Infectious Disease Reports 2017; volume 9:7185 Native joint Propionibacterium septic arthritis Introduction Correspondence: Thomas Taylor, White River Propionibacterium species are anaer- Junction Veterans Affairs Regional Medical obes associated with normal skin flora, and Center, 215 N Main St. White River Jct. VT Thomas Taylor,1,2 Marcus Coe,3,4 05009, USA, cultures may be dismissed as contaminants. Ana Mata-Fink,5 Richard Zuckerman1,4 E-mail: [email protected] They are a less virulent but now well recog- 1 Department of Medicine, Geisel nized cause of infection following shoulder Key words: Propionibacterium, septic arthri- Medical School at Dartmouth, Hanover, surgery; and infection of orthopedic hard- tis, osteoarthritis, anaerobe infection. NH; 2White River Junction VA Regional ware, vertebral osteomyelitis, endovascular Medical Center, VT; 3Department of devices, and cerebrospinal shunts. The Contributions: the authors contributed equally. Orthopedic Surgery, Geisel Medical course is indolent, often without typical Conflict of interest: the authors declare no School at Dartmouth, Hanover, NH; signs or symptoms of infection. Delayed anaerobic growth may contribute to falsely potential conflict of interest. The views 4Dartmouth-Hitchcock Medical Center, negative cultures, late diagnosis, and poor expressed herein do not necessarily represent Lebanon, NH; 5Department of outcomes. Delayed recognition of the views of the Department of Veterans Affairs or the US Orthopedics and Rehabilitation, Yale Propionibacterium septic arthritis follow- Government. Physician’s Building, New Haven, CT, ing shoulder arthroplasty has been well doc- USA 1 umented, but native joint septic arthritis Received for publication: 17 April 2017. may be under recognized, undiagnosed, and Revision received: 15 June 2017. consequently falsely attributed to orthope- Accepted for publication: 24 June 2017. dic surgery. Abstract This work is licensed under a Creative Propionibacterium species are associat- Commons Attribution-NonCommercial 4.0 ed with normal skin flora and cultures may Materials and Methods International License (CC BY-NC 4.0). be dismissed as contaminants. They are We present three cases of only©Copyright T. Taylor et al., 2017 increasingly recognized as a cause of septic Propionibacterium acnes septic arthritis in Licensee PAGEPress, Italy arthritis following shoulder arthroplasty and native joints, which exemplify chronic and Infectious Disease Reports 2017; 9:7185 arthrotomy. We identified three cases of atypical characteristics. The two septic knee doi:10.4081/idr.2017.7185 Propionibacterium septic arthritis in native joints were falsely considered to representuse joints mimicking atypical osteoarthritis and osteoarthritis. We did a search of the litera- (PVNS), other synovial tumor, and extent of review the literature, clinical course, and ture using PubMed citation septic arthritis treatment of 18 cases. Two cases of osteoarthritis. Synovial biopsies were nega- Propionibacterium for cases, and Clinical tive for PVNS, and cultures again grew P. Propionibacterium acne in native knee Key citation Propionibacterium for case acnes. The diagnosis of septic arthritis was joints and one in a sternoclavicular joint are series. Fifteen cases laid out in Table 1 confirmed by synovial pathology and he described. A literature search for alongside our case numbers 1-3 demon- received 6 weeks of IV ceftriaxone and Propionibacterium septic arthritis was per- strate similar presentations and outcomes arthrocentesis with negative cultures. He formed. Clinical course, treatment, and out- (see supplemental references for cases suffered residual painful ambulation and come are reviewed for all cases. Our three reviewed from the literature). cases were combined with 15 cases from post infectious synovitis with recurrent ster- the literature. Fourteen cases showed few ile effusions. He will require future total joint arthroplasty, if cultures remain nega- signs of acute infection, slow culture commercialCase Report #1 growth, and delayed diagnosis. In 3 cases tive and post infectious synovitis subsides. A 56 year-old healthy male with moder- an early culture was dismissed as a contam- ate osteoarthritis of his right knee noted inant. Six cases were reported as caused by swelling and pain in the knee after a night recent arthrocentesis. Fifteen cases were Case Report #2 Non out with friends. Four years prior he had cured with antibiotics, although 5 of these repair of his right knee anterior cruciate lig- A 44 year-old healthy male presented 15 also required surgical intervention. Two ament, without residual hardware or staples. with tricompartment osteoarthritis. In 2001 patients were diagnosed while undergoing He suspected minor trauma superimposed he sustained a patellar rupture that was surgery for osteoarthritis. Four patients on his osteoarthritis and nursed the knee repaired primarily. He subsequently had a required arthroplasty and two of our over 4 months. He presented to Arthritis revision of the repair with xenograft. He patients will require arthroplasty for good Clinic with a large knee effusion for consid- had persistent knee pain and was treated functional results. Propionibacterium as a eration of steroid injection. Arthrocentesis with hyaluronate derivatives, cortisone cause of septic arthritis in native joints yielded 60cc of mildly inflammatory and injections, and multiple knee arthroscopies. demonstrates few signs of acute infection, bloody synovial fluid. Analysis revealed no He presented to the Orthopedic Surgery presents with prolonged course, and is often crystals, many old RBCs, 2169 cells (30% clinic with a joint effusion in August 2014 misdiagnosed or unsuspected. Anaerobic neutrophils, 40% macrophages, 30% lym- to pursue knee arthroplasty. At surgery in growth may be delayed or missed altogeth- phocytes). Culture became positive on the December 2014 the synovium was noted to er, and outcomes are consequently poor. 5th day with P. acnes which was considered be discolored with bloody, brown tinged Consider Propionibacterium septic arthritis to be a skin contaminant; given the long synovial fluid and yellow-brown colored in atypical osteoarthritis prior to arthroplas- duration of symptoms, low cell count, and cartilage with irregularities, fissuring, and ty. minimal pain. No steroid injections were full-thickness loss. Synovial samples were given, and he was referred for arthroscopy taken and the knee was irrigated and closed to assess for polyvillonodular synovitis without arthroplasty. Intra-operative syn- [Infectious Disease Reports 2017; 9:7185] [page 87] Case Report ovial fluid cultures were negative, but syn- ovial tissue culture became positive on the 7th day with P. acnes. He was started on Ceftriaxone and returned to the operating room for a synovectomy. He completed a 6- week course of Ceftriaxone with cure, but prior poor functional status has not improved. Case Report #3 A 60 year-old male with medical comorbidities including obesity, alcohol abuse, and cirrhosis developed pain and swelling at the left sternoclavicular joint in September 2014, while working as a mason, without skin break or direct trauma. He was prescribed prednisone and cyclobenzaprine, but a week later developed fever and was admitted to hospital and given a short course of antibiotics for possible pneumo- nia. CXR was suspicious for a lung nodule. CT and PET scan showed a metabolically active lung mass adjacent to the sternoclav- icular joint and manubrium. He left the hos- only pital without complete evaluation. In November 2014 a follow-up CT scan noted improvement in lung findings, but progres- sive erosion of the SC joint. In February use 2015 he returned to the admitting hospital where a CT guided biopsy revealed mild fibrosis and lymphoplasmacytic infiltrate, and culture grew P. acnes from thyoglyco- late broth only. He remained afebrile; CRP was 10.3. Given the chronic course and pos- sibility of skin contamination, a surgical biopsy was performed and confirmed P. acnes osteomyelitis with 3 of 4 positive tis- sue cultures. He was treated with 6 weeks of IV ceftriaxone followed by 3 weeks of PO moxifloxacin, with improvement in pain, commercial swelling, and function. Results Non Insidious presenting courses occurred in 14 cases, most with predisposing trauma or arthritis, frequently osteoarthritis (OA). Multiple organisms isolated. There were 4 acute presentations (cases 9, µ 10, 11, 12), all with likely unrecognized insidious courses. Case 9 presented with a OA 6 months None None Ceftriaxone Cure Good Cure Ceftriaxone None None 6 months OA hand abscess, acute Propionibacterium sep- § Burns osteomyelitis years Bone resection None Vancomycin more bone resection Failure epithelioid sarcoma Poor sarcoma epithelioid Failure resection bone more None Vancomycin resection Bone years osteomyelitis Burns Trauma years Bone resection None Clindamycin arthrotomy Cure Poor Cure arthrotomy Clindamycin None resection Bone years Trauma OA 4 months ACL repair None Ceftriaxone arthroscopy Cure Poor Cure arthroscopy Ceftriaxone None repair ACL 4 months OA Hand abscess, sepsis 2 weeks None None Clindamycin Cure Good Cure Clindamycin None None 2 weeks sepsis abscess, Hand µ µ µ µ sis, and likely concomitant seeding of an § septic arthritis in joints. native osteoarthritic knee joint. This case was one of 3 polymicrobial infections (noted by µ). In the other two polymicrobial cases, multi- ple organisms were isolated following pro- Initial culture discounted