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Tuesday, March 8, 2016

Infection of ankle joint in an infant due to rare microorganism, for GPs,Paediatricians and Ortho doctors

Paediatric Septic Arthritis of ankle due to Granulicatella adiacens, the first case ever reported in the world literature.


 Introduction:
Septic arthritis is a bacterial infection of a joint with synovial tissue and fluid. It is an Orthopaedic Surgical emergency. Any delay in diagnosis and treatment may result in destruction of articular cartilage and the bone. This condition is common in children, probably due to the immature immune system. Even though Septic arthritis incidence is decreasing worldwide, it is fairly common to encounter this condition in India. 

We encounter around five to six cases of septic arthritis in a year. Bacteriological isolation from the affected joint has always been our prime objective. This is often obtained by either open or arthroscopic drainage. The procedure also ensures thorough washout of the joint to remove all infected materials and the destructive enzymes produced in the process.
The bacteriological growth in our previous study is as shown below.
Candida
5
MRSA
3
MSSA
3
B hemolytic Strep
2
Pseudomonas
2
Achromobacter
1
Klebsiella MDR
1
atypical AFB1
1

As one can see, the predominant organisms are Staphylococcus and Candida. However, rare organisms are also seen. We would like to report this child with septic arthritis due to one such rare organism.


 Case Report:

8 month old female child, presented with swelling and inability to use the ankle and foot due to pain. Clinical examination showed the ankle to be swollen with warmth and tenderness. A clinical diagnosis of Infective process involving the ankle joint and possibly abscess was made. The blood results were as follows. Ultrasound of the ankle showed significant effusion with normal findings on the other side.
The child was given regional anaesthesia with sedation. The affected leg was prepared with aseptic precautions, draped. Ankle joint was aspirated and three milliliter of frank pus was obtained. This specimen was directly placed in the blood culture bottles. Ankle joint was scoped with 2.4mm mini scope. Ankle synovitis was noted and further specimens were obtained by arthroscopic biopsy of the synovial tissue. Antibiotics Ampicillin and Cloxacillin were subsequently given in the operating room.
The portal sites dressings were applied. The ankle joint was immobilized in plaster of paris bandage.  The child showed a good clinical improvement. The child started weight bearing on the affected side in three days without any pain. The wound was inspected and was found to be healthy. The C reactive protein dropped to 24 from the preoperative value of 174, the normal range below 6.
Culture specimens grew cocci which initially mimicked pneumococci, but was subsequently recognized as Granulicatella Adiacens.  The sensitivity pattern is as shown.
Discussion:
Septic arthritis is more common in children than adults. In children, the peak incidence is in children less than three years. In western world, the incidence is quite low. In a large study based on the database of a tertiary care hospital (Kocher et al), there were 82 children with septic arthritis in a time span of over 17 years.  There is a concern that this incidence is now increasing due to MRSA-CA among Pediatricians
 ( Kaplan SL), but there are no strong data in the literature to prove this.

The standard protocol followed for suspected septic arthritis is as follows. The child is admitted under the care of Pediatricians. Antibiotics are not routinely started except when the child is in systemic sepsis. Being a tertiary referral centre, some of these children were already on antibiotics.
Ultrasound is routinely obtained to confirm the clinical suspicion of excess fluid in the joint. MRI is obtained if there is a suspicion of Osteomyelitis or in delayed presentations. Joint is aspirated only in operating room after preparation and draping of the affected limb. Specimens are directly inoculated into blood culture bottles in the following order. Anaerobic, aerobic followed by specimen sterile bottles. Tissue specimens are obtained where possible.
Causative organisms in septic arthritis are Staphylococcus aureus, E.Coli, Group B Streptococci, and other Gram negative organisms. Hemophilus influenza used to be common prior to the era of immunization. Group A streptococci, Streptococcus pneumoniae have also been reported. MRSA community acquired is now increasing in incidence. Our earlier study confirmed this increasing incidence. Our study also highlighted the high incidence of Candida in children who were already receiving antibiotics.
Rare organisms to cause septic arthritis such as pseudomonas and Achromobacter were reported. This Granulicatella Adiacens infection of ankle is the first ever reported case in the World English literature in a child. The previous report of this infection in joints is in a prosthetic knee in a 68 year old patient ( Riede et al).  This isolation of such a rare organism may in part due to our practice of routinely inoculating the specimen directly into the blood culture bottles.
This organism is part of the Nutritionally variant Streptococci (NVS) group which has two sub groups, namely Abiotrophia and Granulicatella. Granulicatella is commonly implicated in the infective endocarditis. It also has been reported in prosthetic infections in CVS, brain abscess and meningitis. (Cargill et al).  In Orthopaedic speciality, this organism had been seen in one case of septic arthritis of a prosthetic joint as mentioned above and in vertebral Osteomyelitis.
Lee et al have presented their series of septic arthritis of ankle which is more common in adults than children. Thus our case report presents a rare joint involvement of ankle joint in a child septic arthritis (Hagino et al) and even unreported being due to this organism Granulicatella Adiacens. Fortunately this organism is very sensitive to common antibiotics. Our patient made a rapid recovery with arthroscopic washout and ampicillin and cloxacillin.  Thus our  case report is also the second reported case of ankle arthroscopy  in an infant and the first ever reported from our part of the world.

References:
xCargill J et al   Granulicatella infection: diagnosis and management  , Journal of Medical Microbiology (2012), 61, 755–761

Hepburn, M. J et al, 2003.   Septic arthritis caused by Granulicatella adiacens: diagnosis by inoculation of synovial fluid into blood culture bottles. Rheumatol Int 23, 255–257

Riede, U., Graber, P. & Ochsner, P. E. (2004). Granulicatella (Abiotrophia) adiacens infection associated with a total knee arthroplasty. Scand J Infect Dis 36, 761–764.

Fukuda, R., Oki, M., Ueda, A., Yanagi, H., Komatsu, M., Itoh, M., Oka, A., Nishina, M., Ozawa, H. & Takagi, A. (2010). Vertebral osteomyelitis associated with Granulicatella adiacens. Tokai J Exp Clin Med 35, 126–129.

Heath, C. H., Bowen, S. F., McCarthy, J. S. & Dwyer, B. (1998). Vertebral osteomyelitis and discitis associated with Abiotrophia adiacens (nutritionally variant streptococcus) infection. Aust N Z J Med 28, 663.

Rosenthal, O., Woywodt, A., Kirschner, P. & Haller, H. (2002). Vertebral osteomyelitis and endocarditis of a pacemaker lead due to Granulicatella (Abiotrophia) adiacens. Infection 30, 317–319

xKocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec. 81(12):1662-70.

Kaplan SL. Challenges in the evaluation and management of bone and joint infections and the role of new antibiotics for gram positive infections. Adv Exp Med Biol. 2009. 634:111-20.
Kirupakaran, Chockalingam,

Chang Gung Med J. 2000 Jul;23(7):420-6.
Septic arthritis of the ankle joint.

Sports Med Arthrosc Rehabil Ther Technol. 2011; 3: 21.
Published online 2011 Oct 1. doi:  10.1186/1758-2555-3-21
PMCID: PMC3192658
xArthroscopic washout of the ankle for septic arthritis in a three-month-old boy


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