Pulmonary Madurella mycetomatis mycetoma secondary to knee eumycetoma, Senegal

Mycetoma is a neglected tropical disease which is endemic in Senegal. Although this subcutaneous mycosis is most commonly found on the foot, extrapodal localisations have also been found, including on the leg, knee, thigh, hand, and arm. To our knowledge, no case of blood-spread eumycetoma has been reported in Senegal. Here, we report a case of pulmonary mycetoma secondary to a Madurella mycetomatis knee eumycetoma. The patient was a 41-year-old farmer living in Louga, Senegal, where the Sudano-Sahelian climate is characterised by a short and unstable rainy season and a steppe vegetation. He suffered a trauma to the right more than 20 years previously and had received treatment for more than 10 years with traditional medicine. He consulted at Le Dantec University Hospital in Dakar for treatment of a right knee mycetoma which had been diagnosed more than 10 years ago. He had experienced a chronic cough for more than a year; tuberculosis documentation was negative. Grains collected from the knee and the sputum isolated M. mycetomatis, confirmed by the rRNA gene ITS regions nucleotide sequence analysis. An amputation above the knee was performed, and antibacterial and antifungal therapy was started with amoxicillin-clavulanic acid and terbinafine. The patient died within a month of his discharge from hospital.

Septic arthritis of the knee: clinical and laboratory comparison of groups with different etiologies

OBJECTIVES:

To clinically and epidemiologically characterize a population diagnosed with and treated for septic arthritis of the knee, to evaluate the treatment results and to analyze the differences between patients with positive and negative culture results, patients with Gram-positive and Gram-negative bacterial isolates and patients with S. aureus- and non-S. aureus-related infections.

METHODS:

One hundred and five patients with septic knee arthritis were included in this study. The clinical and epidemiological data were evaluated. Statistical analysis was performed to compare patients with and without an isolated causative agent, patients with Gram-positive and Gram-negative pathogens and patients with S. aureus-related and non S. aureus-related infections.

RESULTS:

Causative agents were isolated in 81 patients. Gram-positive bacteria were isolated in 65 patients and Gram-negative bacteria were isolated in 16 patients. The most commonly isolated bacterium was S. aureus. Comparing cases with an isolated pathogen to cases without an isolated pathogen, no differences between the studied variables were found except for the longer hospital stays of patients in whom an etiological agent was identified. When comparing Gram-positive bacteria with Gram-negative bacteria, patients with Gram-positive-related infections exhibited higher leukocyte counts. Patients with S. aureus-related infections were more frequently associated with healthcare-related environmental encounters.

CONCLUSION:

S. aureus is the most common pathogen of septic knee arthritis. Major differences were not observed between infections with isolated and non-isolated pathogens and between infections with Gram-positive and Gram-negative bacteria. S. aureus infections were more likely to be associated with a prior healthcare environment exposure.

Successful treatment of methicillin-resistant Staphylococcus aureus osteomyelitis with combination therapy using linezolid and rifampicin under therapeutic drug monitoring

Linezolid is an effective antibiotic against most gram-positive bacteria including drug-resistant strains such as methicillin-resistant Staphylococcus aureus. Although linezolid therapy is known to result in thrombocytopenia, dosage adjustment or therapeutic drug monitoring of linezolid is not generally necessary. In this report, however, we describe the case of a 79-year-old woman with recurrent methicillin-resistant S. aureus osteomyelitis that was successfully treated via surgery and combination therapy using linezolid and rifampicin under therapeutic drug monitoring for maintaining an appropriate serum linezolid concentration. The patient underwent surgery for the removal of the artificial left knee joint and placement of vancomycin-impregnated bone cement beads against methicillin-resistant S. aureus after total left knee implant arthroplasty for osteoarthritis. We also initiated linezolid administration at a conventional dose of 600 mg/h at 12-h intervals, but reduced it to 300 mg/h at 12-h intervals on day 9 because of a decrease in platelet count and an increase in serum linezolid trough concentration. However, when the infection exacerbated, we again increased the linezolid dose to 600 mg/h at 12-h intervals and performed combination therapy with rifampicin, considering their synergistic effects and the control of serum linezolid trough concentration via drug interaction. Methicillin-resistant S. aureus infection improved without reducing the dose of or discontinuing linezolid. The findings in the present case suggest that therapeutic drug monitoring could be useful for ensuring the therapeutic efficacy and safety of combination therapy even in patients with osteomyelitis who require long-term antibiotic administration.

SUCCESSFUL TREATMENT OF MULTIDRUG-RESISTANT ACINETOBACTOR BAUMANII BLISTERS ON THE KNEE

Acinetobacter baumannii (A. baumannii), nosocomial infections, especially those due to multi-drug resistant (MDR) strains, are increasingly detected. This study reports the case of a 50-year-old man with blisters on the right knee for 8 months, first admitted through the outpatient department for incisional biopsy. Microbiological and histo-pathological examination confirmed the diagnosis of blisters extending deeply up to the knee joint caused by MDR- A. baumannii. A broad spectrum antibiotic therapy was administered and later readjusted according to the results of microbiological culture and biopsy report. Intensive hemodynamic support was required. An extensive surgical debridement was promptly performed and repeated until complete control of the infection with intravenous colistins. Blisters were excised; wounds were dressed daily with chlorhexidine dressings and polymyxine-impregnated dressing. Wounds were finally covered with split-thickness skin grafts. The infection was overcome 120 days after admission. The graft take was 40%. Postoperative rehabilitation was required because of the functional limitation of lower limb movements at the knee joint. Follow-up at 8 months showed no functional deficit and an acceptable aesthetic result. AB-MDR affecting soft tissues is a life-threatening disease, especially in patients with poor immunity and limited access to health facilities, whose clinical diagnosis may sometimes be challenging. Early recognition and treatment represent the most important factors influencing survival.

Efficacy of skin preparation in eradicating organisms before total knee arthroplasty

The solution of 2% chlorhexidine gluconate and 70% isopropyl alcohol (Chloraprep) is commonly used for antiseptic skin preparation before surgery. We conducted a study to evaluate the efficacy of this solution in eradicating organisms during skin preparation for total knee arthroplasty (TKA), to isolate the organism type, and to evaluate possible contributing factors leading to infection. Ninety-nine patients who were undergoing TKA were swabbed for cultures in the popliteal fossa before and after solution application. Swabs were collected, cultured, and read. Culture isolates grew in 20 (20%) of the 99 patients before solution application and in 5 (5%) of the 99 after application. Mean presolution body mass index (BMI) was 38 for patients with bacterial isolates and 34 for patients without isolates (P<.03). Mean postsolution BMI was 40 for patients with bacterial isolates and 35 for patients without isolates. BMI was a statistically significant factor in predicting presence of isolates after solution application. In addition, presence of bacteria in presolution cultures was predictive of isolation in postsolution cultures. Diabetic patients were 3.6 times more likely than nondiabetic patients to have a bacterial isolate. Other factors did not predict organism isolation. No patient developed a postoperative infection.

Fungal arthritis of the knee caused by Mycoleptodiscus indicus

Mycoleptodiscus indicus is a recognized plant pathogen which has very rarely been reported as a cause of human infection. It is a tropical or subtropical fungus which is difficult to culture and identify from clinical specimens. This is the first report of septic arthritis with this fungus in a healthy Canadian male. The fungal infection was contracted on a vacation in Costa Rica, probably through direct inoculation through injured skin. The fungus was isolated from synovial fluid and identification was confirmed by DNA sequencing. There has only been one previous case of septic arthritis of the knee and one skin infection reported with this fungus; both cases involved immunocompromised hosts. Both septic arthritis patients required joint surgery and lavage to eradicate the fungus, however, only the immunocompromised patient required antifungal medications. In the future, it is very likely that the number of patients identified with M. indicus infection will rise due to increasing awareness of this pathogen as well as increasing exposure. Many immunocompromised patients on anti-retroviral or biologic therapy are healthy enough to travel, thereby exposing themselves to exotic and infected plants which increase the risk of unusual fungal infections.

Knee septic arthritis due to Streptococcus pyogenes associated with acute thrombosis of the tibial and peroneal veins: case report and review of the literature

We present the case of a 53-y-old patient who complained of fever, pain and oedema of the right knee and the right calf. Colour ultrasonography showed thrombosis of the tibial and peroneal veins, while paracentesis of the knee joint showed characteristics of an inflammatory exudate. Culture of the arthritic fluid revealed Streptococcus pyogenes. Thus, a diagnosis of a septic arthritis of the right knee in association with deep venous thrombosis of the right lower leg was established. From a review of the literature we found no other cases of septic arthritis in association with thrombosis of the adjacent vein. In conclusion, in cases of septic arthritis of a joint one has to consider ruling out thrombosis of the adjacent venous vessels, especially when oedema is not confined to the joint. Missing the diagnosis of such a complication will lead to increased morbidity and mortality.

Arthrite à pneumocoque révélant un myélome

INTRODUCTION

The most common presenting features of multiple myeloma are bone pain, anemia, renal failure or hypercalcemia. Bacterial infection as the initial presentation of this desease is rare.

CLINICAL CASE

We report the case of a 62-year-old man with pneumococcal septic arthritis of the knee revealing a multiple myeloma.

DISCUSSION

Pneumococcal infection should lead to a suspicion of underlying illness and especially the multiple myeloma.

Chlamydia pneumoniae arthritis in a patient with common variable immunodeficiency

BACKGROUND

Arthritis is an important and sometimes life-threatening complication in patients with common variable immunodeficiency (CVID).

OBJECTIVE

To describe a patient with CVID and arthritis due to Chlamydia pneumoniae, which is usually regarded as a respiratory tract pathogen and has not previously been detected in the synovial fluid by cell culture technique.

METHODS

Routine bacteriologic, virologic, mycologic, and tuberculosis cultures were performed. The patient's synovial fluid was examined for fastidious organisms that might be causative pathogens of arthritis, such as chlamydiae, and special cell culture methods were used. Serologic tests were performed to determine viral and bacteriologic etiology.

RESULTS

The patient had a history of recurrent respiratory tract infections, and the latest exacerbation was followed by arthritis. Cytologic examination of the fluid yielded abundant lymphocytes. Chlamydia pneumoniae was detected in synovial fluid specimens by cell culture technique. Her nasopharyngeal swab and sputum culture specimens were also positive for this pathogen. She was diagnosed as having arthritis caused by C pneumoniae and was given antibiotherapy.

CONCLUSION

Chlamydia pneumoniae should be kept in mind as a causative pathogen in patients with CVID and arthritis, especially when effusion fluid is full of lymphocytes rather than polymorphonuclear cells and no organism is grown on routine cultures.

[Surgical treatment of chronic purulent diseases of extremities' bones and great joints]

Results of treatment of chronic purulent diseases of extremities' bones (n=414) and great joints (n=136) were analyzed. Combined treatment included surgical sanation of the inflammatory focus, autospongioplasty of residual cavities and defects after sequesterectomy (87 cases), extrafocal osteosynthesis, aspiration- flushing drainage. In 46 cases of severe suppuration in the zone of hip joint's endoprosthesis the resection arthroplasty was performed, in 43 cases of severe consequences of ankle-joint's fracture-dislocations -- compression talo-tibial and calcaneo-tibial arthrodesis. The follow-up was 15 years. Positive results were seen in 93.6% patients.

Power Doppler evaluation of joint effusions: investigation in a rabbit model

OBJECTIVE

To study the power Doppler findings of septic arthritis and noninfectious synovitis in an animal model.

MATERIALS AND METHODS

The right knees of 10 rabbits were inoculated with an aqueous suspension of Staphylococcus aureus. The right knees of 5 rabbits were injected with talc suspension. The right knees of 5 rabbits were injected with saline. All 20 left knees were injected with saline. Serial power Doppler images were obtained using constant-imaging parameters. Images were reviewed by blinded observers who assessed for increased power Doppler signal.

RESULTS

All 10 knees inoculated with S. aureus developed septic arthritis. Each infected rabbit knee demonstrated increased signal on power Doppler on at least one examination, ranging from 1-6 days after inoculation. Only 23 of 45 examinations of infected knees were unequivocally positive by power Doppler on examinations performed 1 to 6 days after inoculation. No knee with talc synovitis demonstrated increased power Doppler signal. No control knee demonstrated increased power Doppler signal.

CONCLUSION

Increased power Doppler signal may be seen with septic arthritis; however, its intensity and timing may vary from subject to subject. A normal power Doppler examination does not exclude septic arthritis.

Destructive knee joint infection caused by Peptostreptococcus micros: importance of early microbiological diagnosis

Peptostreptococcus micros is a commensal of the oral cavity and the genitourinary tract that rarely causes serious infections. A case of a destructive knee joint infection with rapid progress caused by P. micros is presented. The significance of the microbiological findings was initially not acknowledged, which contributed to a nonsuccessful clinical outcome.

MRI evaluation of infectious and non-infectious synovitis: preliminary studies in a rabbit model

BACKGROUND

Literature on magnetic resonance imaging (MR) evaluation of inflammatory joint effusions is sparse.

OBJECTIVE

To describe an animal model for studying infectious and non-infectious joint effusions with magnetic resonance imaging.

MATERIALS AND METHODS

Ten rabbit knees with septic arthritis and four with talc synovitis were imaged with MR. Contralateral knees injected with saline served as controls. Fat saturation T2-weighted and gadolinium-enhanced T1-weighted images were assessed for joint effusion, and periarticular and adjacent intraosseous increased signal or enhancement. Each knee was cultured and underwent pathologic examination.

RESULTS

Both Staphylococcus aureus and talc produced effusions in all knees. The degree of periarticular signal and enhancement was greater in infected knees than talc-injected knees. No abnormal enhancement was seen within bone. Pathologic examination showed a greater degree of inflammation and joint destruction in the infected knees, but no evidence of osteomyelitis.

CONCLUSION

A greater degree of abnormal signal and enhancement seen on MR suggests a more vigorous inflammatory process, as seen with septic arthritis. In spite of advanced septic arthritis, no enhancement was evident within bone, suggesting that enhancement within bone is not an expected finding in isolated septic arthritis and should raise concern for osteomyelitis.

Coccidioidomycosis of the knee diagnosed by fine-needle aspiration: a case report

A case of septic arthritis from coccidioidomycosis in a 62-year-old man is described. The diagnosis was made by fine-needle aspiration and supported by positive cultures and exoantigen testing. Coccidioidomycosis can infect bones and joints, especially the knee. This case is presented to increase awareness of involvement of the knee by this organism, and to demonstrate the feasibility of diagnosis by fine-needle aspiration. The cytologic findings of coccidioidomycosis of the knee are described and discussed.

Articular aspergillosis: two case reports and review of the literature

We report two cases of septic arthritis of the knee caused by Aspergillus: one by Aspergillus terreus in a cirrhotic patient and the other by Aspergillus fumigatus after vascular graft infection. The recovery of these organisms in synovial fluid should be considered as pathogenic, particularly in immunocompromised hosts. The pathogenic mechanism is discussed and the literature is reviewed.

Candida tropicalis arthritis in a patient with acute myeloid leukemia successfully treated with fluconazole: case report and review of the literature

The case of a 77-year-old woman with acute myeloid leukemia who developed Candida tropicalis septic arthritis of the knee after remission-inducing chemotherapy is reported. A literature review of C. tropicalis non-prosthetic arthritis is included. The isolate was susceptible to fluconazole (MIC 0.25 mg/l). She was treated with fluconazole (400 mg orally) and frequent relieving synovial aspirations. After 1 month of antifungal therapy the synovial fluid became culture negative. Fluconazole concentration in the synovial fluid and serum were 20 mg/l and 19.4 mg/l, respectively. The patient was treated for a total of 7 months and made a full recovery. This is the first report of the successful use of fluconazole in the treatment of septic arthritis due to C. tropicalis.

Septic arthritis due to Actinobacillus actinomycetemcomitans

Actinobacillus actinomycetemcomitans, a gram-negative aerobic bacillus of the family Parvobacteriaceae which is a normal inhabitant of the oral flora, is a rare cause of human infection. We report a case of septic arthritis caused by this organism in an uncompromised child.

Mycoleptodiscus indicus: a new etiologic agent of phaeohyphomycosis

Mycoleptodiscus indicus, a dematiaceous hyphomycete, was identified as the causal agent of subcutaneous infection in the knee of a 72-year-old male gardener residing in coastal South Carolina. The patient had Wegener's granulomatosis and immunodeficiency. Synovial fluid and biopsy tissue sections from the prepatellar bursa stained with hematoxylin and eosin, periodic acid-Schiff, and Gomori methenamine silver stains revealed branched, septate hyphae and many moniliform hyphal elements. When tissue sections were stained by the Fontana-Masson procedure, melanin pigment in the hyphal cell walls and at the septa was evident. A velvety, dematiaceous mold was isolated from both synovial fluid and the biopsy tissue. Sporulation was induced by exposure of slide cultures on potato dextrose agar to UV light for 12 h at 25 degrees C followed by incubation of the slide cultures at 25 degrees C in the dark for 4 weeks. Clypeate sporodochia consisting of ampulliform, compressed, phialidic conidiogenous cells produced curved, hyaline, one-celled conidia with setulae at one or both ends. Initial treatment with fluconazole for 7 days was not effective, and cultures were positive after treatment. Treatment with amphotericin B with concomitant irrigation and debridement of the affected area followed by treatment with itraconazole resulted in resolution of the infection.

Cutaneous sporotrichosis and distant autoinoculation

A 56-year-old woman suffering from cutaneous sporotrichosis on the right cheek and right knee is described. The sporotrichotic nodule of the knee was thought to have been caused by distant autoinoculation.

Isolation of Yokenella regensburgei ("Koserella trabulsii") from a patient with transient bacteremia and from a patient with a septic knee

Yokenella regensburgei ("Koserella trabulsii") was isolated from a 74-year-old male with a septic knee and from a 35-year-old immunocompromised female whose transient bacteremia occurred without overt signs of sepsis. Neither strain was correctly identified by laboratories using a variety of techniques.

Phaeohyphomycosis caused by Exophiala jeanselmei treated with itraconazole

Phaeohyphomycotic cysts developed on the right knee of a 72-year-old woman undergoing immunosuppressive treatment for ulcerative colitis 6 years after accidental inoculation of soil in a bicycle accident. The lesions were red, firm, slightly raised, 0.5-1 cm in size and completely asymptomatic. The diagnosis was made by histopathological examination of three excised cysts and by repeated isolation of Exophiala jeanselmei in pure culture. The excised cyst walls contained large numbers of dematiaceous fungal elements in the form of hyphae, yeast-like cells and some cells dividing internally by a transverse septum. The patient was treated with 200 mg of itraconazole daily, but the treatment had to be stopped because of severe side-effects after 6 weeks. Histologically the cysts were cleared of dematiaceous elements, but E. jeanselmei could still be isolated from one of two skin biopsies 1 month after the end of therapy.

Osteomyelitis of the patella in children

The early diagnosis of osteomyelitis of the patella in children can be difficult due to the rarity of this infection and to the vagaries of presentation which may be either acute with systemic signs or insidious with mild local signs. We present four cases of patellar osteomyelitis to illustrate the spectrum of this disorder. There should be a high index of suspicion with persistent pain and swelling above the knee, septic prepatellar bursitis, and septic knees that do not respond to conventional management. Management parallels treatment of osteomyelitis of other bones.

Septic arthritis involving Capnocytophaga ochracea

Septic arthritis of the knee developed in a 21-month-old child. The causative organism, isolated from two separate arthrocenteses, was identified as Capnocytophaga ochracea morphologically and by biochemical reactions. Previous human infections (bacteremias) have occurred in granulocytopenic hosts with concomitant oral pathology including periodontitis and gingivitis. No abnormalities of oral hygiene were present in this patient, and granulocyte numbers were normal or elevated. Eradication of the infection was accomplished with 8 weeks of antibiotic therapy combined with surgical drainage. Septic arthritis expands the spectrum of infections reported to be caused by Capnocytophaga spp.

Choice of skin slit smears for study of bacterial and morphological indices

Skin slit smears of 46 patients of lepromatous leprosy (16 untreated, 30 long treated) were studied from ear lobules, fingers, elbows and knees. In untreated patients ear lobules gave highest BI, as compared to other sites. MI from ear lobules was higher than elbows and knees but slightly lower than that from fingers. In treated patients sites other than ear lobules yielded solid staining bacilli more frequently. Multiple sites and especially peripheral sites are recommended for study of skin slit smears to discover persistent bacilli.

Geometric total knee arthroplasty. A two-year follow-up study

In a study of our experience with the first 119 geometric arthroplasties of the knee done at the Mayo Clinic, reported after a minimum follow-up period of two years, we noted that relief of pain was the primary goal in 84 per cent of the cases and this was achieved in the majority. The average total motion was relatively unchanged but it became more useful postoperatively.

Polycentric total knee arthroplasty. A two-year follow-up study

Polycentric total knee arthroplasty provided significant relief of pain in 86 per cent of 500 knees. The independence and activity levels of the patients increased dramatically. The frequency of major complications as reflected by reoperation was 10 per cent in this series. There was a 2.8 per cent deep infection rate. One-third of the infected knees were salvaged and two-thirds required arthrodesis. Loosening of a component was noted in 2.4 per cent. After operation the average range of motion was from 6 to 101 degrees of flexion, for a range of 95 degrees; this was a 5-degree increase over average preoperative motion. Ninety-six per cent of the patients expressed satisfaction with the surgical result.