1
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Noteman TW, Ha TT, Tsarfati EM. Neisseria meningitidis serogroup C causing primary polyarthritis in an octogenarian. BMJ Case Rep 2020; 13:13/6/e233378. [PMID: 32532902 DOI: 10.1136/bcr-2019-233378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A man in his 80s presented to the hospital with a 36-hour history of fever, myalgia, bilateral shoulder and right knee pain. Joint fluid aspirates from his shoulders and right knee isolated Gram-negative diplococci. After failing to grow on standard and selective media, Neisseria meningitidis was identified by 16s PCR and subsequently typed as serogroup C. He had no clinical features of meningitis or meningococcaemia. Blood cultures were negative and an EDTA blood sample was negative for meningococcal ctrA gene. Urine PCR was negative for Neisseria gonorrhoeae He was treated successfully with two arthroscopic joint washouts of his right knee, aspirates of both shoulders, 40 days of intravenous ceftriaxone and intensive physiotherapy as both an inpatient and outpatient. In the literature, we have not found any previously documented cases of serogroup C meningococcus causing polyarticular primary septic arthritis in this age group or guidance on duration of antibiotic treatment. Literature on the impact of rehabilitation to baseline function was also found to be lacking. Although rare, primary meningococcal arthritis (PMA) should be considered as a differential diagnosis in cases of acute polyarticular septic arthritis. Polyarticular PMA in older adults may require prolonged rehabilitation before one might expect to return to premorbid function.
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2
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Steele L, Bechman K, De Barra E, Mackworth-Young C. Meningococcal arthritis and myopericarditis: a case report. BMC Infect Dis 2017; 17:751. [PMID: 29207945 PMCID: PMC5718011 DOI: 10.1186/s12879-017-2845-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 11/21/2017] [Indexed: 02/03/2023] Open
Abstract
Background We report the first adult case of Neisseria meningitidis W-135 presenting with meningococcal arthritis and myopericarditis concomitantly, without other classical features of meningococcal disease. Case presentation A 67-year-old Caucasian man presented with acute-onset polyarthralgia, myalgia, and fever. On examination he had polyarticular synovitis. An electrocardiogram (ECG) demonstrated ST-elevation in leads I, II, III, aVF, and V2-V6 without reciprocal depression, and a high-sensitivity troponin level was significantly elevated. Cardiac magnetic resonance (CMR) imaging on day five of admission demonstrated patchy pericardial enhancement. Neisseria meningitidis W-135 was isolated from both synovial fluid and blood cultures. The clinical outcome was favourable with intravenous ceftriaxone and myopericarditis treatment (colchicine and ibuprofen). Conclusions We conclude that this is a rare case of disseminated Neisseria meningitidis W-135 presenting with acute polyarticular septic arthritis and myopericarditis, without other classical features of systemic meningococcal disease. The earlier described entity of primary meningococcal arthritis (PMA) can present in patients with meningococcal bacteraemia, and may not be distinct from disseminated meningococcal disease, but rather an atypical presentation of this. Electronic supplementary material The online version of this article (10.1186/s12879-017-2845-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lloyd Steele
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK.
| | - Katie Bechman
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Eoghan De Barra
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Charles Mackworth-Young
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
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3
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Joyce M, Laing A, Mullet H, Gilmore MF, Cormican M. Isolated Septic Arthritis: Meningococcal Infection. J R Soc Med 2017. [DOI: 10.1177/014107680309600511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- M Joyce
- Department of Orthopaedics, University College Hospital, Galway, Ireland
| | - A Laing
- Department of Orthopaedics, University College Hospital, Galway, Ireland
| | - H Mullet
- Department of Orthopaedics, University College Hospital, Galway, Ireland
| | - M F Gilmore
- Department of Orthopaedics, University College Hospital, Galway, Ireland
| | - M Cormican
- Department of Microbiology, University College Hospital, Galway, Ireland
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4
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Lavoipierre V, Dellyes A, Aubry C, Zandotti C, Lafforgue P, Parola P, Lagier JC. Acute polyarthritis in a young patient caused by meningococcal and parvovirus B19 infections: a case report and review of the literature. J Med Case Rep 2016; 10:362. [PMID: 27998301 PMCID: PMC5175313 DOI: 10.1186/s13256-016-1156-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 11/23/2016] [Indexed: 01/09/2023] Open
Abstract
Background Meningococcal infection is a multifaceted disease including acute polyarthritis. This presentation should be known by clinicians in order to prevent delay in treatment. We report what we believe to be the first case of an association of parvovirus B19 and meningococcal polyarthritis in a young adult. Case presentation A 19-year-old Caucasian woman presented to our hospital with fever, intense leg pain, and a transient rash. A physical examination showed asymmetric polyarthritis and no neurological abnormalities. A parvovirus B19 polymerase chain reaction performed using a blood sample and knee fluid aspirate came back positive, but serology was negative for immunoglobulin M and positive for immunoglobulin G. A blood culture was positive for serotype C meningococcus; a polymerase chain reaction performed for Neisseria meningitidis was positive in joint fluid but negative in blood samples (performed after antibiotic treatment had begun). Our patient was treated with ceftriaxone for 15 days, associated with analgesic therapy. Hydroxychloroquine treatment was introduced 5 months after the onset of polyarthritis because of persisting inflammatory arthralgia. Conclusions To the best of our knowledge, this is the first case report of polyarthritis caused by concomitant meningococcal and parvovirus B19 infections. This unusual presentation of meningococcal disease may have resulted from the persistent parvovirus B19 infection. Our experience with this case illustrates the need for a systematic approach to the diagnosis of febrile acute polyarthritis. Only long-term follow-up will reveal if this infectious polyarthritis will evolve towards an autoimmune rheumatism.
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Affiliation(s)
- Virginie Lavoipierre
- Service de Maladies Infectieuses Aigues, Pôle Maladies Infectieuses, Assistance Publique Hôpitaux de Marseille, CHU Timone, Institut Hospitalo-Universitaire Méditerranée Infection, 13005, Marseille, France
| | - Anna Dellyes
- Service de Rhumatologie, Assistance Publique Hôpitaux de Marseille, CHU Sainte Marguerite, 13009, Marseille, France
| | - Camille Aubry
- Service de Maladies Infectieuses Aigues, Pôle Maladies Infectieuses, Assistance Publique Hôpitaux de Marseille, CHU Timone, Institut Hospitalo-Universitaire Méditerranée Infection, 13005, Marseille, France
| | - Christine Zandotti
- Pôle Maladies Infectieuses, Fédération de Microbiologie, Assistance Publique Hôpitaux de Marseille, CHU Timone, Institut Hospitalo-Universitaire Méditerranée Infection, 13015, Marseille, France
| | - Pierre Lafforgue
- Service de Rhumatologie, Assistance Publique Hôpitaux de Marseille, CHU Sainte Marguerite, 13009, Marseille, France
| | - Philippe Parola
- Service de Maladies Infectieuses Aigues, Pôle Maladies Infectieuses, Assistance Publique Hôpitaux de Marseille, CHU Timone, Institut Hospitalo-Universitaire Méditerranée Infection, 13005, Marseille, France.,Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, INSERM 1095, Faculté de Médecine, Institut Hospitalo-Universitaire Méditerranée-Infection, Marseille, France
| | - Jean-Christophe Lagier
- Service de Maladies Infectieuses Aigues, Pôle Maladies Infectieuses, Assistance Publique Hôpitaux de Marseille, CHU Timone, Institut Hospitalo-Universitaire Méditerranée Infection, 13005, Marseille, France. .,Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, INSERM 1095, Faculté de Médecine, Institut Hospitalo-Universitaire Méditerranée-Infection, Marseille, France.
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5
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Straticiuc S, Ignat A, Hanganu E, Lupu VV, Ciubara AB, Cretu R. Neisseria meningitidis Serogroup C Causing Primary Arthritis in a Child: Case Report. Medicine (Baltimore) 2016; 95:e2745. [PMID: 26844522 PMCID: PMC4748939 DOI: 10.1097/md.0000000000002745] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Neisseria meningitidis (N. meningitidis) is associated with severe invasive infections such as meningitis and fulminant septicemia. Septic arthritis due to N. meningitidis is rare and bone infections have been reported exceptionally. We report the case of a 1-year old girl who presented with a painful, swollen right knee, accompanied by fever and agitation. Arthrocentesis of the right knee, while patient was under anesthesia, yielded grossly purulent fluid, so we made arthrotomy and drainage. The culture from synovial fluid revealed N. meningitidis, sensitive to Ceftriaxone. The patient received intravenous antibiotherapy with Ceftriaxone. The status of the patient improved after surgical drainage and intravenous antibiotic therapy. She recovered completely after 1 month. CONCLUSION This observation illustrates an unusual presentation of invasive meningococcal infection and the early identification of the bacteria, combined with the correct treatment, prevent the complications and even death.
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Affiliation(s)
- Sergiu Straticiuc
- From the Pediatric Orthopaedic Department, "St. Mary" Emergency Children Hospital (SS, RC); Pediatrics Department (AI, VVL); Pediatric Surgery Department (EH); and Anatomy Department, University of Medicine and Pharmacy "Gr. T. Popa"; Orthopaedics Clinic, "St. Spiridon" Emergency Clinical Hospital, Iasi, Romania (ABC)
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6
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Abstract
Primary meningococcal arthritis (PMA) is a relatively rare diagnosis where the role of early surgical intervention for its treatment is not well defined. We report a case of PMA in a young otherwise healthy patient who developed polyarticular joint pain secondary to Niessieria meningitidis without systemic symptoms of meningitis or meningococcemia. He underwent a prolonged course of intravenous antibiotics and serial aspirations of his shoulder. However, symptoms in his shoulder did not improve and he later underwent surgical irrigation and debridement.Intraoperatively, the patient had no signs of articular damage to his right shoulder despite prolonged clinically symptomatic disease. Six weeks after surgery, he has regained normal strength and full range of motion without any deficits.Nonoperative management of PMA is frequently, but not invariably, successful. We report a patient with this diagnosis who ultimately needed surgical evacuation of his shoulder joint to achieve resolution of his symptoms.
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Peralta JE, Chaves F, Viedma E, Rojo P. Artritis séptica con cultivos negativos, utilidad de las técnicas moleculares. Enferm Infecc Microbiol Clin 2012; 30:655-6. [DOI: 10.1016/j.eimc.2012.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 05/20/2012] [Accepted: 05/27/2012] [Indexed: 11/16/2022]
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8
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Cabellos C, Nolla JM, Verdaguer R, Pelegrin I, Ribera A, Ariza J, Viladrich PF. Arthritis related to systemic meningococcal disease: 34 years’ experience. Eur J Clin Microbiol Infect Dis 2012; 31:2661-6. [DOI: 10.1007/s10096-012-1610-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 03/18/2012] [Indexed: 11/28/2022]
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9
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Ibrahim KY, Carvalho NB, Moura MLDN, Piza FMDT, Mimicos EV, Ho YL, França FODS. Infection and immune-mediated meningococcal-associated arthritis: combination features in the same patient. Rev Inst Med Trop Sao Paulo 2012; 54:109-11. [DOI: 10.1590/s0036-46652012000200009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/26/2012] [Indexed: 11/22/2022] Open
Abstract
We present a case of a 16-year-old male patient with sudden-onset, rash, arthritis and meningitis by Neisseria meningitidis one week after an acute upper respiratory infection. On the 10th day of treatment followed by neurological and arthritis clinical improvement, he presented once again a tender and swollen left knee with a moderate effusion, and active and passive range of motion was severely limited secondary to pain, and when he was submitted to surgical drainage and synovial fluid analysis he showed inflammatory characteristics. A non-steroidal anti-inflammatory drug was taken for five days with complete improvement of symptoms. The case is notable for its combination of features of septic and immune-mediated arthritis, which has rarely been reported in the same patient.
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10
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Bilavsky E, Yarden-Bilavsky H, Zevit N, Amir J. Primary meningococcal arthritis in a child: Case report and literature review. ACTA ACUST UNITED AC 2009; 38:396-9. [PMID: 16709548 DOI: 10.1080/00365540500388784] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We present a case of primary meningococcal arthritis in an 8-month-old immunocompetent female. We also review 18 additional paediatric cases and characterize this unique form of meningococcal disease.
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Affiliation(s)
- Efraim Bilavsky
- Department of Paediatrics C, Schneider Children's Medical Center of Israel, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Germino KW, Street MH, Caudill KA, Barenkamp SJ. An unusual cause of acute polyarticular arthritis. Clin Pediatr (Phila) 2009; 48:220-3. [PMID: 18832545 DOI: 10.1177/0009922808323120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kevin W Germino
- Department of Pediatrics, Saint Louis University, Missouri 63104, USA.
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12
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Ramón de Dios J, Julia López de Goikoetxea A, Carlos Vesga J. [Septic arthritis due to meningococcus. Report an atypical case presentation]. REUMATOLOGIA CLINICA 2008; 4:117-118. [PMID: 21794512 DOI: 10.1016/s1699-258x(08)71815-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2007] [Accepted: 04/25/2007] [Indexed: 05/31/2023]
Abstract
We have observed the case of a 73-years-old man with a septic monoarthritis affecting the left knee due to Neisseria meningitidis serogroup B, without previous traumatism, fever, headache or meningeal symptoms. The patient didńt present risk factors of meningococcal infection. The infection was resolved satisfactorily with parenteral ceftriaxone during 2 weeks and oral ciprofloxacin during 1 month.
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Affiliation(s)
- Juan Ramón de Dios
- Servicio de Reumatología. Hospital de Txagorritxu. Vitoria. Álava. España
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13
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Isolated polyarticular septic arthritis: an atypical presentation of meningococcal infection. Am J Med Sci 2008; 335:323-6. [PMID: 18414075 DOI: 10.1097/maj.0b013e318142bb0d] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We are presenting a case of a 19-year-old college student with sudden-onset, asymmetric polyarticular arthritis with Neisseria meningitidis 10 days after an acute upper respiratory infection consisting of fevers, chills, pharyngitis, and productive cough. Primary meningococcal septic arthritis is a rare entity. A majority of these cases present in a monoarticular fashion. The synovial fluid findings, although compatible with inflammatory arthritis, are not typical of septic arthritis. This entity, although rare, should be considered in the differential diagnosis of septic arthritis of large joints, especially since N. meningitiditis does not grow well on routine culture media. A literature review on the diagnosis, treatment, and prevention of primary meningococcal septic arthritis is presented.
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14
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Bhavnagri S, Steele N, Massasso D, Benn R, Youssef P, Bleasel J. Meningococcal-associated arthritis: infection versus immune-mediated. Intern Med J 2008; 38:71-3. [PMID: 18190423 DOI: 10.1111/j.1445-5994.2007.01560.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Weisfelt M, van de Beek D, Spanjaard L, de Gans J. Arthritis in adults with community-acquired bacterial meningitis: a prospective cohort study. BMC Infect Dis 2006; 6:64. [PMID: 16571115 PMCID: PMC1488854 DOI: 10.1186/1471-2334-6-64] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2005] [Accepted: 03/29/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the coexistence of bacterial meningitis and arthritis has been noted in several studies, it remains unclear how often both conditions occur simultaneously. METHODS We evaluated the presence of arthritis in a prospective nationwide cohort of 696 episodes of community-acquired bacterial meningitis, confirmed by culture of cerebrospinal fluid, which occurred in patients aged >16 years. The diagnosis of arthritis was based upon the judgment of the treating physician. To identify differences between groups Fisher exact statistics and the Mann-Whitney U test were used. RESULTS Arthritis was recorded in 48 of 696 (7%) episodes of community-acquired bacterial meningitis in adults. Joint-fluid aspirations were performed in 23 of 48 patients (48%) and joint-fluid cultures yielded bacteria in 6 of 23 patients (26%). Arthritis occurred most frequently in patients with meningococcal meningitis (12%). Of the 48 patients with bacterial meningitis and coexisting arthritis, four died (8%) and 10 (23%) had residual joint symptoms. CONCLUSION Arthritis is a common manifestation in patients with community-acquired bacterial meningitis. Functional outcome of arthritis in bacterial meningitis is generally good because meningococcal arthritis is usually immune-mediated, and pneumococcal arthritis is generally less deforming than staphylococcal arthritis. Nevertheless, additional therapeutic measures should be considered if clinical course is complicated by arthritis. In patients with infectious arthritis prolonged antibiotic therapy is mandatory.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Arthritis, Infectious/complications
- Arthritis, Infectious/epidemiology
- Arthritis, Infectious/microbiology
- Bacteria/classification
- Bacteria/isolation & purification
- Bacteria/pathogenicity
- Cohort Studies
- Community-Acquired Infections/complications
- Community-Acquired Infections/epidemiology
- Community-Acquired Infections/microbiology
- Female
- Humans
- Joints/microbiology
- Male
- Meningitis, Bacterial/complications
- Meningitis, Bacterial/epidemiology
- Meningitis, Bacterial/mortality
- Meningitis, Meningococcal/complications
- Meningitis, Meningococcal/epidemiology
- Middle Aged
- Neisseria meningitidis/isolation & purification
- Netherlands/epidemiology
- Outcome Assessment, Health Care
- Prospective Studies
- Staphylococcus aureus/isolation & purification
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Affiliation(s)
- Martijn Weisfelt
- Department of Neurology, Centre of Infection and Immunity Amsterdam (CINIMA), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Centre of Infection and Immunity Amsterdam (CINIMA), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Lodewijk Spanjaard
- Medical Microbiology, Centre of Infection and Immunity Amsterdam (CINIMA), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan de Gans
- Department of Neurology, Centre of Infection and Immunity Amsterdam (CINIMA), Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Barajas Sánchez MV, Sánchez Granados JM, López Franco M, Blanco Rodríguez M, Bernácer Borja M. Artritis meningocócica como presentación de enfermedad invasiva insospechada. An Pediatr (Barc) 2004; 61:187-8. [PMID: 15274889 DOI: 10.1016/s1695-4033(04)78382-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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17
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Joyce M, Laing A, Mullet H, Gilmore MF, Cormican M. Isolated septic arthritis: meningococcal infection. J R Soc Med 2003; 96:237-8. [PMID: 12724437 PMCID: PMC539480 DOI: 10.1258/jrsm.96.5.237] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- M Joyce
- Department of Orthopaedics, University College Hospital, Galway, Ireland.
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18
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De Laere E, Berghs B, Gordts B, Van Landuyt H. Primary meningococcal arthritis of the hip in an immunocompetent adolescent. Acta Clin Belg 2002; 57:345-8. [PMID: 12723254 DOI: 10.1179/acb.2002.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The clinical spectrum of meningococcal infection ranges from asymptomatic carriage to fulminant sepsis, with meningitis and septicemia being well-recognized clinical presentations. Meningococcal arthritis as a complication of Neisseria meningitidis infection occurs in about 2-10% of cases, whereas primary meningococcal arthritis (PMA) is a relatively rare phenomenon, even in children. We report here a case of meningococcal infection in an immunocompetent adolescent suffering from acute pain of the right hip as the only symptom upon presentation at the hospital. In such a situation, meningococci are not usually considered as a possible causative agent.
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Affiliation(s)
- E De Laere
- Department of Microbiology, Algemeen Ziekenhuis Sint-Jan, Ruddershove 10, B-8000 Brugge, Belgium.
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Affiliation(s)
- Shawn Bonsell
- Department of Orthopedics, Baylor Medical Center of Dallas, Tex, USA
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