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Case Report Prosthetic Hip Joint Infection Caused by Rothia Dentocariosa

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Case Report Prosthetic Hip Joint Infection Caused by Rothia Dentocariosa Int J Clin Exp Med 2015;8(7):11628-11631 www.ijcem.com /ISSN:1940-5901/IJCEM0010162 Case Report Prosthetic hip joint infection caused by Rothia dentocariosa Fırat Ozan1, Eyyüp Sabri Öncel1, Fuat Duygulu1, İlhami Çelik2, Taşkın Altay3 ¹Department of Orthopedics and Traumatology, Kayseri Training and Research Hospital, Kayseri, Turkey; ²Department of Clinical Microbiology and Infectious Diseases, Kayseri Training and Research Hospital, Kayseri, Turkey; ³Department of Orthopedics and Traumatology, İzmir Bozyaka Training and Research Hospital, İzmir, Turkey Received May 12, 2015; Accepted June 26, 2015; Epub July 15, 2015; Published July 30, 2015 Abstract: Rothia dentocariosa is an aerobic, pleomorphic, catalase-positive, non-motile, gram-positive bacteria that is a part of the normal flora in the oral cavity and respiratory tract. Although it is a rare cause of systemic infection, it may be observed in immunosuppressed individuals. Here we report the case of an 85-year old man who developed prosthetic joint infection that was caused by R. dentocariosa after hemiarthroplasty. This is the first case report of a prosthetic hip joint infection caused by R. dentocariosa in the literature. Keywords: Hip arthroplasty, infection, Rothia dentocariosa, joint, prosthetic, treatment Introduction resulting from a fall. Swelling in the right lower extremity, pain during rest, erythema at the inci- Rothia dentocariosa is an aerobic, pleomorph- sion site and drainage developed 2 weeks after ic, catalase-positive, non-motile, gram positive surgery. The laboratory evaluations revealed bacteria that is a part of the normal flora in the the following results: C-reactive protein (CRP), oral cavity and respiratory tract [1, 2]. The 178 mg/L; erythrocyte sedimentation rate organism resembles Nocardia and Actinomyces (ESR), 90 mm/h; white blood cell (WBC), 7.79 × species but it differs in terms of the cell wall 103/µL. structure and physiology from these bacteria [1, 2]. Although R. dentocariosa is commonly Samples obtained from the incision site were associated with dental caries and periodontal inoculated on 5% blood agar and eosin methyl- disorders, it is rarely reported as a cause of ene blue agar, followed by incubation at 37°C systemic infection [1]. Endocarditis is the most for 24 h. Gram-positive bacilli were observed on frequent systemic infection caused by Rothia gram staining of the colony growing in blood species [3]. However, it can be a causative agar on the day 2. R. dentocariosa was identi- agent in several systemic infections, particu- fied by using the BD Phoenix™ automated bac- larly in immunosuppressed patients [3-5]. terial system (BectonDickinson, USA). Based on the sensitivity tests using the disc diffusion Among systemic infections caused by Rothia method, it was determined that the isolate was spp. in areas than the oral cavity, prosthetic sensitive to erythromycin, vancomycin, ceftriax- joint infections were reported in 4 cases [4-10]. one and clindamycin. Antibiotic treatment with Our case is the first report of prosthetic hip vancomycin (30 mg/kg; twice daily) was initiat- joint infection caused by R. dentocariosa in the ed on the basis of the result of the sensitivity literature. test. Case report The patient had a history of chronic obstructive pulmonary disease, previous surgery for benign An 85-year old man underwent bipolar hemiar- prostate hyperplasia, appendectomy and cata- throplasty due to right femoral neck fracture ract surgery. He also underwent bipolar hemiar- Rothia dentocariosa throplasty due to his dete- riorating general condition. Discussion A majority of total hip arthroplasty infections are caused by gram-positive bacteria with the most common causative agents being Staphylococcus aur- eus and Staphylococcus epidermidis [11]. Immuno- suppression, long-term uri- nary catheterization, dia- betes mellitus, rheumatoid disorders, alcoholism, cor- ticosteroid therapy, mali- gnancy, intravenous drug abuse and surgical inter- ventions are predisposing factors for opportunistic infections [8, 12, 13]. R. dentocariosa is a sapro- phytic bacterium observed in the normal oropharynge- al flora of humans [1]. It mainly causes nosocomial or auto-hematogenous in- fections. It is a causative agent in cases of immune disorders or the presence of implants [4-10]. Figure 1. Radiographs of the patient. A. Right hip radiograph. B. Left hip radio- graph. C. Heterogeneously increased density and volume loss on chest radio- graph. R. dentocariosa grows bet- ter in aerobic conditions as compared to anaerobic throplasty due to left femoral neck fracture conditions [1, 2]. It is a slow growing organism resulting from a fall 7 years ago. He underwent with an optimum growth temperature of 37°C. tooth extraction 4 months before fracture of Young colonies appear creamy, resembling th- the right hip. In addition, lung cancer was ose of Corynebacterium and Staphylococcus. detected during preoperative evaluations for Mature colonies have rough, highly convoluted right hip fracture (Figure 1). surfaces. The growth rate, lack of partial acid- fastness, absence of aerial mycelium and fer- Debridement and two-stage surgery were pl- mentation of sugars distinguish Rothia from anned because of the prosthesis infection. Nocardia [1, 2]. However, antibiotic therapy and vacuum-assist- ed wound closure (VAC) therapy were selected Overall, seven joint infections caused by Rothia for the treatment of the patient due to poor spp. have been reported till date [4-10]. Of general health status and refusal of surgery by these, 4 were prosthetic joint infections (3 the patient. On the first month of therapy, CRP, prosthetic knee and 1 prosthetic hip infection) ESR and WBC were found to be 8.43 mg/L, 27 (Table 1) [4-6, 10], while 3 were native joint mm/h and 8.41 × 103/µL, respectively. How- infections (2 native knee and 1 native shoulder ever, the patient died 2 months after hemiar- infection) [7-9]. The causative agent of the 11629 Int J Clin Exp Med 2015;8(7):11628-11631 Rothia dentocariosa Table 1. Reported cases of Rothia genus prosthetic joint infections Prosthetic Reference Species Treatment Outcome joint Mahobia et al. [6] R. aeria Knee Hardware removed, ceftriaxone + teicoplanin Successful Trivedi et al. [5] Rothia species (not known) Knee Hardware removed, ertapenem + moxicillin-clavulanate Successful Michels et al. [10] R. mucilaginosa Hip Hardware removed, vancomycin Successful Klingler et al. [4] R. dentocariosa Knee Cefazolin + amoxicillin-clavulanate Successful prosthetic hip infection was R. mucilaginosa Although R. dentocariosa is a rare causative [10]. Our case is the first report of a prosthetic agent of infection in humans, it should be kept hip infection caused by R. dentocariosa in the in mind that it could be a pathogen after joint literature. It was reported that implants were replacement in patients with chronic pulmo- removed and antibiotic therapy was successful nary disorders, particularly in immunosuppr- in 3 prosthetic joint infections [5, 6, 10]. In one essed patients. case with prosthetic knee infection, the patient Disclosure of conflict of interest was successfully treated with antibiotics while preserving the implants [4]. None. There are several options for the treatment of Address correspondence to: Dr. Fırat Ozan, joint arthroplasty infections including antibiotic Department of Orthopedics and Traumatology, therapy, debridement and sparing prosthesis, Kayseri Training and Research Hospital, Sanayi single-stage revision, two-stage revision and Mah. Atatürk Bulvarı Hastane Cad., Kocasinan, resection arthroplasty [13, 14]. For the selec- Kayseri 38010, Turkey. Tel: +90 352 336 88 84; tion of optimal treatment, it is essential to Fax: +90 352 320 73 13; E-mail: firatozan9@gmail. assess patient-related variables and expecta- com tions of both the patient and the clinician dur- ing therapy. We scheduled a two-stage revision References surgery but antibiotic therapy with VAC therapy [1] Von Graevenitz A. Rothia dentocariosa: taxono- was initiated because of poor general status my and differential diagnosis. Clin Microbiol and refusal of surgery by the patient and his Infect 2004; 10: 399-402. relatives. R. dentocariosa is usually susceptible [2] Brown JM, Georg LK, Waters LC. Laboratory to several antibiotics including aminogl- identification of Rothia dentocariosa and its ycosides, tetracycline, vancomycin, penicillin, occurrence in human clinical materials. Appl ampicillin, erythromycin, imipenem, rifampicin, Microbiol 1969; 17: 150-156. [3] Shakoor S, Fasih N, Jabeen K, Jamil B. Rothia ceftriaxone and cefazolin [4-10]. In our patient, dentocariosa endocarditis with mitral valve vancomycin was selected for antibiotic therapy. prolapse: case report and brief review. It was observed that CRP and ESR returned Infection 2011; 39: 177-179. to near-normal values without drainage being [4] Klingler ET, Verma P, Harris A. Infection of a to- performed at the incision site in the first mon- tal knee arthroplasty with Rothia dentocariosa: th of antibiotic therapy. brief report and review of the literature. Infect Dis Clin Pract 2005; 13: 195-199. Dental diseases are considered to be a risk fac- [5] Trivedi MN, Malhotra P. Rothia prosthetic knee tor for R. dentocariosa infections [7]. Antibiotic joint infection. J Microbiol Immunol Infect 2013; 25: 243-245. prophylaxis prior to dental procedures should [6] Mahobia N, Chaudhary P, Kamat Y. Rothia be considered for patients undergoing high-risk prosthetic knee joint infection: report
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