Septic Polyarthritis and -Surprise!- Cavitary Lung Lesion

 Acid-fast bacilli

Acid-fast bacilli

Dr. Ducey presented a perplexing case of a gentleman from Micronesia who presented with hip and knee pain found to have septic arthritis of both joints and washout cultures growing group B strep. A careful review of systems obtained by the ID consultant team including Dr. Ducey uncovered a several month history of subjective fevers, night sweats, and nonproductive cough prompting an X-Ray showing hilar lymphadenopathy that resulted in an evaluation that uncovered a cavitary lung lesion of the upper segment of the left lower lobe but the workup was unrevealing for etiology. Our discussion centered around the efficient ruling out of tuberculous lung disease, the differential for a cavitary lung lesion including melioidosis (for which our patient was at risk), and the most recent evidence behind the treatment of septic arthritis. Some takeaways courtesy of Dr. Ducey:

  • To rule out active pulmonary tuberculosis, the ATS/IDSA/CDC guidelines suggest:
    • CXR
    • 3 sputum AFM smears and culture
    • At least 3mL, preferably 5-10 mL
    • Sensitivity: 1st specimen: 53.8%, increases 11.1% with second, 2-5% with third (modern practice at PVAMC is to send the third sample for PCR)
    • At least one sample should have a NAA test
    • If cannot provide sputum: induced sputum or bronch
    • If positive smear: test for resistance to rifampin +/- isoniazid
  • Melioidosis
    • Disease caused by Burkholderia pseudomallei
    • Endemic in SE Asia, Northern Australia, and SE Pacific Ocean nations
    • Inoculation occurs by inhalation or ingestion
    • Occurs at higher rates in patients with DM, CKD, alcohol use disorder, and chronic lung disease
    • Clinical manifestations including SSTI, pneumonia, and cavitary lung lesions
    • Acute, chronic, and re-activation disease patterns; if acute with sepsis, mortality 50-90%
    • Diagnosis can be made with culture but sensitivity is ~60% and usually needs to be sent to the CDC which can take weeks
    • Treatment: IV ceftazidime or carbapenem for 10-14 days followed by PO TMP-SMX x12 weeks
    • Exposed indivduals should received post-exposure prophylaxis with TMP-SMX or amox/clav x21 days
  • Treatment of Septic Arthritis
    • In one 6 year retrospective single center UK study including 109 patients with confirmed septic arthritis (SA), the SA treated with aspiration only (60% of patients in the study) resulted in faster functional recovery with no difference in mortality or length of stay

Thanks again to Dr. Ducey for such a dynamic case!

References:

  • David M. Lewinsohn, Michael K. Leonard, Philip A. LoBue, David L. Cohn, Charles L. Daley, Ed Desmond, Joseph Keane, Deborah A. Lewinsohn, Ann M. Loeffler, Gerald H. Mazurek, Richard J. O’Brien, Madhukar Pai, Luca Richeldi, Max Salfinger, Thomas M. Shinnick, Timothy R. Sterling, David M. Warshauer, Gail L. Woods; Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children, Clinical Infectious Diseases, Volume 64, Issue 2, 15 January 2017, Pages e1–e33, https://doi.org/10.1093/cid/ciw694
  • R. Lipsitz, S. Garges, P. Baccam, D.D. Blaney, B.J. Currie, D. Dance, et al.Workshop on treatment of and postexposure prophylaxis for Burkholderia pseudomallei and B. mallei infection, 2010. Emerg Infect Dis, 18 (2012)
  • Ravindran V, Logan I, Bourke BE. Medical vs surgical treatment for the native joint in septic arthritis: a 6-year, single UK academic centre experience. Rheumatology (Oxford). 2009;48:1320–2
  • Butt U, Amissah-Arthur M, Khattak F, et al. What are we doing about septic arthritis? A survey of UK-based rheumatologists and orthopedic surgeons. Clin Rheumatol. 2011;30:707–10
  • Ferrand, Julien et al. “Morbimortality in Adult Patients with Septic Arthritis: A Three-Year Hospital-Based Study.” BMC Infectious Diseases 16 (2016): 239. PMC. Web. 22 Jan. 2018.
  • Nusem I, Jabur MK, Playford EG. Arthroscopic treatment of septic arthritis of the hip. Arthroscopy. 2006;22:902 e1–3.