient, a 75-year-old woman, had seropositive
rheumatoid arthritis (RA), which was in remission while she
was receiving gold salt treatment. However, she suddenly
developed very painful inflammation and swelling of the
right knee. The diagnosis made by her physician was an
exacerbation of RA. After nonsteroidal antiinflammatory
drug treatment was determined to be ineffective, the physician administered an intraarticular injection of triamcinolone
hexacetonide. Chrysotherapy was discontinued at this time,
and the patient was started on a treatment regimen of oral
D-penicillamine (IS0mg/day) and prednisolone (I5 mdday).
which provided no improvement.
Two months later, the patient was hospitalized in our
rheumatology department. Her right knee was very swollen,
particularly in the suprapatellar area, without intraarticular
effusion or cellulitis. Gentle passive mobilization of the joint
was painless. Other joints were not inflamed. Her temperature was 38.5"C. the erythrocyte sedimentation rate (ESR)
was 104 mm/hour. and the white blood cell count was
I2,600/mm3 with 90% polymorphonuclear cells.
Radiography showed bilateral femorotibial narrowing due to RA and, in the right knee, a suprapatellar opacity
in the soft tissues. Ultrasonography showed a self-limited
collection close to the femur. without effusion into the knee
joint cavity (Figure 1). Needle aspiration of the right suprapatellar bursa yielded 100 cc of thick pus. Spneurnoniae was
identified upon examination of cultures of the bursa1 fluid.
Blood and urine cultures remained sterile. N o mode of entry
was identified. The patient's knee was immobilized. Prednisolone was discontinued, and she was started on a treat-
Figure 1. Ultrasonography showing effusion in the suprapatellar bursa of the right knee.
LETTERS
1064
ment regimen. of intravenous amoxicillin (8 gmlday) and
dibekacine (150 mglday).
Ten days later, pain had decreased, but fever persisted: the bursal effusion was sterile but relapsing (needle
aspiration yielded 60-80 cc every 3 days). The ESR had not
improved. Surgical resection of the bursa was performed on
the twentieth day, with drainage of the collection; apyrexia
followed immediately. The patient received oral amoxicillin.
One month later, she had completely recovered without any
sequela.
This is the first reported cade of infection of the
suprapatellar bursa of the knee due to S pneumoniae. The
rare occurrence of deep septic serous bursitis of the knee can
lead to diagnostic errors. In the patient reported here, the
initial diagnosis was an exacerbation of RA. This systemic
disease does, in fact, predispose an individual to septic
reaction. No entry point for the infectious agent was identified in our patient, and the most common risk factors, i.e..
local injury or microtrauma, were absent. Local and general
corticosteroid therapy was initiated after the clinical onset of
symptoms in this patient. The importance of ultrasonography in locating the effusion must be emphasized as an aid in
bursal fluid sampling and subsequent systematic culture.
Surgical drainage, as performed in our patient and in the
patient reported by Taylor ( I ) , is necessary if antibiotic
treatment remains ineffective.
S pneumoniae in the bursa has been reported previously only in 2 patients with olecranon bursitis (in an
alcoholic patient [2], and after bacteremia [3]). In patients
who present with severe pain and inflammation in the knee,
the physician should consider the possibility of infection of
the deep bursa. This diagnosis can be confirmed by careful
physical examination, ultrasonography, and bursal fluid
analysis.
Olivier Brocq, MD
Liana Euller-Ziegler, MD
Emmanuel Petit, MD
GCrard Ziegler, MD
H6pital de I'Archet
Nice, France
1 . Taylor PW: Inflammation of the deep infrapatellar bursa of the
knee. Arthritis Rheum 32:1312-1314. 1989
2. Marchildon A. Slonim RR. Bronnhe A: Primary septic bursitis. J
Fla Med Assoc 5 0 13%141, 1963
3. Gleich S, Fomberstein B: Septic olecranon bursitis due to
hematogenous infection with Streptococcus pneumoniae. J
Rheumatol l2:lO-l8, 1985
Comment on the article by Calabrese et al
To the Editor:
In their brief report on rheumatoid arthritis (RA)
complicated by infection with the human immunodeficiency
virus (HIV) (Calabrese LH, Wilke WS, Perkins AD, Tubbs
RR: Rheumatoid arthritis complicated by infection with the
human immunodeficiency virus and the development of
Sjogren's syndrome. Arthritis Rheum 32: 1453-1457, 1989),
Calabrese et al use certain modifying terms with respect to
the co-occurrence of these 2 diseases in the same individual.
In their introduction, they write of the "relative infrequency
of certain coexisting conditions, particularly rheumatoid
arthritis." Again in their conclusion, they refer to the
"infrequency of reported cases of RA, in association with
HIV infection" (emphasis added).
In fact, these qualifying words are incorrect: There
are currently no reports of any patients with both seropositive RA and the acquired immunodeficiency syndrome
(AIDS) (Jat€e IA: Rheumatoid arthritis and AIDS [letter]. J
Rheumatol 16:845, 1989). If this lack of concomitance between the 2 diseases continues as the total number of AIDS
patients increases. then the hypothesis that the CD4+ cell is
essential for the development of RA will be greatly strengthened.
Israeli A. Jaffe, MD
College of Physicians and Surgeons
Columbia University
New York, N Y
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suprapatellar, pneumoniae, first, due, streptococcus, knee, case, reported, infectious, burst
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