Coccidiomycosis septic arthritis presenting as ankle monoarthritis in a patient with presumed psoriatic arthritis.

A man in his 50s with a history of psoriasis was evaluated for acute on chronic left ankle pain. His symptoms were attributed to psoriatic arthritis, and he tried several immunosuppressive regimens without improvement. Further diagnostic workup confirmed Coccidioides immitis/posadasii septic monarthritis thought secondary to a known remote history of Valley fever while residing in Arizona and subsequent reactivation in the setting of immunosuppression. The patient ultimately required prolonged anti-fungal therapy and multiple surgical debridements.Although psoriatic arthritis can present as monarthritis, it is uncommon, with more likely differential considerations including crystal arthropathies, trauma and both typical and atypical infections. Acute monarthritis should always prompt concern for a septic joint, even in a patient with autoimmune disease. The specific history elicited from the patient, including residence in an endemic region, and known prior Coccidioides infection, increased suspicion for Coccidioides and led to the correct diagnosis and management.

Metagenomic next-generation sequencing promotes pathogen detection over culture in joint infections with previous antibiotic exposure.

Objective: To investigate the diagnostic value of metagenomic next-generation sequencing (mNGS) in detecting pathogens from joint infection (JI) synovial fluid (SF) samples with previous antibiotic exposure. Methods: From January 2019 to January 2022, 59 cases with suspected JI were enrolled. All cases had antibiotic exposure within 2 weeks before sample collection. mNGS and conventional culture were performed on SF samples. JI was diagnosed based on history and clinical symptoms in conjunction with MSIS criteria. The diagnostic values, including sensitivity, specificity, positive/negative predictive values (PPV/NPV), and accuracy, were in comparison with mNGS and culture. Results: There were 47 of the 59 cases diagnosed with JI, while the remaining 12 were diagnosed with non-infectious diseases. The sensitivity of mNGS was 68.1%, which was significantly higher than that of culture (25.5%, p<0.01). The accuracy of mNGS was significantly higher at 71.2% compared to the culture at 39.0% (p <0.01). Eleven pathogenic strains were detected by mNGS but not by microbiological culture, which included Staphylococcus lugdunensis, Staphylococcus cohnii, Finegoldia magna, Enterococcus faecalis, Staphylococcus saprophytics, Escherichia coli, Salmonella enterica, Pseudomonas aeruginosa, Acinetobacter pittii, Brucella ovis, andCoxiella burnetii. Antibiotic therapy was adjusted based on the mNGS results in 32 (68.1%) patients, including 12 (25.5%) and 20 (42.6%) patients, in whom treatment was upgraded and changed, respectively. All JI patients underwent surgery and received subsequent antibiotic therapy. They were followed up for an average of 23 months (20-27 months), and the success rate of treatment was 89.4%. Out of the 33 patients who had positive results for pathogens, reoperation was performed in 1 case (3.03%), while out of the 14 cases with negative results for both mNGS and cultures, reoperation was performed in 4 cases (28.6%). Conclusions: mNGS has advantages over conventional culture in detecting pathogens in SF samples from JI patients previously treated with antibiotics, potentially improving clinical outcomes.

Osteomyelitis and Septic Arthritis of the Foot and Ankle: Imaging Update.

Radiography is considered the first-line screening exam for clinically suspected osteomyelitis. However, additional evaluation is generally needed. MRI is the definitive diagnostic exam with high sensitivity and specificity combined with excellent anatomic definition. Gadolinium contrast can be useful to detect areas of devitalization before surgery. Bone marrow edema on fluid-sensitive images and low signal intensity on T1-weighted images in the presence of secondary MRI findings, including ulcer, sinus tract, and cellulitis with or without abscess are typical findings of osteomyelitis. If MRI is contraindicated, three phase bone scan can be used. Early diagnosis and treatment is essential.

Rapid bone destruction caused by multidrug-resistant Pseudomonas aeruginosa septic arthritis: A case report.

RATIONALE: Infections due to multidrug-resistant (MDR) Pseudomonas aeruginosa are strongly associated with poor outcomes, including prolonged hospitalization and an increased risk of mortality. Antimicrobial options for the treatment of severe infections due to MDR P aeruginosa are quite limited, and treatment remains challenging. PATIENT CONCERNS: A 65-year-old woman presented to our orthopedic clinic with a 3-month history of progressive pain and stiffness in her left knee. Her primary care provider administered a hyaluronic acid injection, which unfortunately resulted in worsening symptoms. Subsequent treatment included a 1-month course of intravenous gentamicin and ceftriaxone, which failed to alleviate her symptoms. DIAGNOSIS: MDR P aeruginosa septic arthritis of the knee. The culture isolate was tested for susceptibility to multiple antibiotics. Magnetic resonance imaging evaluations were conducted, showing notable erosive and osteolytic changes around the joint surfaces that had progressed significantly. INTERVENTIONS: The patient underwent arthroscopic irrigation and synovectomy. The treatment regimen included a combination of intravenous colistin and piperacillin/tazobactam administered over a 6-week period. Total knee arthroplasty was performed 6 months later without additional antibiotic treatment. OUTCOMES: Patient's knee condition remained continuously stable without abnormal findings of inflammation. The patient's knee range of motion increased 0 to 125 degrees, her pain almost disappeared, and she was able to maintain activities of daily life. LESSONS: This case underscores the challenges of managing infections with MDR organisms in complex clinical scenarios, emphasizing the need for timely intervention and appropriate antibiotic therapy.

Analysis of Pathogen Distribution and Antimicrobial Resistance in Bone and Joint Infections Among Young Children.

BACKGROUND: This study aimed to analyze the distribution of pathogens and antimicrobial resistance in bone and joint infections (BJIs) among children under four years old. METHODS: A retrospective analysis was conducted on the clinical data of children under four years old who received inpatient treatment for BJIs at the Children's Hospital of Soochow University between January 2016 and December 2022. Results of bacterial culture and antimicrobial resistance were analyzed. RESULTS: Among the 131 patients, 52 (39.7%) showed positive bacterial culture results. There were Gram-positive (G+) bacteria detected in 38 strains (73.07%), Gram-negative (G-) bacteria in 12 strains (23.08%), and fungi in 2 strains (3.85%). Thirty-one strains of Staphylococcus aureus (S. aureus) were detected (59.62%), including 7 MRSA strains (22.58%). The resistance rate of G+ bacteria to penicillin was 72.97%, while resistance to erythromycin and clindamycin was approximately 50%. No resistance was found against linezolid, vancomycin, and teicoplanin. G- bacteria showed a sensitivity of 100% to carbapenems, including meropenem, ertapenem, and imipenem, a resistance rate of 91.67% to ampicillin-sulbactam, and relatively high resistance rates to compound sulfamethoxazole, ampicillin/sulbactam, and piperacillin. CONCLUSIONS: Regional variations existed in the distribution of pathogens and antimicrobial resistance in children under four years old with BJIs. In our hospital, the most common pathogen is S. aureus, with MRSA accounting for approximately one-fourth of all S. aureus patients. Additionally, extended-spectrum ß-lactamase (ESBL)-producing G- bacteria have been identified, underscoring the importance of careful consideration during empirical antibiotic therapy.

Successful conservative management of advanced pyogenic sternoclavicular joint arthritis with osteomyelitis and pulmonary infiltration: a case report.

BACKGROUND: Sternoclavicular joint arthritis is a rare condition that poses considerable diagnostic and therapeutic challenges, leading to severe complications and a high mortality rate. Although surgical interventions are often considered necessary for advanced cases, some reports have suggested that conservative management with antibiotic therapy can be effective in certain cases. However, to our knowledge, there are no reports of successful conservative treatment in cases exhibiting aggressive spread. This report highlights a case of advanced sternoclavicular joint arthritis with bone destruction and pulmonary infiltration, successfully treated conservatively with outpatient antibiotic therapy. CASE PRESENTATION: A 58-year-old Japanese male presented with a 1-month history of left-sided shoulder pain. Contrast-enhanced computed tomography showed abscess formation and clavicular bone destruction, with infiltrative shadows suggesting lung involvement. The diagnosis of sternoclavicular joint arthritis was made, and outpatient oral antibiotic therapy was initiated. The patient exhibited a marked reduction in inflammatory marker levels and symptoms, and antibiotic therapy was discontinued after 3 weeks, with no recurrence observed at a 4-month follow-up. CONCLUSIONS: This case highlights that conservative management with antibiotics can be effective for treating advanced sternoclavicular joint arthritis, emphasizing the need for individualized management and further research into non-surgical treatment options.

Blau syndrome-the skin as a warning sign.

Blau syndrome is an autosomal dominant chronic inflammatory disease, which may begin with skin manifestations in the first months of life, alerting physicians to the diagnosis. This case reports a patient diagnosed jointly by pediatric dermatology and rheumatology consultants at two years of age.

Effective Management of Methicillin-Resistant Shoulder Septic Arthritis Using Continuous Local Antibiotic Perfusion: A Case Study and Long-Term Follow-Up.

BACKGROUND Septic arthritis of the shoulder is a rare and challenging condition to treat. Typically, arthroscopic debridement is the common approach. Specifically, septic arthritis of the shoulder caused by methicillin-resistant bacteria is extremely difficult to cure due to persistent infection and limited antibiotic options. However, recent studies have demonstrated that continuous local antibiotic perfusion (CLAP) can provide favorable results for bone and soft tissue infections. By administering the antibiotics required to suppress the biofilm, CLAP can effectively treat the infection while sparing the tissue. CASE REPORT A 46-year-old woman undergoing long-term hemodialysis treatment for congenital anomalies of the kidney and urinary tract experienced severe pain in the left shoulder joint during glucocorticoid treatment for amyloid arthritis of the right shoulder. Despite the absence of fever, significant swelling and fluid accumulation were observed in the left shoulder joint, leading to the performance of a puncture. A bacterial examination of the puncture fluid detected methicillin-resistant coagulase-negative Staphylococcus epidermidis (MRCNS). In this report, we present a case in which CLAP was administered for septic arthritis of the shoulder caused by methicillin-resistant bacteria. After irrigation debridement, the patient received intravenous antibiotics and CLAP. Following the initiation of treatment, the dosage of antibiotics was adjusted while performing therapeutic drug monitoring. An early improvement in the inflammatory response and sedation of the infection was observed, with no relapse after 2 years. CONCLUSIONS Septic arthritis can lead to serious functional impairment if left untreated. CLAP is a promising option for managing septic arthritis of the shoulder.

Variants in the Late Cornified Envelope Gene Locus Are Associated With Elevated T-helper 17 Responses in Patients With Postinfectious Lyme Arthritis.

BACKGROUND: Postinfectious Lyme arthritis (LA) is associated with dysregulated immunity and autoreactive T- and B-cell responses in joints. Here we explored the role of host genetic variation in this outcome. METHODS: The frequency of 253 702 single-nucleotide polymorphisms (SNPs) was determined in 147 patients with LA (87 with postinfectious LA and 60 with antibiotic-responsive LA), and for comparison in 90 patients with erythema migrans or the general population (n = 2504). Functional outcome of candidate SNPs was assessed by evaluating their impact on clinical outcome and on immune responses in blood and synovial fluid in patients with LA. RESULTS: Six SNPs associated with late cornified envelope (LCE3) genes were present at greater frequency in patients with postinfectious LA compared to those with antibiotic-responsive LA (70% vs 30%; odds ratio, 2; P < .01). These SNPs were associated with heightened levels of inflammatory Th17 cytokines in serum but lower levels of interleukin 27, a regulatory cytokine, implying that they may contribute to dysregulated Th17 immunity in blood. Moreover, in patients with postinfectious LA, the levels of these Th17 mediators correlated directly with autoantibody responses in synovial fluid, providing a possible link between LCE3 SNPs, maladaptive systemic Th17 immunity, and autoreactive responses in joints. CONCLUSIONS: Variation in the LCE3 locus, a known genetic risk factor in psoriasis and psoriatic arthritis, is associated with dysregulated systemic Th17 immunity and heightened autoantibody responses in joints. These findings underscore the importance of host genetic predisposition and systemic Th17 immunity in the pathogenesis of postinfectious (antibiotic-refractory) Lyme arthritis.

A case of drug fever in the treatment of Brucella arthritis in a child: a case report.

Brucellosis, a zoonotic ailment induced by the Brucella and some patients may present with joint involvement. This report describes a pediatric patient diagnosed with Brucella arthritis, presenting with swelling and pain in the right knee. The patient had a reoccurrence of fever due to sulfamethoxazole-trimethoprim allergy during treatment. Symptoms improved after adjusting the antimicrobial regimen to ceftriaxone and rifampicin. This case emphasizes the importance of the need for brucellosis as a differential diagnosis for arthralgia and fever in brucellosis- endemic areas. Furthermore, it emphasizes the importance of timely recognition that recurrent fever after effective anti-infective therapy must be considered as a possibility of drug fever.

Infectious wrist arthritis complicating acute carpal tunnel syndrome in a child: A CARE-compliant case report.

INTRODUCTION: The objective of this case report is to provide clinical evidence that acute infectious wrist arthritis in children can lead to the rare condition of acute carpal tunnel syndrome (ACTS). This article discusses in detail the characteristics of infectious wrist arthritis complicating ACTS in children in terms of etiology, pathogenic bacteria, treatment modalities, and sequelae to improve the understanding of this disease. PATIENT CONCERNS: A 10-year-old male child presented with a 15-day history of swelling and pain in the left forearm, wrist, and hand. DIAGNOSES: Left-sided infected wrist arthritis complicating ACTS. INTERVENTIONS: The child received emergency surgery and anti-infective treatment combined with regular rehabilitation. OUTCOMES: During the treatment period, the child's wrist pain and swelling gradually improved, and wrist movement was restored compared with the preoperative period. At 6-month follow-up, the activities of the metacarpophalangeal joints of the left hand were close to normal, and the flexion of the left wrist joint was slightly limited. CONCLUSION: In infectious wrist arthritis in children, ACTS is a serious complication that requires aggressive surgical carpal tunnel release to avoid median nerve injury in addition to anti-infective therapy.

Recurrent streptococcal toxic shock syndrome due to distinct episodes of Streptococcus dysgalactiae and Streptococcus agalactiae septic arthritis.

Streptococcal toxic shock syndrome (STSS) is an uncommon disorder characterised by hypotension and multiorgan failure in the setting of streptococcal infection. Recurrent STSS is rare and has been due to recurrence of the same streptococcal species. Here, we present a case of a patient who developed recurrent STSS from a Streptococcus dysgalactiae right native joint septic arthritis and subsequently from a Streptococcus agalactiae left native joint septic arthritis.

Determining the accuracy of the leukocyte esterase reagent strip test in the rapid diagnosis of adult septic arthritis.

BACKGROUNDS: Septic arthritis is a dangerous disease that occurs when microorganisms enter synovial fluid. It needs fast and accurate management; otherwise, it can harm the patient's life. Currently, the tests measure WBC and PMN in SF, so we hypothesized to use a proxy that is easier and faster to measure. Leukocyte esterase is an enzyme secreted by neutrophils that can be found in the synovial fluid of SA patients. In this study, we tried to investigate the sensitivity and specificity of leukocyte esterase in diagnosing septic arthritis. METHODS: We obtained synovial fluid samples from forty-six patients suspected of having septic arthritis and fifty-eight healthy individuals and measured the WBCs, ESR, CRP, PMN, glucose, and protein of SF in 2021. We also used the leukocyte esterase dipstick test to investigate the level of LE in synovial fluid for one minute. RESULTS: Based on clinical and paraclinical criteria, sixteen out of the forty-six patients were diagnosed with SA. When (++) was considered positive, the sensitivity and specificity of the LE dipstick test for the diagnosis of SA were 93.7% (95% CI: 81.8-100%) and 60% (95% CI: 42.4-77.5%, P = 0.000), respectively. When both (+) and (++) were considered positive, they were 100% and 43.3% (95% CI: 25.6-61.0% P = 0.000), respectively. All the patients in the control group had negative cultures and LE test readings (specificity = 100%). CONCLUSION: The LE dipstick test can be a valuable diagnostic tool in the initial diagnosis of SA since it is affordable, fast, and reliable.

Bilateral Facet Joint Septic Arthritis Induced by Acupuncture: A Case Report Highlighting Diagnostic Challenges and the Importance of Early Intervention.

BACKGROUND Facet joint septic arthritis (SAFJ) is a rare clinical entity that is extremely challenging to diagnose, often presenting unilaterally and with nonspecific clinical symptoms. However, SAFJ has significant morbidity and mortality, especially with delayed diagnosis. It becomes all the more important for the clinician to recognize that SAFJ can present bilaterally and be associated with direct inoculation, such as in acupuncture. CASE REPORT A 53-year-old woman with chronic alcoholism and well-controlled type 2 diabetes mellitus was initially admitted for progressively worsening atraumatic lower back pain. Initial non-contrast magnetic resonance imaging (MRI) of the lumbar spine revealed bilateral L4-L5 and L5-S1 nonspecific facet joint effusions. Clinical examination was unremarkable. Biochemically, the patient had mildly elevated inflammatory markers. She was treated conservatively with close outpatient follow-up. However, her back pain progressively worsened, with new-onset lower limb weakness and numbness. Repeat MRI showed L4-L5 bilateral facet joint fluid collection with adjacent bony destruction, as well as posterior paraspinal and epidural fluid collections compatible with L4-L5 bilateral SAFJ with paraspinal and epidural abscesses. Urgent surgical drainage and bilateral lateral facet decompression was performed. Intraoperative cultures revealed methicillin-sensitive Staphylococcus aureus as the causative organism. Postoperatively, 6 weeks of intravenous and oral antibiotics were given with good recovery. CONCLUSIONS We describe a case of bilateral SAFJ following acupuncture that was initially missed. With the increasing prevalence of acupuncture treatment for lower back pain, bilateral SAFJ should be a diagnostic consideration. Detailed clinical history is key; this, as well as a high index of suspicion, early evaluation and treatment, are essential to obtain a favorable outcome.

Bone and Joint Infections in Children With Sickle Cell Disease in French Guiana: A 13-Year Retrospective Multicenter Review.

INTRODUCTION: Sickle cell disease (SCD) is a genetic disorder with a high infectious morbidity and mortality and a heterogeneous distribution in France. One of the challenges is to differentiate a bone and joint infection (BJI) from a vaso-occlusive crisis. This challenge is particularly prevalent in French Guiana, an overseas territory with the highest incidence of SCD in France. The aim of this study was to describe the epidemiology of BJI in children with SCD in French Guiana. METHOD: This was a retrospective multicentric descriptive study of SCD patients living in French Guiana aged under 18 and diagnosed with a BJI between 2010 and 2022. These BJI were divided into 2 groups: those with microbiological documentation (d-BJI) and those without microbiological identification (ud-BJI). RESULTS: A total of 53 episodes of BJI in 42 patients (mean age 7.2 years) were reported. Clinical symptoms on arrival were comparable between the d-BJI and ud-BJI groups. Patients in the d-BJI group had longer average hospital stays (40.4 days vs. 16.8 days, P = 0.01) and Salmonella spp. were the most identified bacteria (n = 8/13). White blood cell count was greater in the d-BJI group (30.3 G/L vs. 18.G/L, P = 0.01) and a collection was more frequently identified on imaging (11/13 vs. 16/40, P = 0.01) in this group. Initial in-hospital antibiotic therapy was longer in the d-BJI group (17.2 days vs. 12.8, P = 0.02), as were infection-related complications (9/13 vs. 12/40 P = 0.01). CONCLUSION: BJI in children with SCD is not sufficiently microbiologically documented. Progress must be made to improve the documentation of BJI.

Performance characteristics of genus or species-specific Polymerase Chain Reaction (PCR) for the microbial diagnosis of joint infections: A systematic review and meta-analysis.

Joint infections cause significant morbidity and mortality. Rapid diagnosis enables prompt initiation of appropriate antimicrobial therapy and surgical treatment. We conducted a systematic review and meta-analysis to evaluate the accuracy of genus- or species-specific polymerase chain reaction (PCR) in diagnosing joint infections. The literature databases were searched for articles from January 2010 to December 2022. The meta-analysis using the split component synthesis (SCS) method, included 20 studies with 2,457 adult participants. The pooled sensitivity, specificity, diagnostic odds ratio, and AUC of PCR were 49 % (95 % CI [37.9-60.2]), 95.7 % (95 % CI [91.6-97.8]), 21.32, and 0.82 respectively. Sensitivity was highest for sonicate fluid and lowest for periprosthetic tissue. The mean turnaround time to results was 4.7 hours (SD 1.1). PCR is a favourable option for diagnosing joint infections due to its rapid results, but it has low sensitivity. To enhance diagnostic yield, the test should be used in conjunction with other methods.

[Aspergillus flavus/oryzae Arthritis of the Knee Joint: First Case in Türkiye]. / Diz Ekleminde Gelisen Aspergillus flavus/oryzae Artriti: Türkiye'de Ilk Olgu.

Aspergillus species are common hyphal fungi. In addition to allergies and mycotoxicosis, Aspergillus species can cause various infections known as aspergillosis. Aspergillosis of the respiratory tract, central nervous system, skin and soft tissues is well described. However, musculoskeletal infections due to invasive aspergillosis are not well described. Fungal joint infection due to invasive aspergillosis is a rare form of septic arthritis. In this case report, a patient who admitted to our hospital for liver transplantation and developed knee joint arthritis caused by Aspergillus flavus/Aspergillus oryzae during this process was presented. A 28-year-old male patient with autoimmune hepatitis was admitted to hospital with decompensated liver cirrhosis and encephalopathy. The patient, who was awaiting an emergency liver transplant, developed pain, swelling and limitation of movement in his right knee and appropriate consultations and tests were requested. Three joint fluid cultures taken one day apart and nine days later were positive for fungal growth. Macroscopic examination of the mould growth and microscopic examination with lactophenol cotton blue suggested a species belonging to the A.flavus complex and the isolate was identified as A.flavus/A.oryzae by matrix-assisted laser desorption/ionisation mass spectrometry (MALDI-TOF MS) (EXS 2600, Zybio, China). As a result of ITS gene sequencing, the species was determined to be A.oryzae. As cases have been reported where A.flavus and A.oryzae species could not be distinguished by ITS gene sequencing, the pathogen was defined as A.flavus/oryzae. The patient died of liver disease during treatment with amphotericin B. There are few cases of arthritis caused by Aspergillus species in the literature. Aspergillus species found in joint infections are, Aspergillus fumigatus, A.flavus, Aspergillus niger and Aspergillus terreus species complexes, in order of frequency. A.flavus and A.oryzae are closely related. They are difficult to distinguish by conventional methods, MALDI-TOF MS or ITS region sequencing, which is commonly used for genus/species identification in fungi. The number of Aspergillus arthritis cases is low and the identification methods applied to the species reported as causative agents in most studies can identify at the species complex level. In addition, it can be assumed that species not previously reported as causative agents may be encountered as a result of developments in identification methods. In the few publications in the literature where A.flavus complex was reported as the causative agent of joint infections, it seems possible that some of the agents may be A.flavus and some may be A.oryzae, since the agents were identified at the complex level. There are a limited number of cases in the literature where A.oryzae is the causative agent, particularly in the respiratory tract. A PubMed search using the keywords "A.oryzae infections, arthritis, osteomyelitis" did not reveal any literature on joint infections caused by A.oryzae.

Efficacy and Accuracy of Diagnosing Septic Arthritis: How Effective are Current Methods for Timely Diagnosis of Septic Arthritis?

The diagnosis of septic arthritis requires a reliance on ancillary tests, including synovial fluid white blood cell count (jWBC), percentage of polymorphonuclear leukocytes (%PMN), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). This study evaluated these tests to determine their diagnostic utility in suspected septic arthritis. A retrospective chart review was performed on patients admitted to an urban hospital who underwent arthrocentesis. The authors evaluated the jWBC, %PMN, ESR, and CRP with receiver operating characteristic (ROC) curve analyses. Two hundred sixty-five patients met inclusion criteria. Sixty-three had a culture-positive aspirate. ROC curve analysis resulted in an area under the curve (AUC) of 0.80 for jWBC with cutoff point of 22,563 cells/mm3 and an AUC of 0.71 for %PMN with cutoff point of 90.5%. CRP and ESR had AUC values of 0.62 and 0.61, respectively. The culture-positive cohort had higher elevations in all assessed diagnostic tests. However, AUC data for ESR and CRP showed little diagnostic utility. Additionally, sensitivities and specificities of jWBC and %PMN were too low. Associated cutoff points would result in excessive unnecessary operative intervention. Further studies should incorporate synovial fluid biomarkers into the workup of a suspected septic joint. (Journal of Surgical Orthopaedic Advances 33(2):108-111, 2024).