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Septic arthritis due to serratia liquefaciens.

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BRIEF REPORT
SEPTIC ARTHRITIS DUE TO SERRA TIA LIQ UEFACIENS
WILLIAM B. HARDEN, JOHN F. FISHER, DONALD H. LOEBL, and JOSEPH P. BAILEY
First reported in 1952 (l), septic arthritis due to
serratiae is a rare opportunistic infection apparently increasing in incidence (2-8). All previous accounts of
these infections have been in debilitated patients receiving broad spectrum antibiotics, patients with compromised host defenses, or heroin addicts. Organisms
isolated from these individuals included Serratia marcescens or Serratia species.
Formerly taxonomically classified in the genus
Enterobacter, Serratia liquefaciens is an infrequent isolate from clinical material. Serratiae are generally considered to be free living commensals found in natural
bodies of water and soil and were formerly considered
nonpathogenic to humans. Serratia species have
emerged that are not only virulent, but also resistant to
many of the antibiotics currently used in clinical practice. In studies from one laboratory, S marcescans accounted for 90% of 1560 clinical isolates of serratiae,
while only 7% were identified as S liquefaciens (9-11).
To our knowledge, septic arthritis due to this organism
has not been previously described.
Case Report. A 34-year-old black woman with
sickle cell anemia recognized at the age of 22 years
and 3 previous episodes of Gram-negative bacillary arthritis involving the left shoulder (Klebsiella), right knee
(Enterobacter), and left hip (Klebsiella) was admitted to
a community hospital because of chest pain. Although
the etiology of the chest pain was not determined, her
hospital course was complicated by the development of
right hip pain, persistent fever, and acute urinary retention. The patient received multiple antibiotics during
From the Department of Medicine, Medical College of
Georgia, Augusta, Georgia.
Address reprint requests to John F. Fisher, MD, Department
of Medicine, Medical College of Georgia, Augusta, Georgia 30912.
Submitted for publication December 17, 1979; accepted in
revised form April I, 1980.
Arthritis and Rheumatism, Vol. 23, No. 8 (August 1980)
this hospitalization including cefoxitin, cephalexin, sulfisoxazole, and gentamicin. She was referred as an outpatient to the Orthopedic Clinic of the Medical College
of Georgia for continued hip discomfort. At the time of
evaluation, the patient complained of fever with severe
pain and decreased right hip mobility. She denied pain
in other joints. Physical examination revealed a temperature of 38.4"C and marked tenderness and limitation
of motion of the right hip joint. Examination of the
right knee disclosed no abnormality. A Foley catheter
was inserted.
The patient was admitted for further studies. Her
hemogram disclosed the following results: hemoglobin
6.5 gm/dl, hematocrit 2 1.5%, reticulocyte count 10.7%,
white blood cell count 19,000 with a predominance of
neutrophils. The urine contained three to five white
blood cells per high power field and innumerable yeast
and bacteria. Although greater than lo5 colonies of
Candida albicans were recovered from urine, bacteria
were not isolated. Radiographs of the right hip were difficult to interpret since aseptic necrosis of the femoral
head, bone infarct, and osteomyelitis could not be reliably excluded. Bone scan disclosed concentration of
radionuclide in the right femoral head and proximal
tibia. A Gram stain of synovial fluid obtained by arthrocentesis of the right hip showed neutrophils, but no
microorganisms. Empirical therapy with cefamandole
was therefore begun.
Because of continued fever and pain, a repeat arthrocentesis was performed yielding serosangiunous
fluid. Serratia liquefaciens, intermediately susceptible to
cefamandole, was subsequently isolated from the material aspirated and from blood cultures. Substitution of
gentamicin for cefamandole resulted in gradual defervescence, relief of pain, and increase in hip mobility.
Because of continued improvement, open drainage was
deemed unnecessary by orthopedic consultants. Gentamicin was administered for 42 days.
BRIEF REPORTS
Discussion. This patient demonstrates the wellknown predilection of patients with sickle cell anemia
for Gram-negative bacillary infections of bone and
joints (12). Actually, patients with sickle cell anemia
have shown to be at increased risk for a variety of
Gram-positive and Gram-negative bacterial infections.
This susceptibility has been attributed not only to functional asplenia but also to a defect in the alternate complement pathway resulting in levels of heat labile opsonins inadequate for the phagocytosis of encapsulated
microorganisms ( 13- 16). Furthermore, constant
erythrophagocytosis by the reticuloendothelial system, a
prominent feature of many hemolytic diseases, results in
impaired killing of microorganisms (17). Compounding
these problems, the hypoxemia resulting in part from
intrapulmonic shunting in these patients may further retard phagocytosis by alveolar macrophages (18). The repeated ischemic insults to the bony skeleton so characteristic of this disease may well have damaged and
predisposed this patient to infection of the right hip and
the previously involved joints.
We were unable to find a report of infectious arthritis caused by either Enterobacter liquefaciens or, as
the organism is currently classified, S liquefaciens, in the
English literature. Although the majority of serratia infections are caused by S marcescens and nosocomially
acquired, little epidemiologic information is available
concerning S liquefaciens. The previously reported occurrence of vertebral osteomyelitis due to this organism
in a heroin addict (19) and the present patient suggest
an opportunistic pattern similar to S marcescens and
other Enterobacteriaceae.
In light of the multiple musculoskeletal pains experienced by patients with sickle cell anemia and the
difficulty in differentiating bone infarct from bone infection in these subjects, it is conceivable that suppurative arthritis in this patient resulted from a previously
unrecognized contiguous focus of chronic osteomyelitis.
The abrupt onset of arthritis in this debilitated individual who had been prolongedly hospitalized and who
had received broad spectrum antibiotics and bladder
catheterization suggests nosocomial acquisition of this
unusual organism with bacteremic seeding of the hip
joint and possibly proximal femur.
Acknowledgments. The authors wish to thank
Ms Alma Bussey and Mrs. Peggy Salter for their secretarial assistance.
947
REFERENCES
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2. Atlas E, Belding ME: Serratia marcescens arthritis requiring amputation. JAMA 204:165-167, 1968
3. Burton DS, Nagel DA: Serratia marcescens infections in
orthopedic surgery. Clin Orthopedics 89: 145-149, 1972
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rheumatoid arthritis. JAMA 225: 1642-1643, 1973
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11. Ewing WH, Davis BR, Fife MA, Lessel EF: Biochemical
characterization of Serratia Iiquefaciens (formerly Enterobacter liquefaciens) and Serratia rubidaea. Int J Syst Bacteriology 23~217-225, 1973
12. Barrett-Connor E: Bacterial infection and sickle cell
anemia. Medicine 50(2):97-112, 1971
13. Winklestein JA, Drachman RH: Deficiency of serum opsonizing activity in sickle-cell disease. N Engl J Med
279:459466, 1968
14. Johnston RB, Newman SL, Struth AG: An abnormality
of the alternate pathway of complement activation in
sickle-cell disease. N Engl J Med 288:803-808, 1973
15. Johnston RB: Increased susceptibility to infection in
sickle cell disease: review of its occurrence and possible
causes. Southern Med J 67: 1342- 1348, 1974
16. Green GM: Pulmonary clearing of infectious agents. Ann
Rev Med 19:315-333, 1968
17. Kaye D, Gill FA, Hook EW: Factors influencing host resistance to salmonella infections: the effects of hemolysis
and erythrophagocytosis. Am J Med Sci 254:205-2 15,
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Joint Surg 58A:132-134, 1976
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