Joint infection by anaerobic bacteriaA case report and review of the literature.код для вставкиСкачать
Joint Infection by Anaerobic Bacteria: A Case Report and Review of the Literature By IRWINZIMENT, M.B., ALVINDAVIS, M.D., A case of Bacteroides fragilis arthritis of the knee following intraarticular steroid therapy is described. Details of a literature review revealing 47 cases of arthritis due to nonsporeforming anaerobic bacteria are presented also. Features which, when present, suggest the possi- I of cases of joint infection, no organism is found when the joint fluid is examined by conventional cultural methods. Since adequate anaerobic cultures may not always be obtained in such cases, it is conceivable that infections caused by anaerobic bacteria are often overlooked. Although such joint infections are undoubtedly uncommon, a number of cases have been described which clearly illustrate the pathogenicity of anaerobic bacteria. We report here the case of a joint infection by an anaerobic organism, Bacteroides fragilis, together with a literature review. N A SIGNIFICANT PROPORTION CASEREPORT A 63-year-old Mexican-American farm laborer was admitted to Orange County General Hospital on December 10, 1964, complaining of a painful swollen left knee and fever of 1 day duration. For 3 years he had had painless swelling of the left IRWINZIMENT, M.B.: Full-time St& Physician, Medical Service, Harbor General Hospital, Torrance, California; and Assistant Professor of Medicine, Department o f Medicine, University of California School of Medicine, Los Angeles, California. ALVINDAVIS,M.D.: Associate Chief, Infectious Disease Section, Medical Service, Wadrworth Hospital, Veterans Administration Center; and Associate Clinical Professor o f Medicine, Lkpartment of Medicine, University of California School of h m n s AND AND SYDNEY M. FINEGOLD, M.D. bility of anaerobic joint infection include foul-smelling pus, gas in a joint, and the unique morphology of many anaerobes on gram stain of pus. The sternoclavicular and sacroiliac joints are peculiarly susceptible to Bacteroides infections. knee, which had increased in the 4 months prior to admission and had become uncomfortable. His physician had aspirated fluid and injected corticosteroids four times during the previous 3 months. At the time of the last aspiration 1 week before admission, the fluid was reported to be “normal.” On admission the temperature was 100.4OF (mouth). The left knee was warm, swollen, and tender, with reddening of the overlying skin. Physical examination otherwise was noncontributory. Radiographic examination of the left knee revealed only slight changes consistent with degenerative arthritis; no gas was present in the tissues. The joint was aspirated, and 30 ml. of a viscous yellow fluid was obtained, which had a white cell count of 30,000 per mm.3, with no differential count reported. The fluid developed a good mucin clot. Examination of the stained aspirate revealed a small number of gram-negative rods resembling Bacteroides. Aerobic culture of the fluid failed to yield growth, but small, pale-staining, somewhat pleomorphic gram-negative rods appeared in fluid thioglycollate medium. The organism was subsequently identified as Bacteroides fragilis. Other laboratory results included the following: hematocrit 40 per cent, white cell count 14,900 Medicine, Los Angeles, California. SYDNEYM. FINEGOLD, M.D.: Chief, Infectious Disease Section, Medical Service, Wadsworth Hospital, Veterans Administration Center; and Professor of Medicine, Departnwnt o f Medicine, University of California School of Medicine, Los Angeks, California. Reprint reque& should be addressed to Or. Finegold at Wadsworth Hospital, Veterans Administration Center, Los Angeles, California 90073. RHEUMATISM, VOL. 12, No. 6 (DECEMBER, 1969) 627 628 ZIMENT ET AL. Table 1.-End Formic Substrate Peptone-yeast Peptone-yeast-glucose Peptone-yeast-pyruvate Products of Fermentation Acid Acetic Acid Propipnic Acid 0 0 0 0.67 * 0.44 1.36 0.64 0.38 0.53 Isobutvric Acid Trace Trace 0.03 Butyric Acid Isovaleric Acid Valeric Acid 0 0 0.17 0 0 0 0 0.02 0.11 *mEq./per 100 ml. of medium. Tests for the presence of DNAse were done on DNAse test medium (BBL ) supplemented with hemin and yeast extract. Glutamic acid decarboxylation and growth in the presence of Victoria blue 4R (1:100,000) were studied using the methods of Suzuki e t aL,i and growth in the presence of brilliant green ( 1: 140,000) was studied by the technic of Beerens.* Antibiotic susceptibility was tested by plate dilution technic using previously described methods.9 The organism isolated from the described case was an obligately anaerobic gram-negative bacillus varying in size from coccobacilli to short filaments, with most of the rods 2-3 microns in length. There was considerable irregularity of staining, but no pleomorphism aside from variable length. Growth in fluid media was diffuse. The organism was nonmotile and did not produce spores. Colonies on blood agar were 2 mm. in diameter, raised, smooth, glistening, entire, and gray to gray-white in color. There was no hemolysis or greening of the medium on blood agar. There was no inhibition of growth in bilecontaining media, and a heavy precipitate was formed. DNAse was not demonstrated, there was no reaction on egg yolk agar, and there was little or no inhibition in media containing Victoria blue or brilliant green. Glutamic acid was decarboxylated. Terminal p H in glucose broth was 5.0 (control, 7.3) with a small amount of gas produced. Other sugars fermented were sucrose, maltose, lactose, galactose, and raffinose. Arabinose, xylose, and rhamnose were not fermented. End products of fermentation, as determined by gas-liquid chromatography following 3 weeks of incubation, are shown in Table 1. BACTERIOLOGICAL STUDIES Silicic acid column chromatography of the glucose-containing broth revealed 0.32 mEq. of Routine bacteriologic tests were done by the succinic acid/ml. of medium (corrected for basal methods described by Conn.1 The effect of bile was studied by the technic of Loesche et al.2 Gas medium); no lactic acid was produced. Propionic acid was not formed from threonine. chromatography and silicic acid column chroAntibiotic susceptibility studies yielded the rematography were used for studies of threonine deamination and analysis of end products of fer- sults shown in Table 2. mentation of glucose and pyruvate, using modificaThese studies indicate that the organism should tions of the technics of Moore and co-workers.3-6 he classified as Buctemides frugilis. per mm.3, with 80 per cent polymorphonuclears, 10 per cent bands, 8 per cent lymphocytes, 2 per cent monocytes. The erythrocyte sedimentation rate, Wintrobe method (corrected), was 38 mm. in the first hour. A fasting blood sugar was 91 mg./100 ml., uric acid was 4.8 mg./100 ml., L E cells were not found, and rheumatoid factor was not present. Treatment was started with procaine penicillin, 600,000 U, and streptomycin, 0.5 Gm., every 12 hours ( both intramuscular). Aqueous penicillin, 500,000 U in 5 ml. saline, was instilled into the affected joint on each of the first 2 days. The patient remained febrile for the next 7 days, and the knee joint was aspirated daily; the fluid obtained was similar to that aspirated on admission. Cultures on 5 successive days yielded the same Bacteroides organism, On the fourth day after admission, tetracycline, 500 mg. four times a day, was substituted for streptomycin. On the seventh hospital day, the knee was incised and drained. Synovial biopsy revealed only chronic inflammation. Following operation, the knee drained serosanguinous fluid with a slight foul smell for several days. Procaine penicillin treatment was stopped 5 days postoperatively, and tetracycline was stopped on the twelfth postoperative day. The patient became afebrile 1 week after surgery and the inflammation in the knee gradually subsided over the next 4 weeks. The patient was discharged from the hospital with a cylinder cast on the left leg, which was removed 5 weeks postoperatively. Subsequent radiograms showed no change from the initial films. Aspiration of an effusion 2 months after discharge yielded only 3 ml. of clear sterile fluid. 629 JOINT INFECTION BY ANAEROBIC BACTERIA Table 2.-Antibiotic Susceptibility Studies* 25.0 0.78 12.5 25.0 6.2 Penicillin G Tetracycline Chloramphenicol Erythromycin Lincomycin Polymyxin B 1.56 Colistin methanesulfonate 1.56 Neomycin 8000.0 Kanamycin >8000.0 Bacitracin >l20.0 * Minimal inhibitory concentration is in pg./ml.except for bacitracin, where the concentration is in units/ml. Table 3.-Bacteriological Studies of Joint Infections: Percentage of Cultures Reported as Negative Author Ref. Year Inge and Liebolt Heberling Altemeier and Largen Watkins et al. Chartier et al. Ward et al. Willkens et al. Ortiz and Miller Baitch Borella et al. Argen et al. 14 15 16 17 18 19 20 21 22 23 10 1935 1941 1952 1956 1959 1960 1960 1961 1962 1962 1966 Total Number of Joints Cultured 35 126 45 51 115 24 22 35 37 52 42 Number of Negative Cultures 3 19 4 0 19 6 5 11 10 17 0 Percentage Ne ative c&lres 9 15 9 0 17 25 23 31 27 33 0 - - - 584 94 Avg. 16% Note: Tuberculous, gonococcal, and brucellosis infections excluded. DISCUSSION The case reported is an example of joint infection after corticosteroid therapy; this type of complication has been reported following both intraarticular and systemic use of these agents.lO-13 Table 3 presents a summary of bacteriological findings in representative series of bacterial joint infections which have been reported in the more recent English literature; tuberculosis, gonococcal infection, and brucellosis have been excluded. In every report Staphylococcus aurem is the most frequent infecting organism. Streptococci, pneumococci, S. epidermidis, Pseudomonas aeruginosa, Klebsiella-Aerobacter, Proteus species, and E . coli account for most of the remaining infections. In a significant proportion of cases no organism is recovered: of the 584 cases considered in Table 3, culture was negative in 94 cases (16 per cent). Furthermore, S. epidemnidis is almost certainly a contaminant. In no report did the authors of the papers reviewed discuss the possibility of an anaerobic organism causing the infection, and no specific mention is made of the use of anaerobic culture technic. In a number of cases, an identifiable organism was found on gramstaining the joint fluid, but culture inexplicably remained negative. Some of the cases in which the joint fluid remained sterile on culture could be accounted for by the administration of antibiotic therapy before arthrocentesis or by cases representing inflammation without infection. Excluding these various explanations for negative cultures leaves the possibility that in some of these cases anaerobic microorganisms were responsible for the infection. In Table 4 are summarized all of the re- 6 6 1 6 2 1 2 1 2 1 26,27,28, 31, 47, 52, 29,30,31, present case 32,33,34, 35,37,38, 40,41,42, 43,46 29 4 Baaemides fragilis 2 1 3 1 2 3 50, 51 45 1 1 2 24, 36 1 1 25 1 1 44 - 6 34,39,48,49 Fusifom Bacilli B . halosepticurn S erophonrc Anaerobic Cooci Plus ( ~ a ~ l gu b hw ( Ristella (Peptococcus and Spirochetes hloseptica) & ‘sa) Peptostreptococcus) - Ankle Metatarsophalangeal Site and type of primary disease or condition: 2 3 Unknown 1 1 Otorhinopharyngeal infection 21 1 1 Pleuropulmonary infection 1 Septicemia 1 1 7 Appendicitis Pelvic abscess 1 1 Perirectal abscess 3 2 1 Trauma, including bites Intraarticular corticosteroids 2 Systemic corticosteroids 1 Aeammaelobulinemia * In several patients, more than one organism, more than one primary disease, and/or more than one joint were involved. f Synonyms: Bacteroides finduldfcnmis, B. necroseos, Fasobacterium necrophorus, Actimnnyces necrophorus, Bacillw pyogenes anaerobias. Knee Toints involved: Shoulder Sternoclavicular Acromioclavicular Elbow Wrist Metacarpophalangeal Vertebral articulations Sacroiliac Hip Total Cases Reported References Sphnero hosus neerop%orust Bacteroides, Type Unspecified Bacteroides nelaninogenicus ( B. nig,escenr) Table 4.4ummary of Reported Cases of Joint Infections Due to Anaerobic Bacteria* P r 8 JOINT INFECTION BY ANAEROBIC BACTERIA 631 ports of joint infections by nonsporulating clearly distinguish between arthralgia and anaerobic bacteria that could be found in purulent arthritis. an extensive search of the literature; the There was no direct evidence as to the table includes the present case. Single source of the infection in the patient whose organism infections with Clostridium and case we are reporting, but it seems likely Actinomyces have not been considered, that the organism was introduced during since their pathogenicity is more clearly injection of corticosteroids into the joint. e s t a b l i ~ h e d . ~ Reports ~ # ~ 3 of joint infection Other authors have documented anaerobic with anaerobic c ~ r y n e b a c t e r i ahave ~ ~ also infection of joints following either intrabeen excluded, since these organisms are articular4’ or ~ y s t e m i c l l *use ~ ~ of corticommon contaminants, and although ar- costeroids. thritis in mice has been produced experiAlthough anaerobic infection of joints is mentally55 the pathogenicity of coryne- an uncommon event, the possibility should bacteria in man has not been clearly be considered when the patient develops established. pyoarthrosis during the course of a severe In a total of 48 patients (including the upper respiratory infection, or when his present case report) there is acceptable immunological defense mechanisms are imdocumentation of anaerobic joint infections; paired by severe disease or by cortiin 33 cases the documentation is very clear; costeroid therapy. The peculiar susceptibilbut in 15 cases clinical and/or bacterio- ity of the sternoclavicular joint to infection logic details are inadequate for full evalua- with gram-negative anaerobic bacilli ( Tation. No attempt has been made to include ble 4 ) is unexplained. In Lemierre’s experithe sacroiliac joint is also very other cases when documentation is totally inadequate, such as those mentioned by the liable to infection with S. necrophorus. An early French workers who showed great important clue may be provided if the joint familiarity with the pathogenicity of the fluid is foul-smelling or contains gas, or if nonsporulating anaerobic b a ~ t e r i a . ~ ~In. ~ 7gram-staining the fluid shows suggestive many of the 48 patients multiple joint in- organisms: Bacteroides are pale, irregularly fections occurred during the course of a staining, pleomorphic gram-negative rods; septicemia. The organism most commonly fusobacteria are gram-negative rods with isolated was Sphaerophorus necrophorus. tapered ends; anaerobic cocci are often In 6 cases there was multiple organism in- smaller than aerobic cocci, and may be volvement, either with mixed aerobic and comparatively minute. Very careful examianaerobic bacteria ( 5 cases), or with more nation of smears, under subdued light, may be necessary to detect the pale-staining than one anaerobic species (1 case). Most often the anaerobes reached the gram-negative rods. Gas may, less often, be involved joint as a result of hematogenous produced by aerobic organisms, however, seeding from a remote site, as was noted and the purulent discharge of anaerobic infections is not always foul-smelling. The by Hall6 in 18985s and by Rist in lWl57; clinical course of the arthritis due to clinical details of these authors’ cases are anaerobic bacteria has no features which insufficient to allow full evaluation, how- distinguish it from that caused by other ever. The most common site of primary in- pyogenic organisms. fection is the upper respiratory tract. Whenever the possibiIity of an anaerobic Lemierre58 and Pham31 found that articular infection of a joint arises, cultures of both lesions commonly occur in Sphaerophorus joint fluid and blood should be made on septicemia, but these authors do not always appropriate media under anaerobic condi- 832 ZIMENT ET AL. tions and the cultures kept for up to 3 weeks to allow for slow-growing anaerobesSSnAlthough the organism from our patient was recovered in fluid thioglycollate medium, this medium by itself is not adequate for initial isolation of most anaerobes. Many B. fragilis stains are relatively nonfastidious, but other anaerobes often require the use of special media and either anaerobic jars or, preferably, anaerobic roll-tube or chamber culture technics. This approach will help establish the true incidence of purulent arthritis due to anaerobic bacteria, and will help ensure appropriate therapy of these infections. Therapy of purulent arthritis due to anaerobes is generally similar to that required in other types of purulent arthritis and should include management of any underlying disease, appropriate drainage (open drainage may be required, as in the case we report), temporary immobilization of the joint, and antibacterial therapy. Penicillin G is the therapy of choice for all anaerobic infections except those due to B. fragilis and those Sphaerophorw strains which are resistant to this agent. Tetracycline and chloramphenicol are very eff ective drugs for anaerobic infections of all types, although some of the microaerophilic or anaerobic cocci are resistant to tetracycline. Lincomycin is quite effective, with a spectrum similar to that of penicillin G. Erythromycin will occasionally be useful, particularly in infections due to anaerobic cocci and in certain B. fragilis infections. Intraarticular therapy should ordinarily not be necessary. SUMMARYAND CONCLUSIONS A case of Bactermdes fragilis infection of a knee joint following intraarticular steroid therapy is described. A review of the literature revealed 47 cases of arthritis caused by nonsporeforming anaerobic bacteria, and details of these cases are presented. The factors predisposing to joint infections include poor host resistance, underlying joint disease, and steroid administration. Although the anaerobic joint infections do not present any characteristic features apart from a foul discharge, the peculiar susceptibility of the sternoclavicular and sacroiliac joint to Bacteroides infection is noted. The presence of gas in a joint and the unique morphology of many anaerobes on gram stain may also be important clues. The possibility of unrecognized anaerobic infection resulting in no growth on routine culture of the fluid from an infected joint is discussed, and the value of anaerobic culture in such cases is stressed. SUMMARIOIN INTERLINGUA Es describite un caso de infection con Bacteroides fragilis de un articulation genicular post therapia a steroide intra-articular. Un revista del litteratura ha revelate 47 casos de arthritis causate per non-sporipare bacterios anaerobie, e detalios de iste casos es presentate. Le factores que predispone a1 disveloppamento de infectiones articular include ( 1) basse resistentia del hospite, ( 2 ) un subjacente morbo articular, e (3) le administration de steroide. Ben que le anaerobie infectiones articular non presenta ulle aspectos characteristic con le exception de un discarga putride, le susceptibilitate peculiar del articulationes sternoclavicular e sacroiliac a infection per Bacteroides es notate. Le presentia de gas in un articulation e le morphologia distinctive de multe organismos anaerobie in le tincturation de Gram etiam pote esser importante indicios. Es commentate le possibilitate de un nonrecognoscite infection anaerobie que resulta in nulle crescentia in culturas routinari del fluido ab un articulation inficite.Le valor de culturation anaerobie in tal casos es sublineate. REFERENCES 1. Conn, H. J.: Manual of Microbiological Methods. Society of American Bacteriologists Committee on Bacteriological Technic. New York, McCraw-Hill, 1957. 2. 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