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Septic sternoclavicular arthritis with pasteurella multocida and streptococcus sanguis.

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467
BRIEF REPORT
SEPTIC STERNOCLAVICULAR ARTHRITIS WITH PASTEURELLA
MULTOCIDA AND STREPTOCOCCUS SANGUIS
JOHN F. NITSCHE, JOHN H. VAUGHAN, GARY WILLIAMS, and JOHN G. CURD
Pasteurella multocida is a small, facultative
bacterium identified by its gram-negativity , nonmotility, and rod-like shape. This resident within the normal
mouth flora of many animals is frequently transmitted
to humans by a cat bite or scratch. Although rarely
pathogenic for humans, the organism may cause human infectious disorders of 3 types: 1) cellulitis with
contiguous septic arthritis or osteomyelitis, 2) superinfection of a chronically diseased lung, and 3) septicemia with meningitis, chorioamnionitis, or endocarditis
(1). Streptococcus sanguis is a member of the viridans
group of streptococci (2). This heterogeneous group of
streptococci have been cultured from the mouth, upper respiratory tract, lower intestinal tract, genitourinary tract, and skin of healthy humans (3). An important component of dental plaque of humans, S sanguis
is the pathogenic agent in a significant percentage of
patients who have subacute bacterial endocarditis (2).
To our knowledge, this organism has never been
reported in a patient with septic arthritis. We now
present the first case report of a patient with septic
arthritis of the sternoclavicular joint from which both
P multocida and S sanguis were recovered in cultures.
Case report. A 27-year-old male gardener entered the hospital of Scripps Clinic and Research
~~
This is publication number 2513, from the Departments of
Clinical Research and Molecular Immunology, Scripps Clinic and
Research Foundation, 10666 North Torrey Pines Road, La Jolla, CA
92037.
Supported by National Institutes of Health Grants AM
07144 and AM 00543.
John F. Nitsche, MD; John H. Vaughan, MD; Gary Williams, MD, PhD; John G. Curd, MD.
Address reprint requests to John G . Curd, MD, Department
of Molecular Immunology, Scripps Clinic and Research Foundation,
10666 North Torrey Pines Road, La Jolla, CA 92037.
Submitted for publication July 2, 1981; accepted in revised
form October 29, 1981.
Arthritis and Rheumatism, Vol. 25, No. 4 (April 1982)
Foundation with a 4-week history of chills, fever, and
pain, swelling, and tenderness around his left sternoclavicular joint. For the preceding 3 weeks, he had
been treated with analgesics and oral corticosteroids.
Ten days before he was admitted to the hospital, he
had received an intraarticular injection of corticosteroids, which brought transient relief, but the pain had
returned and intensified. When he was interviewed at
Scripps, he said that he had no history of skin rash,
headache, conjunctivitis, cough, sore throat, diarrhea,
dysuria, or penile discharge. There was no history of
intravenous drug abuse. He frequently sustained minor abrasions of the hands from his work as a gardener
and regularly played with the 3 cats he owned.
During his admittance physical examination,
his temperature was 38.2"C. The tenderness and swelling that surrounded his left sternoclavicular joint extended laterally over the proximal third of the clavicle,
and movement of the left upper extremity produced
severe pain in this joint. On the same day, an attempt
to aspirate the joint was unsuccessful.
Findings from routine radiographs of the chest,
cervical spine, and sternoclavicular joints were interpreted as normal. By tomography of the left sternoclavicular joint, however, a loss of cortical bone at the
medial margin of the left clavicle was shown (Figure
1). A technitium bone scan revealed definite increased
uptake in the left sternoclavicular joint and probable
increased uptake in the left shoulder (Figure 2 ) .
In the initial laboratory evaluation, his hematocrit was 44%, leukocyte count was 15,800/mm3 (3
bands, 73 segmented, I5 lymphocytes, and 9 monocytes), and erythrocyte sedimentation rate was 43
mm/hour (Westergren). N o antinuclear antibodies or
rheumatoid factors were found in his serum. Serum
levels of uric acid, CH50, C4, and C3 were normal.
There was no bacterial growth in 2 aerobic and 2
BRIEF REPORTS
468
Figure 1. Tomogram of the sternoclavicular joints. Note the smooth contour of the end of the right clavicle in
contrast to the irregular end of the left clavicle (arrow).
anaerobic blood cultures. In subsequent evaluations,
results of his delayed hypersensitivity skin reactions,
quantitation of serum immunoglobins, serum protein
electrophoresis, and serum immunoelectrophoresis
were all normal. Polymorphonuclear leukocyte function, as assessed by zymosan stimulated chemoluminescence and iodination, was also normal.
Because the cause of his persistent monarticular arthritis was unknown and results of ancillary
radiography were abnormal, the patient underwent
open biopsy and debridement of the joint. During
surgery, we found that the joint contained no purulent
fluid, but the cartilagenous articulations of both the
sternum and clavicle had been destroyed. Gram stain
of the specimens revealed gram-positive cocci in pairs
and chains indicative of streptococcus. Intravenous
penicillin was started at a dose of 2.5 million units
every 4 hours. The patient became afebrile in 2 days.
Figure 2. Technitium bone scan. Note the increased uptake of radioactivity in the left sternoclavicular joint
(arrow) compared to the right sternoclavicular joint.
BRIEF REPORTS
Initial cultures of the minced tissues on blood agar
grew S sanguis that was sensitive to penicillin. Within
a week, the anaerobic culture yielded P multocida,
which was also sensitive to penicillin. The antibiotic
was continued intravenously for 4 weeks. The patient
was discharged and felt well at a followup examination
I month later. He had returned to work and had near
normal range of motion in his left sternoclavicular joint
and shoulder.
Discussion. Although both P rnultocida and S
sanguis were grown from the joint tissues from this
patient, we believe that the primary infective agent
was probably P multocida and that S sanguis was
introduced secondarily at the time of injection of
corticosteroids 10 days before admission to Scripps.
This belief is based on the fact that there have been no
previous reports of septic arthritis due to S sanguis,
but there have been 14 cases due to P multocida (416). The first case was reported in 1944 (4) in a patient
with a P multocida bacteremia. In the subsequent 13
reported cases, 7 had rheumatoid arthritis (7,8,1012,15), and 5 of these were receiving regular corticosteroid therapy (7,11,12,15). Altogether, 9 patients had
knee involvement (4,5,7,11-15), 3 of whom had prosthetic joints (1 1,12,14). Contiguous osteomyelitis was
reported in 3 patients (5,8). Ten of the 14 cases
involved significant exposure to cats (6-8,10,13-15).
The organism was sensitive to penicillin in all instances except 1 (7). P multocida was identified in only
2 cases by Gram stain of the synovial fluid (13,15). Our
patient was like these previously reported patients in
respect to the contiguous osteomyelitis, the exposure
to cats, and the fact that the organism was not detected
by Gram stain.
Of approximately 20,000 cultures from inpatients at Scripps Clinic in the past 6 years, P multocida
was reported on only 4 previous occasions and apparently never reported as a contaminant. Three of the
cultures were from the purulent sputa of patients with
chronic obstructive pulmonary disease. The organism
was recovered on a fourth occasion from an animal
bite in a diabetic patient.
Probably the reason that we did not see P
multocida on Gram stain or recover the P multocida
from the aerobic culture plate in the present case was
the low number of infecting organisms. Either the
small amount of innoculum required for blood agar
plates failed to reveal this organism, or the abundant
growth of S sanguis on the aerobic plate might have
prevented detection of a low number of P multocida.
Possibly culturing a larger volume of tissue, such as is
used for anaerobic tube cultures, would facilitate
identification of P multocida (16).
469
This is also the first report of S sanguis recovered from any patient with septic arthritis. We cannot
be sure that this organism was introduced only as a
secondary agent during the intraarticular manipulations that preceded open biopsy in this patient. This is,
however, our preferred interpretation, because S sanguis (but not P multocida) is normally present in
humans; therefore, only S sanguis would normally be
available as a superinfecting organism.
REFERENCES
1 . Gutman LT: Pasteurella, Zinsser Microbiology. Seventeenth edition. Edited by WK Joklik, H P Willet, DB
Amos. New York, Appleton-Century-Crofts, 1980, pp
791-793
2. Gallis HA: Streptococcus, Zinsser Microbiology. Seventeenth edition. Edited by WK Joklik, HP Willet, DB
Amos. New York, Appleton-Century-Crofts, 1980, pp
568-571
3. Washington JA: Medical bacteriology, Clinical Diagnosis and Management by Laboratory Methods. Edited by
J E Henry. Philadelphia, W. B. Saunders Company,
1979, p 1574
4. Robinson R: Human infection with Pasteurella septica.
Br Med J 2:725, 1944
5. Pizey NCD: Infections with Pasteurella septica in a
child aged three weeks. Lancet 2:324-326, 1953
6. Holmes MA, Brandon G: Pasteurella multocida infections in 16 persons in Oregon. Public Health Rep
80: 1107-1 112. 1965
7. Barth WF, Healey LA, Decker JL: Septic arthritis due
to Pasteurella muttocida complicating rheumatoid arthritis. Arthritis Rheum 2:394-399, 1968
8. Bell DB, Marks MI, Eickoff TC: Pasteurella multocida
arthritis and osteomyelitis. JAMA 210:343-345, 1969
9. Jones FL, Smull CE: Infections in man due to Pasteurella muitocida. Pa Med 4:41-44, 1973
10. Pestana 0: Mycotic aneurysm and osteomyelitis secondary to infection with Pusteurella multocida. Am J Clin
Pathol 62:355-360, 1974
11. Griffin AJ, Barber HM: Joint infection by Pasteurella
multocida. Lancet 1:1347-1348, 1975
12. Maurer KH, Hasselbacher P, Schumacher HR: Joint
infection by Pasteurella multocida. Lancet 2:409, 1975
13. Johnson RH, Rumans LW: Unusual infections caused
by Pasteurella multocida. JAMA 237: 146-147, 1977
14. Spagnuolo PJ: Pasteurella multocida infectious arthritis.
Am J Med Sci 275(3):359-363, 1978
15. Williams RA, Fincham WJ: Septic arthritis due to Pasteurella multocida complicating rheumatoid arthritis.
Ann Rheum Dis 38:394-95, 1979
16. Smith JE: Pasteurella, Bergey’s Manual of Determinative Bacteriology. Eighth Edition. Edited by RE BUchanan, N E Gibbons. Baltimore, Williams and Wilkins
Company, 1974, pp 370-372
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