Septic Arthritis Complicating Hip Osteoarthritis

722 Annals of the Rheumatic Diseases 1991; 50: 722-723 Ann Rheum Dis: first published as 10.1136/ard.50.10.722 on 1 October 1991. Downloaded from Septic arthritis complicating hip osteoarthritis

S Donell, D M Williamson, D L Scott

Abstract hips. Her temperature was normal. Movements Four patients with osteoarthritis of the hip, of the right hip were restricted and painful and who developed septic arthritis of the affected radiography showed mild osteoarthritis of both joint, are reported. The septic arthritis hips, but there was no fracture. She was developed insidiously and was diagnosed with discharged. difficulty. One patient died, two required When seen five days later in the outpatient subsequent joint excision, and one arthrodesis clinic her symptoms were worse. She could not despite antibiotics. The presence of a recog- bear weight on the right leg and she had also nised predisposing factor to septic arthritis, developed urinary frequency. Her blood count such as rheumatoid arthritis or a surgically showed haemoglobin 142 g/l, white cell count replaced joint, can provide a diagnostic 9-6x 109 1, and erythrocyte sedimentation rate pointer. These cases suggest that osteo- 64 mm/h. A mid-stream specimen of urine arthritis, similarly, is a predisposing factor. It grew significant numbers of Staphylococcus is concluded that joint sepsis should be aureus. A presumptive diagnosis was made of a considered if a patient with osteoarthritis urinary tract infection. She was treated with develops new symptoms from a single joint oral antibiotics, receiving co-trimoxazole with associated systemic features. (Septrin two tablets twice daily) for seven days and a non-steroidal anti-inflammatory drug. When the antibiotics were stopped her right Septic arthritis can be difficult to diagnose. hip pain returned. A radiograph showed marked Rheumatoid arthritis and surgically replaced destruction of the hip joint, which was then joints are known to predispose to sepsis'-'; in explored surgically. The joint contained pus, these situations the insidious onset of joint which grew Staphylococcus aureus, and she was infection is well recognised. Osteoarthritis is not given prolonged antibiotic treatment. She an accepted risk factor for septic arthritis, developed chronic osteomyelitis, and six however. We report four patients with hip months later needed surgical debridement of osteoarthritis who subsequently developed the with arthrodesis. hip joint http://ard.bmj.com/ septic arthritis. These cases show that joint infection must be considered in osteoarthritic patients who unexpectedly deteriorate with new CASE THREE joint symptoms and systemic features. A 68 year old man was admitted to hospital because he could not walk. He had longstanding osteoarthritis of both hips. One month pre- Case reports viously he had seen his general practitioner with on October 2, 2021 by guest. Protected copyright. CASE ONE a sudden increase in hip pain and had received A 63 year old woman with five years' osteo- increased analgesia. On admissionhecomplained arthritis of the hip presented to hospital with ofa burning sensation over both thighs anteriorly two days' increasing right groin pain, which was and increasing knee pain. Department of worse on weight bearing. There was no history Examination showed he had a tachycardia Orthopaedic Surgery, St Bartholomew's of trauma. Her temperature was normal. Right and tachypnoea. His temperature was 37 3GC. and Homerton Hospitals, hip movement was restricted, and radiography He had marked quadriceps wastingwith reduced London showed mild osteoarthritis of the hip; there was power. Knee and ankle jerks were absent. Joint S Donell no fracture. She was treated with analgesics movements were not recorded in the notes. The Department of alone and after an overnight admission was right sternoclavicular joint was swollen. Orthopaedic Surgery, Nuffield Orthopaedic discharged. His blood count showed haemoglobin 129 g/l, Centre, Oxford Seven days later she became profoundly ill white cell count 17 5x10/l, and erythrocyte D M Williamson with features of septicaemia. She failed to sedimentation rate 98 mm/h. He had abnormal Department of respond to treatment and died the next day. liver function tests. Radiographs confirmed Rheumatology, showed a gross bilateral osteoarthritis. The St Bartholomew's and Necropsy bronchopneumonia compli- hip gross Homerton Hospitals, cating septic arthritis of the right hip. The quadriceps wasting suggested inflammatory London causative organism was Staphylococcus aureus. myositis and a muscle biopsy specimen was D L Scott taken; this showed type II fibre atrophy. His Correspondence to: erythrocyte sedimentation rate rose to over 100 Dr D L Scott, Department ofRheumatology, CASE TWO mm/h, and treatment was started with high dose St Bartholomew's Hospital, A 53 year old woman presented to hospital with prednisolone (40 mg/day). West Smithfield, London ECIA 7BE. five days' increasing pain in the right groin on Four weeks after admission he remained Accepted for publication weight bearing. There was no history of trauma. unwell. An ultrasound examination of his hips 14 September 1990 She had longstanding osteoarthritis of both showed bilateral effusions and turbid fluid was Septic arthritis complicating hip osteoarthritis 723

aspirated, which grew Staphylococcus aureus. osteoarthritis as a risk factor for joint sepsis. The right sternoclavicular joint was also aspirated Kelly et al suggested osteoarthritis as a

and staphylococcus cultured. Both hips were potential predisposing factor for septic arth- Ann Rheum Dis: first published as 10.1136/ard.50.10.722 on 1 October 1991. Downloaded from drained surgically and he was given flucloxacillin ritis," but other workers have largely ignored a (intravenously 500 mg four times a day). After potential relation. Despite this, series of patients another two months he needed sequential with septic arthritis show that substantial bilateral excision of the hips. numbers of osteoarthritic patients develop septic arthritis-for example, Sharp et al re- ported 113 patients with septic arthritis seen CASE FOUR over 14 years'2; five had osteoarthritis and six A 68 year old man presented with two days' had rheumatoid arthritis. pain in the right groin and inner thigh, worse on Osteoarthritis is a common finding, especially weight bearing. There was no history of trauma. after 60 years of age (three of our cases were in He looked well but was feverish (38 5°C). His this age group), and it is difficult to prove a right hip movements were reduced and painful. causative relation in our cases, but the balance A radiograph showed mild degenerative of evidence points to osteoarthritis predisposing changes of the right hip joint. to septic arthritis. This may be especially Investigations showed haemoglobin 142 g/l, relevant in elderly patients; one series of 23 white cell count 10 8 x I09/l, and erythrocyte geriatric cases with septic arthritis included sedimentation rate 5 mm/h. An isotope bone several patients with osteoarthritis."9 scan showed no abnormality of the right hip. We conclude that patients with osteoarthritis The hip was aspirated, but there was no growth who show sudden deterioration with symptoms on culture. Blood cultures grew an anaerobic from a single joint may be at risk of septic streptococcus. He was given a. cephalosporin arthritis; their symptoms should not merely be (cefuroxime 1'5 g three times a day) together ascribed to the osteoarthritis, and detailed with metronidazole 500 mg three times a day investigation is needed. The initial symptoms of intravenously for a presumptive diagnosis of septic arthritis in patients with osteoarthritis septicaemia. may be mild and can easily be overlooked. His condition worsened and after two days Delayed treatment may cause significant mor- his right leg became very swollen, his white cell bidity or death. count rose to 15 9x 109/l, and his erythrocyte rate rose to 98 mm/h. By three We thank the Arthritis and Rheumatism Council and the Joint sedimentation Research Board of St Bartholomew's Hospital for their support. weeks he had developed a fluctuant swelling Dr Scott is the Muir Hambro Fellow of the Royal College of over the greater trochanterand pus was aspirated. Physicians. A repeat radiograph showed marked destruction which was aspirated and 1 Kellgren J H, Ball J, Fairbrother R W, Barnes K L. of the right hip joint, Suppurative arthritis complicating rheumatoid arthritis. drained. Streptococcus milleri was cultured. BMJ 1958; i: 1193-200. he underwent 2 Rimoin D L, Wennberg J E. Acute septic arthritis complicat- Three months after admission chronic rheumatoid arthritis. JAMA 1966; 196: arthroplasty of the right hip owing to ing excision 617-21. http://ard.bmj.com/ 3 Myers A R, Miller L M, Pinals R S. Pyarthrosis complicating persistent pain. rheumatoid arthritis. Lancet 1969; ii: 714-6. 4 Russell A S, Ansell B M. Septic arthritis. Ann Rheum Dis 1972; 31: 40-4. 5 Mitchell W S, Brooks P M, Stevenson R D, Buchanan W W. Discussion Septic arthritis in patients with rheumatoid disease: a still underdiagnosed complication. J Rheumatol 1976; 3: Septic arthritis of the hip is often difficult to 124-33. diagnose. The presence of a recognised predis- 6 Stinchfield F E, Bigliani L U, Neu H C, Goss T P, Foster C infection of total joint replacement. posing factor, such as rheumatoid arthritis'5 or JR. Late hematogenous Bone joint Surg [Am] 1980; 62: 1345-50. on October 2, 2021 by guest. Protected copyright. a joint replacement,69 can point towards the 7 Poss R, Thornhill T S, Ewald F C, Thomas W H, Batte N J, In our four cases, where there was Sledge C B. Factors influencing the incidence and outcome diagnosis. of infection following total joint arthroplasty. Clin Orthop pre-existing osteoarthritis, diagnosis was 1984; 182: 117-26. The hip pain was not 8 Hunter G A, Welsh R P, Cameron H U, Bailey W H. The particularly difficult. results of revision of total hip arthroplasty. J Bone Joint severe initially and was readily attributed to the Surg [Br] 1979; 61: 419-21. The patients had a 9 Inman R D, Gallegos K V, Brause B D, Redecha P B, pre-existing osteoarthritis. Christian C L. Clinical and microbial features of prosthetic poor outcome: one died, one needed arthrodesis, joint infection. AmJ Med 1984; 77: 47-53. and two required subsequent joint excision. 10 Bulmer J H. Septic arthritis of the hips in adults. 7 BoneJoint Surg [Br] 1966; 48: 289-98. Our first case is particularly disturbing because 11 Kelly P J, Martin W J, Coventry M B. Bacterial (suppurative) arthritis arthritis in the adult. J Bone joint Surg [Aml 1970; 52: her death seemed preventable if septic 1595-602. had been diagnosed when she presented with 12 Sharp J T, Lidsky M D, Duffy J, Duncan D W. Infectious new symptoms from her osteoarthritic hip. arthritis. Arch Intern Med 1979; 139: 112-30. 13 Barker C S, Symmons D P M, Scott D L, Bacon P A. Joint The evidence that rheumatoid arthritis pre- sepsis as a complication of seronegative arthritis. Clin disposes to septic arthritis comes from case Rheumatol 1984; 4: 51-5. 14 Quismorio F P, Dubois E L. Septic arthritis in systemic reports,'15 and reviews of series of patients with lupus erythematosus. J Rheumatol 1975; 2: 73-82. arthritis.'0--2 The high suspicion of joint 15 Hunter T, Plummer F A. Infectious arthritis complicating septic systemic lupus erythematosus. Can Med AssocJ 1980; 122: sepsis in rheumatoid arthritis allows early 791-3. and treatment in potential cases of 16 Hess R J, Martin J H. Pyarthrosis complicating gout. AMA investigation 1971- 218: 592-~3. joint infection. Septic arthritis has also been 17 Lurie D P, Musil G. Staphylococcal septic arthritis present-. in patients with other arthropathies, ing as acute flare of pseudogout: clinical, pathological and described arthroscopic findings with a review of the literature. including seronegative arthritis,'3 systemic J Rhew,natol 1983; 10: 503-6. erythematosus,'4 15 gout,'6 and pseudt- 18 Goldenberg D L, Reed J I. Bacterial arthritis. N EnglJ Med lupus 1985; 312: 764-71 gout.'7 Reviews of septic arthritis, such as that 19 McGuire N M, Kauffman C A. Septic arthritis in the elderly. by Goldenberg and Reed,'8 do not consider J Am Geriatr Soc 1985; 33: 170-4.