Novel Infection Status Post Electrocution Requiring a 4th Ray Amputation WilliamJudson IV, D.O.1, John Murphy, D.O.1, Phillip Sussman, D.O.1, John Harker D.O.1 HCA Healthcare/USF Morsani College of Medicine GME Programs/Largo Medical Center

Background Treatment • Prevotella bivia is an anaerobic, non-pigmented, Gram-negative bacillus species that is known to inhabit the human female vaginal tract and oral flora. It is most commonly associated with endometritis and pelvic inflammatory disease.1, 2 • Rarely, P. bivia has been found in the nail bed, chest wall, intervertebral discs, and hip and knee joints.1 The bacteria has been linked to necrotizing fasciitis, osteomyelitis, or septic arthritis.3, 4

• Only 3 other reports have described P. bivia infections in the upper Figure 1: Dorsum of the right hand on Figure 2: Ulnar aspect of right 4th and 5th Figures 13 and 14: Most recent images of patients hand in March, 2020. 2 presentation fingers Wound over the dorsum of the hand completely healed. Patient with flexion extremity with one patient requiring amputation , and one with deep soft contractures of remaining digits. tissue infection requiring multiple debridements and extensive tenosynovectomy.5 Discussion • Delays in diagnosis are common due to P. bivia’s long incubation period • P. bivia infections, although rare in orthopedic practice, can lead to and association with aerobic organisms that more commonly cause soft extensive debridements and possible amputation leading to great tissue infections leading to inappropriate antibiotic coverage. morbidity when affecting the upper extremities.1, 2, 5 • Here we present a case on P. bivia that resulted in extensive • It is suggested that P. bivia needs to grow in conjunction with an aerobic tenosynovectomy, multiple irrigations and debridements and eventually organism in order to cause disease.2 In this case P. bivia grew in amputation of the 4th ray and digit of the hand conjunction with group B streptococcus. Figure 3: Intraoperative images of the Figure 4: Post operative images of the • Aerobes in conjunction with P. bivia are known to increase the initial flexor tynosenovectomy and initial flexor tynosenovectomy and Case Presentation Irrigation and debridement Irrigation and debridement pathogenicity of the P. biva, this allows it to become the dominant strain 4, 6, 7 • 5/9/19: Consult for worsening right hand pain and swelling for 5 days after in the infection. suffering electrical burns to right ring and index finger 2 weeks prior. • It is proposed that P. Biva has elastolytic capacity, which allows it to possibly induce destruction of host tissues facilitating the need for Associated fevers (Tmax 100.9), WBC 20.8, ESR 104, CRP 26.7. MRI further debridements after the index surgery.2 concerning for 4th finger flexor tenosynovitis. • In most cases an aerobic organism is isolated first from the cultures • 5/10/19: Right ring finger flexor tynosynovectomy, right hand irrigation and followed several days later with a positive culture for P. biva. This was sharp excisional debridement of superficial tissue and muscle. the case for our patient which took three days to begin growing P. biva Intraoperative Cultures growing Strep agalactiae (Group B), Gram + Flora, after initial cultures grew GBS and various gram positive flora. continued on vancomycin, cefepime, flagyl per Infectious disease. • As is the case for most gram negative anaerobes, antibiotic selection • 5/12/19: Repeat Irrigation and debridement of right hand and 4th digit. Figures 5 and 6: Preoperative images prior to 4th irrigation and debridement showing lack of becomes difficult to determine. P. biva is also thought to possess beta- viability of the flexor tendon as well as cyanotic nature of the 4th digit 8 Additional cultures obtained. lactamase, thus making this a challenging bacteria to treat. • Some studies suggest that clindamycin, amoxicillin/clavulanate, • 5/14/19: Further excisional debridement of skin, subcutaneous fatty tissue, metronidazole, and imipenem are all effective against P. bivia.1 tendon sheath, and muscle with irrigation. • As with any case that involves multiple irrigations and debridements with • 5/15/19: Intraoperative cultures from 5-12-19 (2nd surgery) begin to grow associated amputation, it is important to discuss realistic expectations Prevotella biva and Candida lusitaniae in addition to Strep agalactiae with the patient including the need for extensive rehabilitation and (Group B Strep) permanent loss of function or range of motion. • 5/16/19: Repeat, irrigation and debridement of right hand and 4th digit. Decision made to discuss amputation with patient given lack of viability of References th the flexor tendon and cyanotic nature of the 4 finger. 1. Mirza A, Bove JJ, Litwa J, Appelbe G. Mixed Infections of the Paronychium with Prevotella bivia. J Hand Figures 7, 8 and 9: Intraoperative images of 4th ray resection and amputation of the 4th digit of ‐ th Microsurg. 2012;4(2):77 80. • 5/18/19: Right 4 finger ray amputation, irrigation and debridement to the patient’s right hand 2. Riesbeck K. Paronychia due to Prevotella bivia that resulted in amputation: fast and correct bacteriological bone. diagnosis is crucial. J Clin Microbiol. 2003;41(10):4901‐4903. 3. Alegre-Sancho, J. J., X. Juanola, F. J. Narvaez, and D. Roig-Escofet. Septic arthritis due to Prevotella bivia in a • 5/22/19: Patient stable to be discharged from an orthopedic standpoint patient with rheumatoid arthritis. Joint Bone Spine. 2000; 67:228–229. 4. Laiho, K., and P. Kotilainen. Septic arthritis due to Prevotella bivia after intra-articular hip joint injection. Joint with follow up instructions. Infectious disease signed off case with Bone Spine. 2001; 68:443–444. recommendations to continue zosyn for an additional 4 weeks. Patient to 5. A. Kinsella, S. Parson, D. M. Davidson. Necrotizing fasciitis of the hand and wrist due to Prevotella bivia. The Journal of Hand Surgery. 2014; (Eur) 40(7). 757-758. follow with wound care team in the outpatient setting. 6. Hsu GJ, Chen CR, Lai MC et al. Chest wall abscess due to Prevotella bivia. J Zhejiang Univ Sci B. 2009; 10(3): 233–236. • 8/2019: Wound vac discontinued and patient demonstrating granulation 7. Mikamo, H., K. Kawazoe, K. Izumi, K. Watanabe, K. Ueno, and T. Tamaya. Studies on the pathogenicity of anaerobes, especially Prevotella bivia, in a rat pyometra model. Infect. Dis. Obstet. Gynecol. 1998; 6:61–65. tissue formation and adequate wound healing. 8. Bahar H, Torun MM, Demirci M et al. Antimicrobial resistance and beta-lactamase production of clinical isolates of prevotella and porphyromonas species. Chemotherapy. 2005; 51 (1):9–14. • 12/2/19: Wound over the dorsum of the hand now completely healed. Figures 10, 11 and 12: Images of various stages of healing with the wound vac device with closure of the wound over the dorsum of the right hand