A rare organism causing septic arthritis of hip joint

MidhunMadhavan PC1,  S. Chockalingam2 ,  Thilagavathy3 

1DNB PG orthopedic surgery, Kauvery Hospital, Cantonment, Trichy

2Senior consultant, department of orthopedics, Kauvery Hospital, Cantonment, Trichy

3Consultant – Microbiologist, Kauvery Hospital, Trichy

Abstract

Septic arthritis of hip joint is caused by inoculation or invasion of joint space by microorganisms leading to arthritis. It can be either direct inoculation or by haematogenous spread or by contiguous infection from nearby tissue. The most common bacteria that cause of septic arthritis of hip are Staphylococcus Aureus, Streptococcus Pneumonia and Streptococcus Viridans. One rare cause of septic arthritis is Melioidosis which is caused by Burkholderia pseudomallei. In septic arthritis of the hip, increased fluid pressure can lead to avascular necrosis of the head of femur, and septic arthritis of hip joint is a surgical emergency.

Case report

A 30 years aged patient came to the orthopedic department with complaints of intermittent fever and right hip pain for one and a half months duration. The fever was intermittent, with spikes more in the night, and occasional chills. Along with the fever he developed right hip pain which started initially as dull, on and off, pain, progressing in intensity, present more during the night , aggravated by right hip movements and relieved by rest and medication. Later on, the pain was present even during rest and the daily activities of the patient were severely limited due to the pain.

The patient was not a known diabetic or hypertensive; no history of pulmonary tuberculosis in the past. Patient had a history of fever and jaundice five months back for which he took treatment and was cured. He is an occasional consumer of alcohol.

The patient consulted a local hospital for hip pain. Arthroscopic synovial. biopsy and core decompression were done there. The surgical wound did not heal fully and had non foulsmelling scanty discharge from the wound site. Culture and sensitivity taken from outside hospital showed growth of MorganellaMorganii.

On arrival at our hospital the patient was febrile and tachycardic, with swelling of right hip and discharging sinus from one of the arthroscopic surgical portal site. Local warmth and tenderness were there, and right thigh also was swollen and tender. There was minimal right knee effusion. Range of movements of the right hip were grossly limited.Distal pulses , sensations and toe and ankle movements were normal

His blood investigations showed anemia, elevated ESR and C Reactive protein.Xray showed degenerative changes in the head of femur and evidence of core decompression procedure. MRI was suggestive of septic arthritis of right hip with abscess collection in joint space, head of femur and vastus lateralis muscle, which was in communication with the exterior skin through a sinus tract.

The patient was taken up for surgery and open washout of right hip joint. Intraoperatively, the patient was noted to have severe destruction of the femoral head and articular cartilage and excision arthroplasty of the right hip with antibiotic impregnated cement bead (meropenem+ cefotaxime) application was done. Patient was put on intravenous antibiotics and analgesics, and post operatively skin traction was applied. Synovial biopsy taken during the surgery showed non specific synovitis and histopathological examination of femoral head showed osteomyelitic changes.

The patient was taken up for surgery and open washout of right hip joint. Intraoperatively, the patient was noted to have severe destruction of the femoral head and articular cartilage and excision arthroplasty of the right hip with antibiotic impregnated cement bead (meropenem+ cefotaxime) application was done. Patient was put on intravenous antibiotics and analgesics, and post operatively skin traction was applied. Synovial biopsy taken during the surgery showed non specific synovitis and histopathological examination of femoral head showed osteomyelitic changes.

On the 1stpost op day, the patient developed breathing difficulty, persistent tachycardia, tachypnoea and drop in Oxygen saturation to 76%. He had persistent fever spikes.

Post op investigations showed low Hb- 7.6, elevated LFT & ALP.

In view of SIRS and early ARDS, thepatient was intubated, ventilated, blood and blood products transfused, and antibiotics escalated. Patient was put on DVT prophylaxis.Pus culture and sensitivity taken during the surgery showed heavy growth of Bulkholderia Pseudomallei. Antibiotics were changed appropriately and supportive care given.

With the above measures the patient improved, and his CRP decreased serially, Liver function improved. The patient was weaned from ventilator on POD6, extubated on POD7 and shifted to ward on POD8. He was taken up for wound wash and removal of antibiotic impregnated cement beads on the 16th post op day.He continued to receive appropriate IV antibiotics, analgesics and supportive care and his general condition improved. Physiotherapy and mobilization were done, his surgical wounds healed and was discharged with advice to continue long term antibiotics.

The patient was readmitted after six months for right total hip replacement, and uncemented right total hip replacement was done for him. Since then the patient has been comfortable, ambulant with a painless hip.

Melioidosis and its orthopedic manifestations

Melioidosis is caused by a gram negative bacilli – Burkholderia pseudomallei/mallei found in moist soil and water. It is endemic in south east Asia and Australia. The usual mode of infection is either by inoculation, ingestion or inhalation.People with diabetes, chronic alcoholism, immuno suppressed individuals etc are found to be affected more commonly. Melioidosis has a broad spectrum of clinical manifestations and may present as pneumonia, fever, myalgia, or rare but well recognized orthopedic manifestations such as septic arthritis. A study published in the Malaysian journal of orthopedics in 2009 showed that abscesses were the main cause of orthopedic referral in melioidosis cases accounting for up to 63.6% followed by septic arthritis and cellulitis. Melioidosis can also lead to severe septicemia and may prove to be life threatening.

Conclusion

Melioidosis is a pyogenic infection caused by the gram-negative bacilli Burkholderia pseudomallei with a wide variety of clinical manifestations and high mortality .It may present as a simple pneumonia. Septicarthritis or even severe sepsis. So diagnosis should be made with a high index of clinical suspicion and prompt measures should be taken to ensure the patients wellbeing.

Dr Chokalingam

Dr. S. Chockalingam
Senior Consultant – Orthopaedic Surgeon

Dr.Thilagavathy

Dr. Thilagavathy
Microbiologist

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