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Septic arthritis due to mycoplasma hominis.

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1044
BRIEF REPORT
SEPTIC ARTHRITIS DUE TO MYCOPLASMA HOMZNZS
MALCOLM I. McDONALD, JOSEPH 0. MOORE, JOHN M. HARRELSON, CLARE P. BROWNING,
and HARRY A. GALLIS
Mycoplasma hominis is commonly found in the
normal female genital tract (1) and has been implicated
as an etiologic agent in pelvic inflammatory disease
(2), acute pyelonephritis (3), and postpartum fever (4),
occasionally associated with bloodstream invasion in
the latter setting (5,6). In addition, 3 cases of septic
arthritis in the postpartum period due to M hominis
have been reported (7,8). To our knowledge, no cases
of septic arthritis have been reported outside this
context.
The following report describes a case of it4
hominis septic arthritis of the wrist and hip in a patient
with non-Hodgkin’s lymphoma.
Case report. In August 1978, a 54-year-old
white woman presented with generalized lymphadenopathy, hepatosplenomegaly, and ascites. Lymph node
mass was found in the paraaortic area, displacing both
kidneys laterally and extending into the pelvis; biopsy
revealed nodular poorly differentiated lymphocytic
lymphoma. She received 16 courses of cyclophosphamide, vincristine, and prednisone, which produced
only partial remission. Subsequently multiple agent
chemotherapy with combinations including Bicnu and
Adriamycin was begun.
From the Duke University Medical Center, Durham, North
Carolina.
Malcolm I. McDonald, FRACP: Infectious Disease Fellow;
Joseph 0. Moore, MD: Assistant Professor, Division of Hematology
and Medical Oncology; John M. Harrelson, MD: Assistant Professor, Division of Orthopedic Surgery and Assistant Professor of
Pathology; Clare P. Browning, MASCP: Microbiology Technologist; Harry A. Gallis, MD: Assistant Professor, Division of Infectious Diseases.
Address reprint requests to Dr. Malcolm McDonald, Box
3825, Duke University Medical Center, Durham, NC 27710.
Submitted for publication September 21, 1982; accepted in
revised form March 7, 1983.
Arthritis and Rheumatism, Vol. 26, No. 8 (August 1983)
In July 1981 she developed oliguria and renal
failure, and retrograde pyelography showed bilateral
ureteric obstruction. A stent was placed in the right
side past a distal obstruction, and the patient received
radiation therapy to the abdomen. Her renal function
improved and a regimen of long-term oral trimethopridsulfamethoxazole (TMP-SMX) 80 mg/400 mg, 1
tablet every 12 hours, was begun for urinary prophylaxis.
In October 1981 chemotherapy was recommenced for advancing lymphoma. She complained of
increasing abdominal discomfort and on October 13,
cystoscopy and retrograde studies were repeated.
There was free reflux of contrast up the right ureteric
stent, no obstruction was found, and it was considered
that the discomfort was due to the tumor mass. Urine
culture was sterile and microscopy results normal.
TMP-SMX prophylaxis was continued.
In November she developed arthralgia in the
left wrist, left shoulder, and both knees. Although
afebrile, she was taking prednisone, 30 mg and 10 mg
on alternate days. No specific diagnosis was made and
treatment with tolmetin sodium resulted in relief of
pain except in the left wrist.
On December 22, a roentgenogram of the left
wrist was reported as showing degenerative changes
and reduced joint space between the radius and the
carpus “consistent with rheumatoid arthritis.” She
had little relief from splinting, local heat, and oral
analgesics. During the next week pain developed in the
left hip, and the patient was readmitted to the hospital.
She was pale and afebrile with a large abdominal mass
palpable from the epigastrium to the suprapubic area.
The left hip joint, while still weight bearing, was tender
anteriorly. The left wrist was warm, swollen, and had
marked limitation of movement.
1045
BRIEF REPORTS
Figure 1. Radiograph of left hip. showing obliteration of articular
space with periarticular osteoporosis.
Laboratory values included hematocrit of
19.8% with a white blood cell count (WBC) of
l,000/mm3 (1 x 109/liter) with 68% neutrophils. The
Westergren erythrocyte sedimentation rate (ESR) was
126 mm/hour. Roentgenogram of the left hip (Figure I )
showed obliteration of the articular space with periarticular osteoporosis; another roentgenogram of her left
wrist showed further loss of articular space (Figure 2).
Tests for the rheumatoid factor and antinuclear antibodies were negative. Routine urine culture was negative and there was no pyuria. Pancytopenia was
thought to be due to tolmetin sodium, and this was
discontinued.
On January 9, 1982, a left hip aspirate was
A
performed and microscopy showed 150.000/mm3 (1.5
x IO"/liter) red cells and a WBC of 100,000/mm3 ( 1 X
10"Aiter) (96% neutrophils and 4% lymphocytes). The
fluid contained no birefringent crystals and Gram stain
was negative. There was no bacterial growth on routine culture media.
She began receiving nafcillin and amikacin intravenously and TMP-SMX was discontinued. Her
peripheral white cell count had by this time returned to
7,000/mm3 (7 x 109/liter).
There was no symptomatic improvement, and
on January 25 a synovial biopsy was performed on the
left wrist. Histology showed fragments of synovial
tissue with fibrosis and focal acute inflammatory
changes. Direct stains for bacteria, acid fast bacilli,
and fungi were negative. Normal aerobic cultures were
also negative. However, small colonies were noted
from the wrist fluid on the anaerobic incubations. The
tentative report was of an organism of the Mycoplnsma genus. In view of this, a regimen of oral doxycycline was begun, and the other antibacterial agents
were stopped.
The pain in the left hip was not controlled with
analgesics, and on February 8 a Girdlestone resection
of the left femoral head was performed. Histologic
examination showed an inflammatory infiltrate of the
hip capsule and marrow spaces, composed of plasma
cells, histiocytes, eosinophils, and lymphocytes. Intertrabecular fibrosis and focal trabecular bone necrosis
were also seen. Special stains for bacteria and fungi
were again negative.
The organism cultured from the wrist and subsequently from the hip was identified as Mycoplasma
hominis.
B
Figure 2. A, Radiograph of left wrist, showing reduced joint space between radius and carpus. B, Radiograph of normal
right wrist, for comparison.
1046
During the next 3 weeks pain in the left wrist
steadily diminished, and the patient regained some use
of the hand. Her left leg remained in traction and the
wound healed well. Her ESR fell to 35 mm/hour.
In the last week of February, she developed
gastric outlet obstruction due to lymphoma. Her condition rapidly deteriorated, and she died on March 8.
Unfortunately, no joint material was obtained postmortem for histology or cultures.
Discussion. Mycoplasmas have been previously
associated with acute and chronic inflammatory joint
disease, and there are a number of reports of monarticular and migratory polyarthritis after Mycoplasma
pneurnoniae infection (9-1 I). A serologic diagnosis
was made in most cases, the clinical picture being
more suggestive of an immune synovial response than
that of septic arthritis. Recently, however, Ureaplasma ureafyticumhas been recovered from joints of
2 patients with septic arthritis and hypogammaglobulinemia (12,131. Both patients responded to appropriate antimicrobial chemotherapy.
The 2 cases of M hominis septic arthritis discussed by Andrews (7) occurred within 3 weeks of
childbirth. The first patient, a 23-year-old woman,
presented with a painful swollen knee and pyrexia
(38.6”C). Following aspiration of the joint, she was
treated with TMP-SMX and then cloxacillin, followed
later by an arthrotomy. M horninis was isolated in pure
heavy growth from the joint aspirate. She was subsequently treated with tetracycline and had a full recovery.
The second case occurred in a 17-year-old girl,
who developed septic arthritis of the left hip, with M
horninis recovered from blood and joint fluid (7).
There is no record of her treatment or outcome.
The patient described by Verinder (8) was a 40year-old primigravida who developed postpartum fever and pain in the left hip 48 hours after giving birth.
The hip was explored and the articular cartilage was
found to be covered by fibrous exudate. M horninis
was identified 3 days later from cultures of the joint
fluid, blood, and vaginal discharge. She was treated
with tetracycline and had a good clinical response,
although there was radiologic evidence of residual
joint space narrowing.
In this case report, the patient was severely
immunosuppressed due to extensive lymphoma, corticosteroids, and anti-tumor chemotherapy, followed
by probable drug-induced neutropenia. While such a
patient has increased susceptibility to a wide range of
viral, bacterial, and fungal infections, mycoplasmas
BRIEF REPORTS
are not generally recognized as important pathogens.
It is probable that the urinary tract became
colonized following the insertion of the ureteric stent.
No urinary infection was documented using routine
culture techniques, and the patient was receiving
TMP-SMX prophylaxis. Unfortunately, however, no
urine was submitted for culture of mycoplasmas before the patient began receiving doxycycline. The
cystoscopy and retrograde contrast studies on October
13, 1981 could have produced a bacteremia, perhaps
seeding a number of joints. The patient first complained of joint pain 4 weeks later, and her illness
followed a subacute course for 2 months until joint
aspirate fluid and histology of biopsy material showed
a destructive septic arthritis. M hominis is capable of
producing pyogenic infections (14) and there was no
evidence of other bacterial pathogens, including mycobacteria or fungi. Furthermore, symptoms worsened
on a broad spectrum antibacterial cover, and there was
no clinical improvement until treatment with doxycycline was instituted.
In this case, colonies from the wrist synovial
fluid were initially recognized on the anaerobic plates
(phenyl ethyl alcohol agar [BBL] and sheep blood) at
72 hours from “blind” subculture of the broth. Isolates from the hip subsequently also grew directly on
the anaerobic plates only, and colonies were recognized on day 4. M horninis can be initially identified by
biochemical characteristics, but the definitive speciation procedure is to demonstrate growth inhibition
with specific antiserum.
Immunocompromised patients are not only
more susceptible to infection caused by commonly
recognized pathogens but may also acquire serious
infections due to microorganisms regarded to be of low
pathogenicity. It is important to maintain a high index
of suspicion for unusual pathogens in such a setting. M
horninis grows best in a microaerophilic or anaerobic
atmosphere. Had the joint fluid from this patient not
been cultured anaerobically or had the microbiology
laboratory technician been less astute, the diagnosis
may well have been overlooked.
Acknowledgment. The authors wish to thank Wallace
A. Clyde, Jr., MD, Professor of Pediatrics and Bacteriology,
University of North Carolina, for speciating the organism
and for his valuable advice.
REFERENCES
1. Sautter RL, Brown WJ: Sequential vaginal cultures from
normal young women. J Clin Microbiol 1:479-484, 1980
2. Taylor-Robinson D, McCormick WM: The genital my-
BRIEF REPORTS
3.
4.
5.
6.
7.
8.
coplasmas. N Engl J Med 302:1003-1009, 1063-1067,
I980
Thomsen AC: Occurrence of mycoplasmas in urinary
tracts of patients with acute pyelonephritis. J Clin Microbiol 8:84-88, 1978
Platt R, Warren JW, Edelin KC, Lin J-SL, Rosen B,
McCormick WM: Infection with Mycoplasma hominis in
postpartum fever. Lancet 2: 1217-1221. 1980
Wallace RJ Jr, Albert S, Browne K , Lin J-SL, McCormick WM: Isolation of Mycoplasma hominis from blood
cultures in patients with postpartum fever. Obstet Gynecol 5: 181-185, 1978
Tully JG, Smith LG: Postpartum septicemia with Mycoplasma hominis. JAMA 204:827-828, 1968
Andrews BE: Public Health Laboratory Service (Britain). Communicable Disease Reports 31, 1974
Verinder DGR: Septic arthritis due to Mycoplasma
hominis. J Bone Joint Surg (Br) 60:224, 1978
1047
9. Weinstein MP, Hall CB: Mycoplasma pneumoniae infection associated with migratory polyarthritis. Am J Dis
Child 127:125-126, 1974
10. Hernandez LA, Urquhart G E , Dick WC: Mycoplasma
pneumoniae infection and arthritis in man. Br Med J
2:14-16, 1977
1 1 . Ponka A: Arthritis associated with Mycoplasma pneurnoniae infection. Scand J Rheumatol 8:27-32, 1979
12. Stuckey M, Quinn PA, Gelfand EW: Identification of
Ureaplasma urealyticum (T-strain mycoplasma) in patient with polyarthritis. Lancet 2:917-920, 1978
13. Webster DB, Taylor-Robinson D. Furr MP. Asherson
GL: Mycoplasmal (ureaplasma) septic arthritis in hypogammaglobulinaemia. Br Med J 1:478-479, 1978
14. M%rdh P-A, Westrom L: Tuba1 and cervical cultures in
the acute salpingitis with special reference to Mycoplasma hominis and T-strain mycoplasmas. Br J Vener Dis
46: 179-186, 1970
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