Paediatric Septic Arthritis of
ankle due to Granulicatella adiacens, the first case ever reported in the world
literature.
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.
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.
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Kirupakaran, Chockalingam,
Septic arthritis of the
ankle joint.
Sports Med Arthrosc Rehabil Ther
Technol. 2011; 3: 21.
PMCID: PMC3192658
xArthroscopic washout of the
ankle for septic arthritis in a three-month-old boy
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