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Pseudopodagra from Hemophilus Influenza in an Adult.

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68 1
BRIEF REPORTS
PSEUDOPODAGRA FROM HEMOPHIL U S INFL UENZA
IN AN ADULT
WILLIAM M. McCLATCHEY, MD, and JOHN A. GOLDMAN. M D
Septic arthritis due to Hemophilus influenza, although common in infancy, is an exceedingly rare cause
of pyarthrosis in the adult. It is thought to be rare because type specific antibodies are almost ubiquitous
in adult sera. An exhaustive search of the literature
has revealed only 12 prior cases of H influenza pyarthrosis in the adult. We report here the first case presenting as podagra and only the second case to involve a
small joint of the extremities, along with a summary review of all previous cases.
Case report. A 50-year-old man with poorly differentiated lymphatic lymphoma involving the spleen,
bone marrow, and intraperitoneal nodes, and associated
with a monoclonal IgG kappa spike developed pain in
his right first metatarsophalangeal (MTP) joint. He had
received 6 monthly courses of BCNU, cyclophosphamide, vincristine, prednisone; allopurinol was given for
10 days of each month. Twelve days before the pain he
had received a single 800 mg intravenous dose of chlorambucil followed by 100 mg/day of prednisone for 5
days. A week after the completion of prednisone, the
pain began and within 24 hours, he developed fever to
40.6"C, as well as nausea and vomiting. He received
cephalexin monohydrate 500 mg orally and was referred to Emory University Hospital.
He had a temperature of 4 1.1"C and complained
of a retroorbital headache and severe pain in the first
MTP joint of the right foot. His neck was painful on
flexion, and he had marked erythema, tenderness, and a
limited range of motion in the right first MTP joint. His
laboratory studies revealed a leukocytosis of 20,800/
mm3, with 31 polys, 61 bands, 4 metamyelocytes, 3
myelocytes, 1 lymphocyte, and 1 monocyte. His uric
From the Department of Medicine, Division of Rheumatology-Immunology, Emory University School of Medicine and Emory
University Clinic, Atlanta, Georgia.
Supported in part by a grant from the Department of Human
Resources, State of Georgia.
Address reprints requests to John A. Goldman, MD, Associate Professor of Medicine, Division of Rheumatology-Immunology,
Emory University Clinic, 1365 Clifton Road, NE, Atlanta GA 30322.
Submitted for publication December 26, 1978; accepted in
revised form February 19, 1979.
Arthritis and Rheumatism, Vol. 22, No. 6 (June 1979)
acid was 6.4 mg% and his IgA of 23 mg% and IgM of 46
mg% were both decreased. His IgG was 2109 mg%. A
lumbar puncture showed one lymphocyte, a protein of
50 mg%, and glucose of 87 mg%. He was diagnosed as
having acute podagra from gouty arthritis and possible
infection. Treatment with 2 mg intravenous colchicine
along with cefazolin and amikacin intravenously effected no relief from the podagra. He later developed
brainstem herniation with respiratory arrest, at which
time a ventriculotomy showed 235 white blood cells,
100% polys, a protein of 130 mg%, and a glucose of 80
mg%. Blood cultures grew a gram negative coccobacillus and the patient was treated with chloramphenicol
and cefazolin sodium along with dexamethasone and
mannitol.
He was then seen by the Rheumatology-Immunology Service because of the persistent podagra. Aspiration showed 3 cc of tenacious yellow-green pus with a
count of >200,000/mm3 cells and the gram stain
showed multiple gram negative coccobacillary organisms. No crystals were seen by compensated polarized
light microscopy. Subsequently, cultures of blood, cerebrospinal fluid, and synovial fluid all grew Hemophilus
influenza, type b. He responded to chloramphenicol and
his podagra completely resolved in 3 days.
Discussion. This is the first case of pseudopodagra due to Hemophilus influenza and only the
thirteenth reported case of hemophilus pyarthrosis in an
adult (1-12). In Huskisson's classic paper on pseudopodagra, fourteen causes of podagra other than gout are
recorded, including infection (13). The findings in this
patient confirm that the demonstration of intracellular
monosodium urate crystals in synovial fluid is the only
certain way to diagnose acute gouty arthritis.
Among the predisposing factors for hemophilus
pyarthrosis in the adult, trauma is the most significant
(6 cases) followed by a preceding upper respiratory infection (4 cases) and a history of some prior form of arthritis (4 cases). The case of coexisting gout and infection (Table 1, case 12) (3), where characteristic crystals
and Hemophilus influenza were both demonstrated in a
knee, was not associated with podagra, although it had
occurred previously.
BRIEF REPORTS
682
Table 1. Patients reported to have septic arthritis due to Hemophilus inffuenzo
Case*
Age,
sex
Pre-existing illness?
59, F
Diabetes
48, F
65, F
Upper respiratory
infection
None
No description
43, F
RA
Yellow-green
59, M
Alcoholism,
Yellow pus
pharyngitis
DJD 20 years prior Yellow pus
56, F
37, M
41, F
63, M
73, F
22, F
Involved joints5
Source of
positive culture#
100 cc thin, yellow
R knee
Joint
l+D
Pink
L shoulder, both
ankles
R knee,
R shoulder,
L knee, R foot
R elbow,
R knee
R knee
R shoulder,
negative blood
Joint, CSF, blood,
Pharynx
Tet, chlor, strep
Blood, joint, CSF
1+D, chlor, strep
Joint, blood
I+D, PCN, chlor
R ankle
Joint, blood
Full recovery
R hip
Joint
R knee
Joint, blood
PCN, tet, chlor,
I+D
PCN, AMP, tet,
I+D
PCN, ceph, tet,
chlor
R knee
Joint. blood
1+D, PCN, AMP
Full recovery
3rd L MTP,
Joint. blood
L knee
Joint, blood
L foot, R elbow,
tenosynovitis,
pustules
R sternoclavicular, Joint, blood,
R knee
pharynx
I+D, PCN, AMP
Full recovery
Ceph, chlor
Full recovery
PCN, gent, AMP,
I+D
Full recovery
1st R MTP
Ceph, gent, chlor
Meningitis, full
recovery
Joint fluid*
Alcoholism, hyper- Yellow-green
calcemia, trauma
60 cc yellow pus,
Prior mastoiditis,
29,700/mm3
urinary infection
glucose 56/ 133
Pharyngitis, degen- Green, yellow,
98,500/rnm3
erative arthritis,
prior trauma
Pharyngitis
78, 160/mrn3
yellow
Yellow, green pus,
SLE, trauma.
steroid
182,000/mm3
51, M Gout, trauma
58, M
Yellow pus
1 54,000/mm3
crystals
Lymphoma, steroid, Yellow-green
chemotherapy,
> 200,000/mm3
splenectomy
Joint, blood, CSF
Treatment1
Chlor, gent, strep
Results
Full recovery, postoperative myocardial infarction
Full recovery
Meningitis,
staphylococcus
sepsis, death
Meningitis, full
recovery
Full recovery
Arthrodesis
Full recovery
Reference number in parenthesis.
t DJD = degenerative joint disease; SLE = systemic lupus erythernatosus.
4 mm3 refers to white blood cell count.
8 R = right; L = left; MTP = metatarsophalangeal.
# CSF = cerebrospinal fluid.
1I+D = incision and debridment; tet = tetracycline; chlor = chloramphenicol; strep
AMP = ampicillin; ceph = cephalothin.
The synovial fluids characterized in 5 cases
showed a type 111 fluid with counts ranging from 29,000
to 200,000/mm3. In only 4 cases was the fluid described
as green, a supposed characteristic of hemophilus exudates.
In 2 other cases meningitis was a part of the infection (43); in these and our cases the arthritis preceded the meningeal infection. Of 10 patients in whom
blood cultures were obtained, 8 were positive, a finding
that suggested hematogenous spread as the most likely
source of infection. All of these patients appeared septic
and quite ill at presentation. In 8, the peripheral white
blood cell count was over 15,000/mm3 (440035, 150/mm3).In none of the 13 cases was the correct diagnosis made prior to culture results. In 5, gonococcal
=
streptomycin; gent = gentamycin; PCN = penicillin;
arthritis was the initial diagnosis, a point stressed by
Krauss et a1 (4).
The involved joints were almost exclusively
large; the knee and ankle were the most common. Six
patients had multiple joints involved. In a large number
of cases the arthritis occurred on the right as opposed to
the left side (15 versus 5). The dominant side of the patients was not recorded, so it is speculation whether preexisting minor trauma in the dominant side contributes
to the location of this infectious arthritis. A right sided
prevalence has been previously noted in gonococcal and
other infectious arthritides (7). Our patient’s podagra
occurred on his dominant side. Race and age did not
seem to have any relation in this series.
The treatment of hemophilus pyarthrosis does
BRIEF REPORTS
not seem to be a problem once a diagnosis is made. Ampicillin and chloramphenicol appear equally effective,
although susceptibility reports should determine the final choice. Full recovery occurred in all but 2 patients.
In one (case 3) the arthritis and meningitis had resolved
and death was due to staphylococcal septicemia (4). In
the only case where permanent joint destruction occurred (case 7), the presence of an infected hip after
trauma went unrecognized for over 30 days (8). The patient subsequently required an arthrodesis. Surgical
drainage was performed in 7 patients, including the first
report in 1938 in which it was the exclusive and successful mode of therapy (9).
Acknowledgment. The authors would like to
thank Ms Jennie Crook for her help in the preparation
of the manuscript.
REFERENCES
McConville JH, Pototsky RJ, Calia FM, Pachas, WN:
Septic and crystalline joint disease: a simultaneous occurrence. JAMA 231:841-842, 1975
Meligrana F, Hawks H, Marotta T: Hemophilus influenza
septicemia with polyarthritis and meningitis in an adult.
Can Med Assoc J 89:132-134, 1953
Norden CW, Sellers TF: Hemophilus influenza pyarthrosis in an adult. JAMA 189:694-695, 1964
683
4. Krauss DS, Aronson MD, Gump DW, Newcombe DS:
Hemophilus influenza septic arthritis. a mimicker of
gonococcal arthritis. Arthritis Rheum 17:267-27 I, 1974
5. Garcia-Kutzbach A, Masi AT: Acute infectious agent arthritis (IAA): a detailed comparison of proved gonococcal
and other blood-borne bacterial arthritis. J Rheumatol
1:93-101, 1974
6. Hoaglund FT, Lord GP: Hemophilus influenza septic arthritis in adults: two case reports with review of previous
cases. Arch Intern Med 119:648-652, 1967
7. Weaver JB, Sherwood L: Hematogenous pyarthrosis due
to bacillus hemophilus influenzae and corynebacterium
xerosis. Surgery 4908-913, 1938
8. Dyer RF, Romansky MJ, Holmes JR: Hemophilus
pyarthrosis in an adult. Arch Intern Med 102:580-583,
1958
9. Goldstein E, Janoski AH: Hemophilus influenza septic arthritis in adults: two case reports with review of previous
cases. Arch Intern Med 114:647-650, 1964
10. Patterson RL, Levine DB: Hemophilus influenza pyarthrosis in an adult. J Bone Joint Surg 47A:1250-1252, 1965
1 I , Lefkowitz AM, Noonan JR: Septic arthritis caused by hemophilus influenza in an adult. Case report. J Am Geriatr
SOC16:1150-1152, 1968
12. Raff MJ, Dannaher CL: Hemophilus influenza arthritis in
adults. Report of a case and review of the literature. J
Bone Joint Surg 56A:408412, 1974
13. Huskisson EC, Balme HW: Pseudopodagra: the differential diagnosis of gout. Lancet 2:269-27 1, 1972
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