Destructive pneumococcal septic arthritis in end-stage renal disease

Clinical rheumatology,

16,

Case Report

Destructive Pneumococcal

End-Stage Renal

Septic Arthritis in

Disease

I . F . C I E R N I K ,

J . C . G E R S T E R ,

P. B U R C K H A R D T

Summaly

Pneumococcal arthritis generally presents as non-destructive monoar-

thritis, although some underlying metabolic disorders such as liver failure and di-

abetes have been suggested to represent a risk factor for severe joint disease. Here

we report a case of destructive pneumococcal arthritis of the left hip joint in a pa-

tient suffering from chronic renal failure treated with hemodialysis for ten years.

Inspite of effective anti-pneumococcal antibiotic treatment, the patient with pre-

existing renal osteopathy and a mild osteoarthritis continued to suffer from se-

vere and disabling pain of the left hip. This case demonstrates that pneumococca !

joint infection in patients with underlying uremic bone disease can lead to quick

deterioration of the affected joint.

Key words

Arthritis, Sepsis, Streptococcus Pneumoniae, Pneumococcal

Infection, Arthritic Complications, Haemodialysis, Chronic Renal Failure.

I N T R O D U C T I O N

Streptococcus pneumoniae

is a rare cause of septic ar-

thritis that accounts for 2 to 6% of nongonococcal bac-

terial arthritis (1,2). Before the introduction of antibi-

otics, pneumococci-induced pneumonia was frequently

associated with arthritic manifestations (3). Although

pneumococcal arthritis may lead to cartilage destruc-

tion and subchondral bone erosions if untreated, imme-

diate antibiotic treatment generally prevents progres-

sion to severe joint destruction (4,5). Haematogenous

spread of pneumococci to joints is favored by underly-

ing medical conditions such as diabetes mellitus or cir-

rhosis, or by local predisposing factors such as osteoar-

thritis or rheumatoid arthritis.

Here we report a case of pneumococcal arthritis of a

hip in a patient with terminal renal failure of long dura-

tion, leading to severe residual joint disease after infec-

tion with

S. pneumoniae,

which to our knowledge has not

been reported so far.

From the Ddpartement de m6decine interne et service de rhumatol- ogic, Centre hospitalier universitaire vaudois, 1005 Lausanne, Swit- zerland.

CASE R E P O R T

A 67-year-old Caucasian lady was admitted to the emer-

gency room of our hospital for a severe pain of the left

hip associated with fever and chills, which developed on

the same day. Her previous medical history revealed ter-

minal renal failure due to polykystic kidney disease re-

quiring haemodialysis for 9 1/2 years, three times per

week. Two years prior to admission, the patient under-

went a subtotal parathyroidectomy due to secondary hy-

perparathyroidism. She had been suffering from short-

ness of breath due to haemodialysis-associated dilative

cardiomyopathy for eight years.

A physical exam revealed decreased mobility of the left

hip and a clinical work-up showed a left lower lobar pneu-

monia. A blood count showed normochromic, normocyt-

ic anaemia with a haemoglobin of 113 g/1. The leuko-

cyte count was 5.2 G/1 with 40% of hyposegmented poly-

morphonuclear leukocytes (PMN). The sedimentation

rate was 95 mm/h and the CRP was elevated at 272 mg/

1. A radiograph of the left hip showed a severe osteoar-

thritis with subchondral lytic changes of the left hip (Fig-

ure lb) which were not present two years before admis-

sion (Figure la). A magnetic resonance imaging revealed

an increased amount of joint fluid, but no signs of ostei-

tis or bone necrosis. Fluid aspirate from the hip joint was

slightly haemorrhagic with moderate viscosity and con-

478

E Ciernik, J.C. Gerster, E Burckhardt

A

Fig. 1: Anteroposterior view of the left hip of a 67 years old uremic patient undergoing haemodialysis since 1986. An X-ray on the Febru- ary 5th 1993 shows mild changes of bone structure (a). Osteoarthritis is present on the day of admission for acute hip pain on November 28th 1995 (b). After antibiotic treatment of septic pneumococcal arthritis, progressive osteoarthritis is revealed on January 16th 1996 (c).

"I'B

tained 22.5 G/I leukocytes with a PMN fraction of 86%.

Two out of two blood cultures were positive for

One culture of synovial fluid showed

as well. The patient was treated with intravenous

ceftriaxone for 10 weeks. Although laboratory parame-

ters suggested an effective antimicrobial effect, an in-

validating pain of the left hip persisted and a new radio-

graph confirmed the severe progressive destruction of

the left hip joint (Figure lc). Because of severe cardi-

omyopathy surgical treatment was refused. The patient

was offered a 23-polyvalent pneumococcal vaccine at the end

of her hospitalization and used two crutches for walking.

DISCUSSION

Patients undergoing chronic haemodialysis are known

to suffer from an altered immune function and are at in-

creased risk for severe infectious diseases including sep-

tic arthritis (6-9). In the general population, infections

due to

presenting as pneumonia are fre-

quently associated with bacteriaemia and positive blood

cultures can be observed in up to 25% (10). Involve-

ment of joints leading to septic pneumococcal arthritis

is rare and presents generally as a non-destructive sep-

tic monoarthritis usually of the knee, although other sites

such as the wrist, shoulder, and ankle can also be affect-

ed. Involvement of the hip joint is uncommon (11). De-

structive pneumococcal arthritis of one or two joints, es-

pecially the knee and the shoulder joints, has been de-

Pneumococcal Arthritis 479 s c r i b e d i n p a t i e n t s with c h r o n i c a l c o h o l i s m , cirrhosis, o r d i a b e t e s m e l l i t u s (3). N o n - d e s t r u c t i v e p n e u m o c o c c a l ar- thritis h a s b e e n a s s o c i a t e d with o t h e r m e d i c a l c o n d i t i o n s as well, such as F e l t y ' s s y n d r o m e , b o n e m a r r o w t r a n s - p l a n t a t i o n , or m u l t i p l e m y e l o m a (12-14). I n dialysis p a - t i e n t s i n f e c t i o u s a r t h r i t i s h a s b e e n r e p o r t e d i n v o l v i n g s o m e t i m e s u n c o m m o n sites s u c h as t h e s t e r n o c l a v i c u - lar, sacroiliac, a n d a c r o m i o c l a v i c u l a r j o i n t s (8). N o t r e n d to a n i n c r e a s e d risk for r e s i d u a l s e v e r e j o i n t d i s e a s e has

b e e n n o t e d so far. E n d - s t a g e r e n a l d i s e a s e has n o t b e e n r e p o r t e d t o p r e d i s p o s e f o r p n e u m o c o c c a l a r t h r i t i s , at- t h o u g h t h e o v e r a l l risk f o r i n f e c t i o n s in u r e m i c p a t i e n t s r e m a i n s s u b s t a n t i a l (7,15). T h i s r e p o r t i n d i c a t e s , t h a t di- alysis p a t i e n t s m a y s u f f e r f r o m p n e u m o c o c c a l arthritis, w h i c h i n o u r case l e d to s e v e r e r e s i d u a l d e g e n e r a t i v e j o i n t disease. M o r e i n f o r m a t i o n o n the prognosis o f p n e u - m o c o c c a l a r t h r i t i s i n u r e m i c p a t i e n t s is w a r r a n t e d .

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Received: 22 May 1996.

Revision-accepted: 19 February- 1997. Correspondence to: I.E CIERNIK, M.D.,

Departement ffir Inhere Medizin, Universit~tsspital Z/]rich, R~mistrasse 100, 8091 Z/~rich, SWITZERLAND.