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.}

^{Lee CH1, Chen YJ, Ueng SW, Hsu RW.}

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

Tetsuo Hagino,1 Masanori Wako,2 and Satoshi Ochiai1

For doctors and paramedics, a brief about chest injury

Chest injury and breathing

Why is it important to understand Chest Trauma?

It is important to understand Chest Trauma since it affects both the breathing and Circulation in trauma patients

Is it a common problem and how significant is it in trauma?

It is very significant as it a common cause of death in trauma patients

Why is it relevant to me as I am not a cardio thoracic surgeon?

Chest trauma does not need surgery in majority of patients. Less than 10% patients need surgery in chest trauma. Majority of them need simple procedures such as giving oxygen, chest drain insertion etc which often saves a patient from dying.

Can you explain about chest trauma in simple terms so that i can understand?

We need to understand the anatomy to understand the chest injury and the different types of the injury

The injuries may not be obvious at first as normal chest x ray does not rule out chest trauma.  Hence it is essential to understand the physiology.

Explain to me in simple terms about the anatomy behind the chest trauma.

Essential anatomy:       1. Lungs with the airways and blood vessels with a cavity                                          around called pleural cavity

                                       2. Heart with a cavity around called peritoneal cavity

                                       3.  Mediastinum which has all the major vessels and the airways                                            and the oesophagus

        4. the chest is covered with bones [ribs and                                              clavicle], muscles [intercostal vessels] and separated from the abdomen by  diaphragm.

 How do i remember all this Anatomy when i see a patient and read a chest x ray

                                as simple as ABC…….

        1. A   Airway: Trachea

        2. B   Breathing: lungs, pleural cavity, chest wall

        3. C   Circulation: Heart, pericardial cavity, major vessels

        4. D   Diaphragm

        5. E   Everything else: includes Esophagus, Entered tubes & lines

Essential physiology

                                Chest has the gas exchange chamber

The chamber itself with the air in and the exhaust:     trachea and airways

the motor :                  Chest wall with the ribs, muscles and diaphragm

the current which is needed to operate the motor for gas                                        exchange chamber : the intercostal nerves  and the phrenic nerve

Chest has the main pump of the body namely the heart and the main vessels

how do i remember all this physiology when i am confronted with a patient

              As simple as what is taught in your MBBS

                                assess the patient with

                                Oxygen saturation : oxygen delivery to skin

                                alertness                :  oxygen delivery to brain and  CO2                clearance

                                Pulse              : heart rate

                                blood pressure  : heart output and resistance to the flow of blood

                                urine output   : heart function to keep the kidneys working well

I understand all this. Now tell me a way to assess and manage a patient with chest trauma.

                        When faced a patient with chest trauma, always and always

                                Go back to airway

                               

                                ensure a patient airway

                                       talk to the patient

                                       check his nose, mouth, teeth, tongue, throat and larynx      area are normal.

                                       make sure that his cervical spine is protected if injury cannot be excluded.

                                then follow what you have been taught at medical school

                                inspect

                                palpate

                                percuss

                                auscultate

                                and then measure

Inpect and palpate  for         breathless ness and tachypnoea

                                               open wounds and abnormal chest wall movements

                                               trachea position and neck swelling

                                               tenderness and crepitus

percuss and ausculate        resonance to percussion

               

                                               air entry

                                               heart sounds

measure and assess           Oxygen sauration

               

                                               pulse

                                               blood pressure

                                               and all parameters for shock including urine output

                                               be liberal with chest x ray

i have all done all the assessments as above, how do i manage the patient with chest injury

                                Identify life threatening injury and manage then and there

                                identify any non life threatening injury and come back to its management after completing the primary survey and management

Life threatening injuries

                                characterised by what you find in your assessment

                during inspection and palpation

                                1. air hunger and cyanosis

                                2. open chest wall wounds

                                3. abnormal chest wall movements

                                4. tracheal deviation

                during percussion and auscultation

                                absent breath sounds & either no or hyper resonant on percussion

                during measurement

               

                                low oxygen saturation

if you find any of these, patient may die with the following injuries if you do not act now

                Airway obstruciton

                tension pneumothorax

                open pneumothorax

                massive hemothorax

                cardiac tamponade

                                              

                flail chest

how do one recognise these conditions and how do i treat them as i detect them

airway obstruction       

        Diagnosis:                                            

        air hunger, cyanosis    

        stridor                                                                                 

        patient not talking and unable to talk                                                                                                                         

        Treatment: Oxygen, manual clearance, suction and secure airway

Tension pneumothorax

                       

        Diagnosis:

        Trachea deviated to one side                    

        Hyperresonant chest with no air entry                      

        Engorged veins and shock

        Treatment

                Airway first and

                needle decompression and                                                                          chest drain

               

Massive hemothorax

       

        Diagnosis:

        Engorged veins and shock

        Trachea deviated

        Dull chest and no air entry

        Treatment:

        Airway first and

        IV access and fluids and Blood transfusion

        ICD chest drain insertion

       

Open pneumothorax

       

        Diagnosis

        Open wound in chest

        Pneumothorax features

        Treatment

       

        Airway first and

        Three way dressing

        Chest drain insertion

       

Cardiac tamponade

        Diagnosis

        Engorged veins and shock

        Muffled heart sounds

Treatment

        Airway first and

        Needle drainage

        ECG monitoring

               

Flail chest

        Diagnosis:

        Paradoxical breathing

        With multiple rib fractures

Treatment

        Pain relief

        ICD

        Ready to intubate and internal splinting

Summary:

Chest trauma is common, can kill a patient if not recognized and treated promptly. Majority of treatment in chest trauma is ensuring a patent airway, oxygen, simple measures such as chest drain.