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Rheumatological Manifestations of Infective Endocarditis

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Rheumatological Manifestations of Infective Endocarditis Ann Rheum Dis: first published as 10.1136/ard.43.5.716 on 1 October 1984. Downloaded from Annals of the Rheumatic Diseases, 1984, 43, 716-720 Rheumatological manifestations of infective endocarditis Ph. THOMAS,' J. ALLAL,2 D. BONTOUX,' F. ROSSI,3 J. Y. POUPET,3 J. P. PETITALOT,2 AND B. BECQ-GIRAUDON4 From the Departments of 'Rheumatology, 2Cardiology A, 3Internal Medicine, 4Infectious Diseases, CHU La Miletrie, 86000 Poitiers, France SUMMARY A retrospective study showed musculoskeletal manifestations in 32 of 108 patients treated for infective endocarditis in several departments at the Poitiers CHU. Such manifesta- tions included articular pain or aseptic arthritis, typically involving the major joints, as well as vertebral osteomyelitis, low back pain (inflammatory or non-inflammatory), and myalgia. Patients showing such signs were generally younger than those without musculoskeletal involvement, diagnosis was made later, and prognosis was worse; streptococcus D was more often involved, and microscopic haematuria was more common. With the exception of vertebral osteomyelitis, the pathogenesis was not clear. Key words: bacterial endocarditis, rheumatology, arthritis, arthralgia, low back pain, vertebral osteomyelitis. copyright. Musculoskeletal manifestations of infective en- increase in organic murmur. Echocardiographic, docarditis (IE) are particularly hard to diagnose, surgical, or necropsy reports confirmed the diagno- and until recently their frequency has been under- sis in all cases where they were available. estimated. Reviewing 108 cases of patients admitted Assay of circulating immune complexes (CIC) to hospital for IE at the Poitiers CHU we sought to was carried out by a modified polyethylene glycol http://ard.bmj.com/ determine: (a) the type and frequency of rheumato- (PEG)-precipitation technique.' C4 precipitated by logical manifestations of IE; (b) the clinical and PEG was expressed as a function of serum C4 laboratory characteristics of IE with or without such concentration, with assay carried out by nephel- manifestations. ometry and results expressed as percentage C4 precipitated. The percentage precipitation increases Materials and methods with increasing quantities of circulating immune complexes (normally less than 20%). on September 26, 2021 by guest. Protected This study included 108 cases of infective endocardi- Statistical analysis was carried out by Student's t tis, 77 males and 31 females, treated between 1 test, the x2 test with Yates's correction where the January, 1966 and 30 September, 1983 at the samples were less than or equal to 5, and Wilcoxon's Poitiers CHU in the Departments of Cardiology A, non-parametric test. Infectious Diseases, Internal Medicine, and Rheumatology. This diversified recruitment pre- Results vented statistical bias from the specialisation of a single department. For patients to be included they MUSCULOSKELETAL MANIFESTATIONS had to have the following: (a) organic valvular (or Thirty-two of 108 (29.6%) patients had musculo- prosthetic) involvement; (b) demonstration of skeletal manifestations (Table 1). Arthritis or pathogens by haemoculture or culture of valvular arthralgia developed in the major joints of the arms tissue, or clinical septicaemia with development or and legs; while arthritis involved only one joint per in 4 of 7 Accepted for publication 15 May 1984. patient, it was accompanied by arthralgia Correspondence to Dr Ph. Thomas, Department of Rheuma- cases. There were no radiological signs, and in the tology, La Mildtrie BP 577, 86021 Poitiers cedex, France. two cases where synovial fluid was taken, though it 716 Ann Rheum Dis: first published as 10.1136/ard.43.5.716 on 1 October 1984. Downloaded from Rheumatological manifestations of infective endocarditis 717 Table 1 Type ofmusculoskeletal manifestations in radiological signs: in three cases the frequency of the endocarditis patients: n=number ofpatients (32 of108). pain was poorly defined or permanent, while three The sum exceeds 32 owing to the presence ofmultiple others (including two with unilateral sciatica) re- symptoms in some patients ported aggravation by mechanical factors, including cough; this was suggestive of mechanical com- Number pression. Of the last three patients one each Arthritis alone 4 reported diffuse back pain without precise temporal Arthritis+arthralgia 4 distribution, continuous sacroiliac pain without Oligoarthralgia 8 x-ray signs, and inflammatory neck pain. Polyarthralgia 5 3 cases of mobile polyarthralgia Pain involving the shoulder or hip was noted in Diffuse back pain 1 five cases, in two together with arthralgia, and in Lower back pain 6 2 with unilateral sciatica one with both arthralgia and C4-C5 vertebral Inflammatory neck pain 1 osteomyelitis. Clinical sacroiliitis 1 Vertebral osteomyelitis 4 All aseptic musculoskeletal manifestations were 13-L4 (streptococcus D) rapidly diagnosed and yielded easily to treatment. 14-L5 (Staphylococcus aureus) They resolved after several days (or at most, several C4-C5 (Staphylococcus aureus) weeks) of treatment with appropriate antibiotics, L2-L3 (no pathogen isolated) Myalgia 5 and there were no sequelae. A new episode of arthralgia during treatment occurred in only one case, with simultaneous recurrence of fever; death was rich in granulocytes, it remained sterile. followed within a few days. Arthralgia was generally stationary, but it was mobile in three cases of non-D streptococcus en- COMPARISON OF INFECTIOUS ENDOCARDITIS Arthritis and in- docarditis. arthralgia particularly WITH OR WITHOUT MUSCULOSKELETAL copyright. volved the major joints of the arms and legs (Table MANIFESTATIONS 2). These two groups of patients did not differ in terms Spinal involvement (in four cases this was verteb- of portal of entry, cardiac history, age, sex, distribu- ral osteomyelitis) was noted in 13 patients (12%). tion, or clinical signs. Six patients reported low back pain without clear Laboratory values, including assay for cryoglobu- lins (negative in all cases studied) were quite Table 2 Localisation and type ofmusculoskeletal similar. There was a slight difference in terms of two manifestations in endocarditis patients: n =number oftimes parameters: CIC levels (rather than presence in http://ard.bmj.com/ that a given joint was involved in this group of patients abnormal quantities, identical in both groups) were partially reflected in the percentage of C4 precipita- Arthralgia, n=17 Arthritis, n= 7 tion, which was higher in those patients with Knee 16 4 musculoskeletal signs (31.5, SD 8%, versus 26.8, SD Shoulder 14 7%), and in the Waaler-Rose reaction, which was Ankle 6 1 more frequently positive in the patients,with such Wrist 5 1 signs. were not Nevertheless, differences statistically on September 26, 2021 by guest. Protected Elbow 4 1 Metacarpohalangial 3 significant. This is also the case for the frequency of Hip 1 streptococcal infection in patients with positive serology for rheumatoid factor. TabWe 3 Bacteriological data (blood culture); n=number ofpatients: n is greater than 32 in thefirst column owing to isolation ofseveralpathogens in 2 cases ofIE. p=Statistical significance, NS=not significant Musculoskeletal signs present (n=32) Musculoskeletal signs absent (n=76) p Number % Number % Non-D streptococcus 10 31 24 31 NS Streptococcus D 9 28 10 13 0.01 Staphylococcus aureus 9 28 12 16 NS Staphylococcus albus 0 0 3 4 NS Other pathogens 4 12 11 14 NS Blood cultures negative 2 6 16 21 0-01 Ann Rheum Dis: first published as 10.1136/ard.43.5.716 on 1 October 1984. Downloaded from 718 Thomas, Allal, Bontoux, Rossi, Poupet, Petitalot, Becq-Giraudon Table 4 Initial diagnosis in endocarditis patients with account for the high mortality in subjects with the musculoskeletal manifestations: n=number ofpatients rheumatic form of IE. The pathogenesis of arthralgia and arthritis in Number infective endocarditis is somewhat obscure. The appear Atypical polyarthritis 2 hypothesis of septic foci in the joints would Low back pain 3 to be contradicted by the usual presence of sterile Sciatica 2 synovial fluid2 12 as well as by the rapid resolution of Vertebral osteomyelitis 1 peripheral manifestations without radiological Arthritis 1 cases Horton's disease 1 sequelae. Nevertheless, three of septic Influenza-like syndrome 4 arthritis during IE were reported, two confirmed by examination of synovial fluidl' and the other by culture of a biopsy fragment of synovium from a patient in whom the fluid was sterile.'2 Further- more, in other situations synovial culture has On the other hand, patients with detectable allowed isolation of a pathogen which could not be rheumatoid factor (RF) had a significantly longer isolated from the fluid,t3 14 and since biopsy was not delay between first clinical manifestations and di- always carried out in such cases we cannot formally agnosis (82 days, SD 43, versus 26, SD 14 for the exclude the hypothesis of sepsis. seronegative subjects, p<0-05). Microscopic haema- Data concerning bacteriological results in the turia was more frequent in those with rheumatic majority of cases, as well as progress under treat- signs: 15 out of 30 versus 14 out of 68 (p=005). ment, tend to suggest a 'reactive' arthritis.'5 This Comparison of causal pathogens in the two would be in keeping with the parallel development groups showed no significant differences except for of musculoskeletal signs and clinical endocarditis, streptococcus D, which was more frequently found notably the relapse of joint involvement following in patients with musculoskeletal
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