Septic arthritis due to Mycoplasma hominis

An enemy in shadows-Mycoplasma hominis septic arthritis and iliopsoas abscess: Case report and review of the literature

Mycoplasma hominis (M. hominis) is fastidious and difficult to grow bacteria with the ability to colonize the genitourinary and respiratory tracts. Infrequently can cause a variety of genitourinary tract infections, pregnancy complications, and neonatal diseases. M. hominis rarely reported to cause extragenital infections and seldomly native joint septic arthritis particularly in immunocompromised hosts, raising diagnostic challenges and is often associated with delayed diagnosis and high morbidity and mortality. We report the case of a 30-year-old patient who developed M. hominis native left hip septic arthritis with iliopsoas abscess after receiving rituximab for newly diagnosed thrombotic thrombocytopenic purpura (TTP). The diagnosis of M. hominis hip septic arthritis with iliopsoas involvement was confirmed following repeated joint and abscess aspiration and identification of the organism with the aid of culture and specific Polymerase chain reaction (PCR). The patient was subsequently treated with a prolonged course of antibiotics targeting the organism with a favorable outcome. The clinical presentations, assessment, and management of this rare entity of M. hominis related extragenital infections are outlined. In addition, the literature on similar cases was reviewed to raise awareness and avoid devastating consequences.

Diagnosis and treatment of mycoplasmal septic arthritis: a systematic review

PURPOSE

Septic arthritis caused by Mycoplasma is rare. The diagnosis and effective treatment of mycoplasmal septic arthritis remains a serious problem for clinicians. The aim of this systematic review was to document the available evidence on the diagnosis and treatment methods for mycoplasmal septic arthritis and to provide guidance for clinicians.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched in December 2018.The searches were limited to the English language. Article screening and data extraction and compilation were conducted by two independent reviewers. All the included studies were assessed using the Methodological Index for Non-randomized Studies (MINORS) tool.

RESULTS

There was a total of 33 articles including 34 cases of mycoplasmal septic arthritis and eight of them were periprosthetic joint infection (PJI). Twenty-four patients (70.6%) were immunocompromised, and the synovial fluid white blood cell (WBC) count was significantly lower in the immunocompromised group than in the immunocompetent group (48,527 × 10⁶/L vs. 100,640 × 10⁶/L; P = 0.009). The traditional culture method took longer, and the positivity rate was lower than that of nucleic acid testing (50% vs. 100%; P = 0.016). Only 19.2% (5/26) of patients treated with empiric antibiotics were relieved of symptoms, while 82.4% (28/34) of patients achieved satisfactory results after being treated with antibiotics against Mycoplasma.

CONCLUSION

The possibility of mycoplasmal septic arthritis should be considered if patients with joint infections have a history of immunocompromised, repeated negative cultures, and poor empiric antibiotic treatment results. The rational use of nucleic acid testing technologies can help in the clinical diagnosis and treatment of mycoplasmal septic arthritis.

Septic arthritis in immunocompetent and immunosuppressed hosts

Septic arthritis has long been considered an orthopedic emergency. Historically, Neisseria gonorrhoeae and Staphylococcus aureus have been the most common causes of septic arthritis worldwide but in the modern era of biological therapy and extensive use of prosthetic joint replacements, the spectrum of microbiological causes of septic arthritis has widened considerably. There are also new approaches to diagnosis but therapy remains a challenge, with a need for careful consideration of a combined medical and surgical approach in most cases.

Mycoplasma hominis deep wound infection after neuromuscular scoliosis surgery: the use of real-time polymerase chain reaction (PCR)

Mycoplasma hominis is a commensal of the genitourinary tract. It mostly causes infections to associated structures of this system; however, occasionally it is a pathogen in nongenitourinary tract infections. Since, M. hominis strains require special growth conditions and cannot be Gram stained, they may be missed or delay diagnosis. This report describes a deep wound infection caused by M. hominis after neuromuscular scoliosis surgery; M. hominis was recovered by real-time polymerase chain reaction (PCR). An awareness of the role of M. hominis as an extragenital pathogen in musculoskeletal infections, especially in neuromuscular scoliosis, being a high-risk group for postoperative wound infection, it is necessary to identify this pathogen. Real-time PCR for postoperative deep wound infection, in patients with a history of genitourinary infections, decreases the delay in diagnosis and treatment. In these cases rapid real-time PCR on deep cultures should be considered.

Hematogenous septic arthritis of the adult hip

A retrospective review of 10 patients admitted to 4 regional hospitals between 1987 and 1997 in whom acute septic hip arthritis was diagnosed was performed to compare presentation, laboratory and radiographic findings, treatment, and outcome. Patients presented with fever, hip or groin pain, and an inability to bear weight. Most patients manifested a leukocytosis, and all patients had an elevated erythrocyte sedimentation rate. Hematogenous septic hip arthritis is rare. The consequences of a missed diagnosis are serious and include death. Clinical examination combined with appropriate laboratory and radiographic studies leads to prompt diagnosis and treatment.

Septic arthritis of the glenohumeral joint. A report of 11 cases and review of the literature

Eleven cases (6 adults and 5 pediatrics) of shoulder septic arthritis are described, and the English literature from 1960 to 1997 reviewed, for a total of 168 cases. Shoulder septic arthritis is an uncommon and difficult diagnosis requiring a high index of suspicion and early evaluation of the affected shoulder by the clinician. The disease usually involves very young infants or elderly patients (65-75 years old). Associated medical conditions were identified in 60% of the patients and include systemic disorders such as liver diseases, alcoholism, and malignancies in 46%; preceding chronic arthritic disorders in 24%; and associated infectious focus in 13% of the patients. Associated infections were more prevalent in the pediatric population. Intravenous drug abuse appears not to constitute a major risk factor; it was identified in less than 5% of patients. All patients presented with acute shoulder ache or with exacerbation of existing chronic pain in joints previously damaged. Elevated body temperature (over 38 degrees C) appeared in 67% of the adult patients and in over 90% of the pediatric patients. Shoulder arthritis was frequently accompanied by an accelerated erythrocyte sedimentation rate that may rise above 100 mm/hr. Increased white blood cell count was found in approximately 40% of patients. The initial X-rays were frequently normal, while ultrasonography supported the diagnosis in some cases by demonstrating accumulation of fluid inside the joint space. Aspiration of synovial fluid from the affected glenohumeral joint was necessary to evaluate the offending pathogen. False-negative Gram stain appeared in approximately 90% of the patients, whereas synovial fluid cultures demonstrated the pathogen in 88% of patients. Blood cultures were positive in 50% of adult patients and 90% of pediatric patients. The most common isolated pathogen was Staphylococcus aureus, which accounted for 41% of infections. Gram-negative bacilli, which accounted for about 20% of infections, are more prevalent in the pediatric population, especially the neonates. Pyogenic shoulder arthritis should first be treated with intravenous antibiotics, effective at least against staphylococcal infections, until the organisms and sensitivities are identified. Duration of antibiotic therapy should be 3-6 weeks. Unfortunately, our experience in addition to the literature summary does not allow statistical analysis and firm conclusions concerning the best therapeutic approach. However, it appears that in the adult population an operative draining procedure is preferred, whereas in the pediatric population, a closed needle aspiration, if needed at all, is the optimal treatment. With prompt antibiotic therapy and drainage of the shoulder, the patient can be expected to improve clinically, with no serious long-term debilitating effects from the disease.

Common variable immunodeficiency presenting as a Mycoplasma hominis septic arthritis

A case is reported of common variable immunodeficiency (CVID) presenting as an acute septic arthritis due to Mycoplasma hominis. The diagnosis was not considered until the hypogammaglobulinaemia was discovered and the synovial fluid cultured specifically for mycoplasmas. The importance of diagnosing immunodeficiency states and searching for mycoplasmas in 'bacteriologically culture negative' cases is emphasized.

Sternotomy infection due to Mycoplasma hominis and Ureaplasma urealyticum

Mycoplasma hominis infections outside the urogenital tract are uncommon. An unusual case of sternal infection caused by both Mycoplasma hominis and Ureaplasma urealyticum is described. This is the first report found in the literature of mixed infection due to these microorganisms at this site. The outcome was favourable after drainage of the surgical wound and antibiotic therapy with clindamycin, gentamicin and doxycycline.

Posthysterectomy wound infection. A review

We reviewed the microorganisms isolated from gynecologic surgery wounds showing signs of infection, from January to December 1990. A total of 88 samples of abdominal wall exudates from as many patients who had undergone abdominal hysterectomy were studied. In 54 women (61.3%), cultures were positive and, in 26 specimens (48.1%), mixed aerobic-anaerobic flora were isolated. In 28 cases (51.9%), a single microorganism was isolated, the most frequent being Staphylococcus aureus, followed by Mycoplasma hominis and Escherichia coli. Mycoplasma hominis was unexpectedly frequent, appearing in five women with wall abscess and fever.

Extragenital Mycoplasma hominis infections in adults

PURPOSE

To heighten awareness of the role of Mycoplasma hominis as an extragenital pathogen in adults.

PATIENTS AND METHODS AND RESULTS

Patients ranged in age from 14 to 76 years. Thirteen patients were immunosuppressed, including nine organ transplant recipients; three were receiving steroids, and two had an underlying malignancy. The remainder were immunocompetent. Thirteen patients had prior surgery at or near the site of infection. M. hominis was isolated from normally sterile sites such as blood or cerebrospinal, pleural, abdominal and joint fluids, and bone. Non-sterile sites of isolation included surgical wounds and pulmonary secretions. The organism was detected in anaerobic cultures of clinical specimens sent to the laboratory for routine bacteriologic culture. Gram stains of fluids or wound drainage revealed neutrophils but no bacteria. Anti-mycoplasmal therapy was effective in eradicating the organism in 13 of 15 patients who were treated. Of those in whom treatment failed, one patient had an antibiotic-resistant isolate and the other had M. hominis isolated from the lung at postmortem after just 2 days of therapy.

CONCLUSION

Our experience suggests that significant infections due to M. hominis, although uncommon, are not rare, and methods to isolate and identify this organism should be available for general adult medical and surgical populations.

Mycoplasma hominis septic thrombophlebitis in a patient with multiple trauma: a case report and literature review

Mycoplasma hominis was recovered from the site of a septic thrombophlebitis on the left cephalic veins of a patient with pelvic and other multiple trauma. The organisms were initially isolated from routine cultures in conventional blood agar media incubated anaerobically. The absence of other demonstrable pathogens and the patient's serologic response to the isolate support the role of the organism as the cause of this previously unreported mycoplasmal infection. M. hominis should be considered a possible cause of sepsis in selected cases of infections following pelvic trauma or manipulations of the genitourinary tract.

Postcesarean wound infection by Mycoplasma hominis in a patient with persistent postpartum fever

Mycoplasma hominis was isolated in pure culture from a wound infection following delivery by cesarean section. The importance of recognizing this organism as a potential pathogen of the female genital tract is emphasized. Two commercially available isolation systems that allow the recovery of this organism are also described.

Pathogenesis and significance of urogenital mycoplasmal infections

U. urealyticum and M. hominis can no longer be considered as harmless commensals of the lower genitourinary tract. Both can produce disease in humans. Diagnosis and management of infections due to these organisms must be based upon isolation of the organisms from the affected site and preferably the number of organisms present. Due to the frequent resistance of both organisms to tetracycline, treatment must be based upon appropriate antibiotic sensitivities. For a more detailed description of the basic biology of these organisms and isolation and identification and treatment, the reader is referred to several recent reviews.