Case Series
Native Joint Propionibacterium Septic Arthritis
Thomas Taylor*, Marcus Coe, Ana Mata-Fink and Richard Zuckerman
Department of Rheumatology and Infectious Diseases, White River Jct. VA Regional Medical Center, USA
*Corresponding author: Thomas Taylor, Department of Rheumatology and Infectious Diseases, White River Jct. VA Regional Medical Center, Geisel Medical School at Dartmouth, USA
Published: 17 Mar, 2017
Cite this article as: Taylor T, Coe M, Mata-Fink
A, Zuckerman R. Native Joint
Propionibacterium Septic Arthritis. Ann
Clin Case Rep. 2017; 2: 1306.
Abstract
Objective: Propionibacterium species are associated with normal skin flora and cultures may be
dismissed as contaminants. They are increasingly recognized as a cause of septic arthritis following
shoulder arthroplasty and arthrotomy. We identified three cases of Propionibacterium septic
arthritis in native joints mimicking atypical osteoarthritis and review the literature, clinical course,
and treatment of 18 cases.
Methods: Two cases of Propionibacterium acne in native knee joints and one in a sternoclavicular
joint are described. A literature search for Propionibacterium septic arthritis was performed. Clinical
course, treatment, and outcome are reviewed for all cases.
Results: Our three cases were combined with 15 cases from the literature. Fourteen cases showed few
signs of acute infection, slow culture growth, and delayed diagnosis. In 3 cases an early culture was
dismissed as a contaminant. Six cases were reported as caused by recent arthrocentesis. Fifteen cases
were cured with antibiotics, although 5 of these 15 also required surgical intervention. Two patients
were diagnosed while undergoing surgery for osteoarthritis. Four patients required arthroplasty and
two of our patients will require arthroplasty for good functional results.
Conclusion: Propionibacterium as a cause of septic arthritis in native joints demonstrates few signs
of acute infection, presents with prolonged course, and is often misdiagnosed or unsuspected.
Anaerobic growth may be delayed or missed altogether, and outcomes are consequently poor.
Consider Propionibacterium septic arthritis in atypical osteoarthritis prior to arthroplasty.
Introduction
Propionibacterium species are anaerobes associated with normal skin flora, and cultures may be dismissed as contaminants. They are a less virulent but now well recognized cause of infection following shoulder surgery; and infection of orthopedic hardware, vertebral osteomyelitis, endovascular devices, and cerebrospinal shunts. The course is Indolent, often without typical signs or symptoms of infection. Delayed anaerobic growth may contribute to falsely negative cultures, late diagnosis, and poor outcomes. Delayed recognition of Propionibacterium septic arthritis following shoulder arthroplasty has been well documented [1], but native joint septic arthritis may be under recognized, undiagnosed, and consequently falsely attributed to orthopedic surgery.
Case Presentation
Patients and Methods
We present three cases of Propionibacterium acnes septic arthritis in native joints, which
exemplify chronic and atypical characteristics. The two septic knee joints were falsely considered
to represent osteoarthritis. We did a search of the literature using PubMed citation septic arthritis
Propionibacterium for cases, and ClinicalKey citation Propionibacterium for case series. Fifteen
cases laid out in Table 1 alongside our case numbers 1-3 demonstrate similar presentations and
outcomes (see supplemental references for cases reviewed from the literature).
Case 1
A 56 year-old healthy male with moderate osteoarthritis of his right knee noted swelling and pain
in the knee after a night out with friends. Four years prior he had repair of his right knee anterior
cruciate ligament, without residual hardware or staples. He suspected minor trauma superimposed
on his osteoarthritis and nursed the kneeover 4 months. He presented to Arthritis Clinic with a
large knee effusion for consideration of steroid injection. Arthrocentesis yielded 60cc of mildly
inflammatory and bloody synovial fluid. Analysis revealed no crystals, many old RBCs, 2169 cells
(30% neutrophils, 40% macrophages, 30% lymphocytes). Culture became positive on the 5th day with
P.acnes which was considered to be a skin contaminant; given the long duration of symptoms, low cell count, and minimal pain. No steroid injections were given, and he
was referred for arthroscopy to assess for poly villonodular synovitis
(PVNS), other synovial tumor, and extent of osteoarthritis. Synovial
biopsies were negative for PVNS, and cultures again grew P.acnes.
The diagnosis of septic arthritis was confirmed by synovial pathology
and he received 6 weeks of IV ceftriaxone and arthrocentesis with
negative cultures. He suffered residual painful ambulation and post
infectious synovitis with recurrent sterile effusions. He will require
future total joint arthroplasty, if cultures remain negative and post
infectious synovitis subsides.
Case 2
A 44 year-old healthy male presented with tricompartment
osteoarthritis. In 2001 he sustained a patellar rupture that was
repaired primarily. He subsequently had a revision of the repair
with xenograft. He had persistent knee pain and was treated with
hyaluronate derivatives, cortisone injections, and multiple knee
arthroscopies. He presented to the Orthopedic Surgery clinic with
a joint effusion in August 2014 to pursue knee arthroplasty. At
surgery in December 2014 the synovium was noted to be discolored
with bloody, brown tinged synovial fluid and yellow-brown colored
cartilage with irregularities, fissuring, and full-thickness loss. Synovial
samples were taken and the knee was irrigated and closed without
arthroplasty. Intra-operative synovial fluid cultures were negative,
but synovial 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 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 pneumonia. CXR was suspicious for a lung nodule. CT
and PET scan showed a metabolically active lung mass adjacent to the
sternoclavicular joint and manubrium. He left the hospital without
complete evaluation. In November 2014 a follow-up CT scannoted
improvement in lung findings, but progressive erosion of the SC
joint. In February 2015 he returned to the admitting hospital where
a CT guided biopsy revealed mild fibrosis and lymphoplasmacytic
infiltrate, and culture grew P.acnes from thioglycollate broth only.
He remained afebrile; CRP was 10.3. Given the chronic course and
possibility of skin contamination, a surgical biopsy was performed
and confirmed P.acnes osteomyelitis with 3 of 4 positive tissue
cultures. He was treated with 6 weeks of IV ceftriaxone followed by 3
weeks of PO moxifloxacin, with improvement in pain, swelling, and
function.
Results of Review
Insidious presenting courses occurred in 14 cases, most with
predisposing trauma or arthritis, frequently osteoarthritis (OA).
There were 4 acute presentations (cases 9, 10, 11, 12), all with likely
unrecognized insidious courses. Case 9 presented with a hand abscess,
acute Propionibacterium sepsis, and likely concomitant seeding of
an osteoarthritic knee joint. This case was one of 3 polymicrobial
infections (noted by μ). In the other two polymicrobialcases, multiple
organisms were isolated following prolonged presenting symptoms (cases 7 and 8). Case 10 was diagnosed as acute crystal proven calcium
pyrophosphate wrist arthritis, but progressed slowly over 9 weeks
before a synovectomy with multiple cultures grew Propionibacterium.
Case 11 had underlying Juvenile Inflammatory Arthritis (JIA) and
case 12 had underlying Rheumatoid Arthritis (RA). These two short
presentations may have ignored longer courses attributed to the
underlying inflammatory arthritis. The most common predisposing
condition for Propionibacterium septic arthritis was underlying
arthritis, and only one patient (case 16) was immunocompromised,
with underlying lymphoma.
Propionibacterium can be difficult to grow, and when cultures
are positive skin contamination complicates interpretation. In at
least three cases an earlier culture was positive for Propionibacterium
and was dismissed as a contaminant (noted by §). Propionibacterium
are common skin flora; it is difficult to discern true infection from
skin contamination. In our 3 cases, cultures took 5 days to 7 days
for growth. All cases grew P. acnes except one which was P.avidum.
Species known to cause deep infection include P.acnes, P.avidum,
and P.propionicum. Since many laboratories do not speciate
Propionibacterium, a request for speciation might help distinguish
colonization from true infection.
Multiple cultures have been required when this organism is
sought following septic shoulder arthroplasty [2]. Cases 2, 10 and
14 grew only from synovial biopsy cultures; synovial fluid cultures
were negative.Several cases were not suspected and discovered at
surgery (cases 2, 4, 5, 7). Case 17 is unique in that after a synovial fluid
culture grew P. acnes, a stored frozen synovial biopsy specimen from
4 months earlier was retrospectively cultured anaerobically and also
grew P.acnes. This case documents at least a four month course of
septic arthritis, diagnosed as reactive arthritis and eventually treated
as SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and
osteitis) with poor outcome.
Although arthrocentesis associated septic arthritis is very rare, 6
cases were reported as possibly caused by recent arthrocentesis (noted
by*). These cases do not report concurrent cultures from incident
arthrocentesis. Since Propionibacterium are knownto colonize
normal skin, it is possible the organism was introduced by injection.
Shoulders have been shown to harbor more Propionibacterium seated
in anaerobic deep sweat glands and hair follicles thanother anatomic
locations [3] accounting for septic complication following shoulder
arthroplasty [4]. However, joint infection following arthrocentesis
or Joint injection varies between 0.007% and 0.037% [5,6]. Given the
rarity of needle induced septic arthritis, it is more likely the 6 cases
thought to be arthrocentesis associated were actually previously
infected cases of insidious onset septic arthritis, true to the nature
of Propionibacterium arthritis and misdiagnosed as various chronic
arthritidies.
All caseswere cured of infection, except one complicated by
adjacent epithelioid sarcoma (case 8), and one that failed to respond
but was not recultured (case 18). Propionibacterium is susceptible to
most antibiotics, with the notable exception of metronidazole [7]. All
patients received at least six weeks of appropriate antibiotics. Four
patients required arthroplasty, and two of our patients will require
arthroplasty to achieve good functional outcome. Outcomes in other
patients were often complicated or poorly functional.
Two patients were diagnosed while undergoing surgery for OA.
In our case number 2, arthroplasty was deferred. In case number 4, shoulder arthroplasty was performed, but failed and required
subsequent two stage revision arthroplasty. Case 5 was also diagnosed
from cultures taken during hip arthroplasty; ORIF of an intracapsular
fracture failed with hip subluxation. Cure required prosthesis
removal, Girdlestone fixation, antibiotics and eventual second stage
arthroplasty. Six additional patients (cases 7, 8, 10, 11, 15, 18) had
poor functional outcomes; one patient had bone necrosis, another
had severe joint erosion, one required arthrotomy with debridement,
one required synovectomy with poor wrist function, another required
bone resection, and case 18 failed azithromycin and was treated as
SAPHO syndrome.One patient (case 6) suffered necrosis of the
steronomanubrial joint, of little functional consequence. The patient
with acute septic arthritis due to hand abscess and sepsis had good
functional outcome of the secondary knee infection. Three patients
with RA (cases 12, 13, 14) underwentrelatively early diagnostic
arthrocentesis for monoarticular arthritis and had good outcomes.
Propionibacterium arthritis was curable in this series; but gradual
onset, few hallmarks of acute infection, and delayed diagnosis often
resulted in poor function.
Discussion
Propionibacteria are anaerobes of low virulence and part of our
normal flora; but isolates at sterile sites, positive Gram stain, pure
growth of Propionibacterium species acne, and indolent monoarticular
arthritis in native joints may all indicate true infection. Arthrocentesis
and culture including anaerobic broth should be considered for joints
with chronic inflammatory arthritis prior to steroid injection or joint
arthroplasty. The shoulder is heavily colonized with Propionibacerium
[3]. Infection after joint arthroplasty or rotator cuff surgery in a native
joint may be due to Propionibacterium.Shoulder osteoarthritis is
rare, because shoulders are non-weight bearing joints; this diagnosis
particularly merits arthrocentesis with anaerobic culture prior to
arthroplasty.
Propionibacteria form biofilms and truly septic joints need to
be cleared of infection prior to insertion of hardware. Cases 4 and 5,
where arthroplasties were retained, both failed curewith antibiotics
alone. Propionibacterium septic prosthetic joints may benefit from
two stage revision arthroplasty (case 4), as debridement with retention
or one stage arthroplasty is likely to fail secondary to biofilms.
Cultures taken at surgery can be interpreted as infection or as
contamination. Two studies cultured shoulders at multiple sites in
the operating room just prior to total shoulder arthroplasty utilizing
anaerobic thioglycolate broth held for at least 14 days; 41.8% and
56% had at least one culture positive for P.acnes [4,8]. Another
perioperative culture study grew P.acnes in just 3.1% of patients,
but did not use thioglycolate broth for their anaerobic culture,
perioperative antibiotics were given prior to culture, and shoulders
were not considered infected by histopathology [9]. Early septic
arthritis following shoulder arthroplasty occurs in less than 1%, so
are these culture positive preoperative shoulder joints infected or
just colonized? The first study treated all culture positive joints with
one month of oral antibiotics following arthroplasty. Mook et al.
[10] tried to determine the rate of deep meticulous culture growth
from patients undergoing open surgery of the glenohumeral joint. In patients without prior surgery, 18% had at least one positive culture,
93% of which grew P.acnes. None were considered infected, but an
accompanying editorial reviewed other studies and concluded the
management of painful shoulder arthroplasty remains highly variable
[11].
SAPHO syndrome represents a constellation of synovitis, acne,
palmo-plantar pustulosis, hyperostosis, and osteitis. The well-known
association with P.acnes is exemplified by a study confirming 14 of
21 patients with culture positive needle biopsies of osteitis lesions,
and their response to antibiotics [12]. Previously considered
a form of reactive arthritis, could SAPHO represent insidious
Propionibacterium infection, or autoimmunity initiated by such
infection? Diagnosis of atypical osteoarthritis syndromes, such as
Milwaukee Shoulder, SAPHO syndrome, and Chronic Recurrent
Multifocal Osteitis (CRMO) [13] should all be reconsidered in this
context.
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