Ozone Treatment Unveils the Veil of Candida parapsilosis Infection in the Knee Joint: A Case Report and Literature Review.

Candida infection is common, while Candida parapsilosis infection in the knee joint is rare. Local symptoms of Candida infections in the knee are atypical, rarely associated with systemic symptoms, and difficult to distinguish from other types of knee arthritis. We here report a special case of C. parapsilosis infections in the knee joint. A patient had previously undergone knee puncture in a private clinic for the treatment of osteoarthritis and developed a left knee joint infection with C. parapsilosis. However, the patient only showed more severe local knee symptoms, and there was no systemic manifestation associated with any Candida infection. Surprisingly, after receiving ozone lavage, the patient showed symptoms of a systemic infection such as fever and chills. There was no positive finding in the blood cultures. Finally, the synovial fluid cultures showed a C. parapsilosis infections. After antifungal treatment and another knee ozone therapy, the patient did not experience recurrence of the infections. It is suggested that in this special case, the strong sterilization with ozone caused the destruction of C. parapsilosis, leading to a transient systemic toxin reaction. In addition, we reviewed the 17 cases of C. parapsilosis infections that have been reported thus far.

Coexisting polyarticular septic arthritis, gout and pseudogout.

A case of a 67-year-old man with coexisting polyarticular septic arthritis due to group G Streptococcus, gout and pseudogout is presented. Septic arthritis of the left knee joint was further complicated by the development of an adjacent osteomyelitis. Appropriate management led to a full clinical recovery. Atypical clinical presentations in elderly, need for a sampling of more than one joint in polyarthritis and a summary of similar cases in literature is discussed.

Comparative Genomics Study of Staphylococcus epidermidis Isolates from Orthopedic-Device-Related Infections Correlated with Patient Outcome.

Staphylococcus epidermidis has emerged as an important opportunistic pathogen causing orthopedic-device-related infections (ODRI). This study investigated the association of genome variation and phenotypic features of the infecting S. epidermidis isolate with the clinical outcome for the infected patient. S. epidermidis isolates were collected from 104 patients with ODRI. Their clinical outcomes were evaluated, after an average of 26 months, as either "cured" or "not cured." The isolates were tested for antibiotic susceptibility and biofilm formation. Whole-genome sequencing was performed on all isolates, and genomic variation was related to features associated with "cured" and "not cured." Strong biofilm formation and aminoglycoside resistance were associated with a "not-cured" outcome (P = 0.031 and P < 0.001, respectively). Based on gene-by-gene analysis, some accessory genes were more prevalent in isolates from the "not-cured" group. These included the biofilm-associated bhp gene, the antiseptic resistance qacA gene, the cassette chromosome recombinase-encoding genes ccrA and ccrB, and the IS256-like transposase gene. This study identifies biofilm formation and antibiotic resistance as associated with poor outcome in S. epidermidis ODRI. Whole-genome sequencing identified specific genes associated with a "not-cured" outcome that should be validated in future studies. (The study has been registered at ClinicalTrials.gov with identifier NCT02640937.).

Brucella melitensis es un agente de la artritis pediatrica: Serie de casos / Brucella melitensis is an agent in pediatric arthritis: Case series

La brucelosis es un importante problema de salud y, en algunas regiones, es endémica. En ella, es muy frecuente observar un compromiso osteoarticular (20%-60%). En regiones donde es endémica, al analizar la etiología de la artritis, hay que pensar en esta entidad. En este artículo, se informan los casos de 12 pacientes; 11 de ellos eran varones, y la media de edad fue de 12 años (intervalo: de 2 a 17 años). Se determinó el compromiso de la cadera en 9 pacientes; de la articulación sacroilíaca, en 2; y de la rodilla, en 1. Todos los pacientes tenían artralgia; 8 pacientes tuvieron fiebre; y 1 paciente, leucocitosis. A un paciente se lo sometió a un tratamiento quirúrgico debido a artritis séptica. La infección puede derivar en complicaciones graves, especialmente en el compromiso del aparato locomotor. Debe tenerse en cuenta que, mediante el diagnóstico y tratamiento tempranos, es posible prevenir las complicaciones.

Brucellosis is a significant health problem and is endemic in some regions. Osteoarticular involvement is seen most frequently in brucellosis (20-60%). In regions where brucellosis is endemic, it should be considered in the etiology of arthritis. We report the 12 cases, were 11 males with a mean age of 12 years (range, 2-17 years). Involvement was determined in the hip in 9 cases, the sacroiliac joint in 2 and the knee in 1. All the cases had arthralgia, fever was determined in 8 cases and leukocytosis in one case. Surgical treatment was applied to one case because of septic arthritis. Serious complications of the infection may be encountered and particularly in musculoskeletal system involvement, it should be kept in mind that complications can be prevented by early diagnosis and treatment

[Brucella melitensis is an agent in pediatric arthritis: Case series]. / Brucella melitensis es un agente de la artritis pediatrica: Serie de casos.

Brucellosis is a significant health problem and is endemic in some regions. Osteoarticular involvement is seen most frequently in brucellosis (20-60%). In regions where brucellosis is endemic, it should be considered in the etiology of arthritis. We report the 12 cases, were 11 males with a mean age of 12 years (range, 2-17 years). Involvement was determined in the hip in 9 cases, the sacroiliac joint in 2 and the knee in 1. All the cases had arthralgia, fever was determined in 8 cases and leukocytosis in one case. Surgical treatment was applied to one case because of septic arthritis. Serious complications of the infection may be encountered and particularly in musculoskeletal system involvement, it should be kept in mind that complications can be prevented by early diagnosis and treatment.

La brucelosis es un importante problema de salud y, en algunas regiones, es endémica. En ella, es muy frecuente observar un compromiso osteoarticular (20%-60%). En regiones donde es endémica, al analizar la etiología de la artritis, hay que pensar en esta entidad. En este artículo, se informan los casos de 12pacientes; 11 de ellos eran varones, y la media de edad fue de 12 años (intervalo: de 2 a 17 años). Se determinó el compromiso de la cadera en 9 pacientes; de la articulación sacroilíaca, en 2; y de la rodilla, en 1. Todos los pacientes tenían artralgia; 8 pacientes tuvieron fiebre; y 1 paciente, leucocitosis. A un paciente se lo sometió a un tratamiento quirúrgico debido a artritis séptica. La infección puede derivar en complicaciones graves, especialmente en el compromiso del aparato locomotor. Debe tenerse en cuenta que, mediante el diagnóstico y tratamiento tempranos, es posible prevenir las complicaciones

Prosthetic knee arthritis due to Granulicatella adiacens after dental treatment.

We report prosthetic knee arthritis in a 55-year-old diabetic man due to Granulicatella adiacens, a micro-organism present in the oral flora, usually described in endocarditis but rarely in prosthesis joint infection. This patient had undergone a dental extraction without antibiotic prophylaxis one month before, and an aseptic loosening of the prosthesis had been diagnosed previously. If antimicrobial prophylaxis against infective endocarditis for dental procedures is well established, such an approach is still controversial for joint prosthesis and should be considered in some conditions.

Murine Borrelia arthritis is highly dependent on ASC and caspase-1, but independent of NLRP3.

INTRODUCTION: The protein platform called the NOD-like-receptor -family member (NLRP)-3 inflammasome needs to be activated to process intracellular caspase-1. Active caspase-1 is able to cleave pro-Interleukin (IL)-1ß, resulting in bioactive IL-1ß. IL-1ß is a potent proinflammatory cytokine, and thought to play a key role in the pathogenesis of Lyme arthritis, a common manifestation of Borrelia burgdorferi infection. The precise pathways through which B. burgdorferi recognition leads to inflammasome activation and processing of IL-1ß in Lyme arthritis has not been elucidated. In the present study, we investigated the contribution of several pattern recognition receptors and inflammasome components in a novel murine model of Lyme arthritis. METHODS: Lyme arthritis was elicited by live B. burgdorferi, injected intra-articularly in knee joints of mice. To identify the relevant pathway components, the model was applied to wild-type, NLRP3-/-, ASC-/-, caspase-1-/-, NOD1-/-, NOD2-/-, and RICK-/- mice. As a control, TLR2-/-, Myd88-/- and IL-1R-/- mice were used. Peritoneal macrophages and bone marrow-derived macrophages were used for in vitro cytokine production and inflammasome activation studies. Joint inflammation was analyzed in synovial specimens and whole knee joints. Mann-Whitney U tests were used to detect statistical differences. RESULTS: We demonstrate that ASC/caspase-1-driven IL-1ß is crucial for induction of B. burgdorferi-induced murine Lyme arthritis. In addition, we show that B. burgdorferi-induced murine Lyme arthritis is less dependent on NOD1/NOD2/RICK pathways while the TLR2-MyD88 pathway is crucial. CONCLUSIONS: Murine Lyme arthritis is strongly dependent on IL-1 production, and B. burgdorferi induces inflammasome-mediated caspase-1 activation. Next to that, murine Lyme arthritis is ASC- and caspase-1-dependent, but NLRP3, NOD1, NOD2, and RICK independent. Also, caspase-1 activation by B. burgdorferi is dependent on TLR2 and MyD88. Based on present results indicating that IL-1 is one of the major mediators in Lyme arthritis, there is a rationale to propose that neutralizing IL-1 activity may also have beneficial effects in chronic Lyme arthritis.

Prosthetic knee infection in the young immigrant patient--do not forget tuberculosis!

Skeletal tuberculosis (TB) frequently masquerades as more common etiologies and can be difficult to diagnose. We describe a case of TB knee arthritis in a young Haitian-born woman in whom the diagnosis was not initially suspected, resulting in treatment with total knee arthroplasty that subsequently failed. A long course of medical and surgical therapies was then necessary to treat this patient. Issues in the diagnosis and management of TB in the native and prosthetic knee joint are presented.

Tuberculous arthritis of the knee joint mimicking pigmented villonodular synovitis.

UNLABELLED: Tuberculous arthritis is difficult to diagnose early because of its atypical insidious clinical manifestations and non-specific imaging findings. Specifically, monoarticular tuberculosis of the knee may mimic pigmented villonodular synovitis (PVNS). The present report describes a young patient with tuberculous arthritis of the knee. Proper diagnosis was delayed due to magnetic resonance imaging findings, such as hemosiderin deposits and a nodular mass around the knee joint, suggesting the diffuse type of PVNS. These findings suggest that the first step in the diagnosis of tuberculous knee arthritis is to have a high index of suspicion. LEVEL OF EVIDENCE: IV.

Septic polyarthritis caused by group A streptococcus in an immunocompetent adult: rare case.

We report a rare case of multifocal septic arthritis associated to spondylodiscitis and endocarditis caused by group A beta-hemolytic streptococcus (GABHS) in an immunocompetent adult, and we discuss diagnosis and therapeutic difficulties, while insisting into the rational use of corticosteroids that seems to be the only risk factor in our patient.

Multifocal infection of mycobacterium other than tuberculosis mimicking a soft tissue tumor of the extremity.

Mycobacterium other than tuberculosis infections rarely develop in healthy individuals, but direct inoculation such as contaminated acupuncture can cause mycobacteriosis even in an immunocompetent host. A 56-year-old woman gradually developed pain on the anterior aspect of the left knee and the distal thigh after hiking without trauma. She received acupuncture for 3 consecutive days on the bilateral knees at the suprapatellar and infrapopliteal areas. After acupuncture, mild localized heat and painful swelling developed around the knees bilaterally. Magnetic resonance imaging (MRI) demonstrated soft tissue masses with a lobulated contour at the prefemoral fat between the suprapatellar pouch and the distal femur and at the proximal tibia behind the knee joint capsule. Fibromatosis, pigmented villonodular synovitis, and soft tissue sarcoma were considered. On pathologic examination, multiple granulomas with lymphoplasmatic infiltration were evident, and acid-fast bacteria staining revealed acid-fast bacilli. A mycobacterial culture confirmed Mycobacterium other than tuberculosis infection, and a polymerase chain reaction-fragment length polymorphism assay identified the isolates as Mycobacterium abscessus. After treatment with appropriate antibiotics, the patient had no evidence of disease and reported no pain during activities of daily living. Acupuncture is growing in prominence in Europe and the United States, and the number of reports on complications increases with its widespread use. Although the risk to an individual patient is difficult to determine, acupuncture may cause serious complications in patients with coagulopathy, heart valve disease, and immune deficiency. In addition, direct inoculation such as contaminated acupuncture can cause mycobacteriosis even in an immunocompetent host.

Acupuncture needle-associated prosthetic knee infection after total knee arthroplasty.

The case of a patient who previously had permanent acupuncture needles placed in the knee joint and had been doing well, with no evidence of infection, but who eventually underwent a revision total knee arthroplasty due to acupuncture needle-associated prosthetic infection is presented. The microorganism responsible for the infection was Enterococcus faecalis, a bacterium which rarely causes infection following arthroplasty. This case should be highlighted to increase the awareness of healthcare providers to acupuncture-associated subclinical infection that may be exacerbated by surgical manipulation.

Characterization of small-colony variants of Enterococcus faecalis isolated from chickens with amyloid arthropathy.

In this study we report the isolation and characterization of normal-sized and small-colony variants of Enterococcus faecalis from outbreaks of amyloid arthropathy in chickens. Postmortem examinations of 59 chickens revealed orange deposits in the knee joints, typical for amyloid arthropathy. Bacterial cultures from 102 joints and 43 spleens exhibited pure (n = 88) and mixed (n = 11) cultures of normal (n = 60) and pinpoint (n = 28) colonies of E. faecalis. Pulsed-field gel electrophoresis of 62 isolates demonstrated seven different band patterns with at most two band size variations, and multilocus sequence typing demonstrated two different sequence types, sharing six out of seven alleles, suggesting a close evolutionary relationship between isolates obtained from four outbreaks. In addition, all isolates were clonally related to an amyloid arthropathy reference strain from The Netherlands, previously shown to be globally dispersed. Initial investigation of the isolated small-colony variant phenotype revealed no difference in whole-cell protein profiling between normal and pinpoint colonies. However, the pinpoint colony isolates appeared to be more virulent in an in vivo challenge model in chickens than their normal-sized-colony counterparts. In addition, pinpoint morphology and associated slow growth were expressed without reversion after in vitro and in vivo passage, suggesting a genuine altered phenotype, and in some instances normal colonies converted to pinpoint morphology postinfection. In conclusion, small-colony variants of E. faecalis are described for the first time from veterinary clinical sources and in relation to amyloid arthropathy in chickens.

Infectious arthritis as the single manifestation of sporotrichosis: Serology from serum and synovial fluid samples as an aid to diagnosis

En la mayoría de las veces, la esporotricosis es una infección cutánea,granulomatosa, crónica y benigna. De modo más raro, la enfermedad puedeafectar las articulaciones. El comprometimiento articular en general secaracteriza por monoartrite sin síntomas sistémicos con presentación clínicahabitual de lesiones cutáneas y con frecuencia despunta en las personasinmunodeprimidas. El caso descrito es de una paciente sana que presentóartritis en la rodilla sin lesiones cutáneas, con el diagnostico de esporotricosisy que fue tratada con itraconazol oral. En este caso se concluye que lasorología es una herramienta valiosa para el diagnóstico de la artritis sinlesiones cutáneas producida por el hongo Sporothrix schenckii(AU)

Sporotrichosis is a generally cutaneous, granulomatous, chronic and benigninfection. Less frequently the disease may affect the joints. Articularinvolvement is usually characterized by monoarthritis in the absence ofsystemic symptoms, generally preceded by skin lesions, and frequently affectsimmunosuppressed individuals. We describe here the case of a healthy patientpresenting knee arthritis without skin lesions, diagnosed as sporotrichosis, andtreated with oral itraconazole. Serology used in this case was an invaluabletool for the diagnosis of sporotrichosis arthritis lacking skin lesions(AU)

[Implication of dexamethasone adjunctive therapy after the onset of cerebral vasculitis in Streptococcus pneumoniae meningitis]. / Implication du traitement adjuvant par dexaméthasone dans la survenue d'une artérite septique cérébrale au cours d'une méningite à Streptococcus pneumoniae.

Few adverse effects have been reported with adjunctive dexamethasone treatment in pneumococcal meningitis. Nevertheless, we report a case of cerebral vasculitis. A 49-year-old man was admitted for fever and altered mental status. Lumbar puncture revealed a high inflammatory response and Streptococcus pneumoniae was identified by culture. Antibacterial therapy and adjunctive dexamethasone treatment were initiated as recommended. The immediate outcome was favorable but due to the onset of focal cerebral abnormalities, a CT scan was performed on the ninth day showing cerebral vasculitis. The patient died on the thirteenth day despite antibacterial therapy and resuscitation. In our case, a secondary neurological worsening appeared when adjunctive dexamethasone treatment was stopped suggesting a rebound effect. Observation of similar cases may lead to modifying adjunctive dexamethasone treatment protocol in bacterial meningitis.

[Salmonella prosthetic knee septic arthritis successful retention of the prosthesis with prolonged suppressive therapy].

A 75 years old woman suffered from Salmonella enteritidis infected prosthetic knee joint septic arthritis. Maintenance of the prosthesis was achieved by surgical drainage and debridement of the joint followed by 3 weeks of intravenous ceftriaxone and 3 months of oral ciprofloxacin therapy.

Sigma factor B and RsbU are required for virulence in Staphylococcus aureus-induced arthritis and sepsis.

The prototype Staphylococcus aureus strain 8325-4 produces high levels of hemolysins and proteases. Recently it has been shown that this property depends on a deficiency of sigma factor B (SigB) activity controlling the activation of regulatory genes such as agr and sarA. SigB deficiency is in turn due to a mutation in the rsbU gene, which is required for posttranslational activation of SigB. The rsbU defect of strain 8325-4 has recently been repaired, and we used this strain (SH1000), along with its isogenic sigB-negative mutant, to investigate the contributions of RsbU and SigB in a murine model of septic arthritis. Intravenous inoculation with the rsbU-repaired isogenic strain SH1000 resulted in significantly more severe arthritis, weight decrease, and mortality compared to those of the parental strain 8325-4 (rsbU-negative) or the isogenic sigB-negative mutant (MJH502). SH1000 also persisted more in kidneys and joints of infected mice. Our data strongly suggest that RsbU and SigB regulate important virulence factors, thereby contributing significantly to the outcome of staphylococcal infection.

Acupuncture-associated arthritis in a joint with an orthopaedic implant.

Viral infection is a well-recognized complication of acupuncture therapy. Bacterial infection however is rare. We report a rare case of intra-articular bacterial knee infection due to inadvertent acupuncture needle penetration.

Intra-articularly localized bacterial DNA containing CpG motifs induces arthritis.

Unmethylated CpG motifs are often found in bacterial DNA, and exert immunostimulatory effects on hematopoietic cells. Bacteria produce severe joint inflammation in septic and reactive arthritides; bacterial DNA may be involved in this process. We injected bacterial DNA originating from Escherichia coli and Staphylococcus aureus and oligonucleotides containing CpG directly into the knee joints of mice of different strains. Arthritis was seen by histopathology within 2 hours and lasted for at least 14 days. Unmethylated CpG motifs were responsible for this induction of arthritis, as oligonucleotides containing these motifs produced the arthritis. The arthritis was characterized by an influx of monocytic, Mac-1+ cells and by a lack of T lymphocytes. Depletion of monocytes resulted in abrogation of the synovial inflammation. Tumor necrosis factor (TNF)-alpha, a cytokine produced by cells of the monocyte/macrophage lineage, is an important mediator of this disease, as expression of mRNA for TNF-alpha was evident in the inflamed joints, and the CpG-mediated inflammation was abrogated in mice genetically unable to produce this cytokine. These findings demonstrate that bacterial DNA containing unmethylated CpG motifs induces arthritis, and indicate an important pathogenic role for bacterial DNA in septic arthritis.