Case report 285
Septic arthritis of the elbow in a child due to Pseudomonas aeruginosa: a case report Terue Hatakenaka, Kazutaka Uemura, Toshiro Itsubo, Masanori Hayashi, Shigeharu Uchiyama and Hiroyuki Kato We present a rare case of septic arthritis of the elbow in a child caused by Pseudomonas aeruginosa infection. In our patient, the 15-day delay before drainage may have led to the osteomyelitis of the capitulum and resulted in some persistent radiographic abnormalities. Although our patient has no subjective symptoms 5 years postoperatively, he has a slightly abnormal range of motion and gross lateral instability. Children with elbow pain and/or swelling with fever should be carefully examined for septic arthritis. Pseudomonas aeruginosa should always be kept in mind in such cases to avoid any delay in effective treatment. J Pediatr Orthop B
c 2014 Wolters Kluwer Health | Lippincott 23:285–287 Williams & Wilkins.
Introduction
diagnosed with septic arthritis of the left elbow and osteomyelitis and was admitted to the hospital. Emergency surgery was performed on the same day.
Septic arthritis of the elbow is relatively uncommon in children. Our report describes a case of septic arthritis of the elbow in a child caused by Pseudomonas aeruginosa infection.
Case report A 15-month-old boy complained of pain in his left elbow after falling down on it. On the following day, he was brought to an orthopedic clinic, and radiographs showed no abnormalities. Three days after the fall, he visited the pediatric department of our hospital for a periodic examination for iron-deficiency anemia and was referred to our orthopedic department for ongoing swelling and pain in his elbow. Radiographs showed no abnormalities at that time, and he was diagnosed with an elbow sprain. Five days after the first examination at our orthopedic department, he was examined in our upper extremity orthopedic outpatient clinic. On examination, he had a fever of 381C and swelling, local heat, and pain in his elbow. Radiographs showed slight irregularity of the distal posterior humerus (Fig. 1). On that basis a left supracondylar fracture was diagnosed and a posterior splint applied. Upon follow-up examination after 1 week, the patient continued to have fever and swelling, local heat, and pain in his elbow. Laboratory investigation revealed a white blood cell count of 11 100/ml and a C-reactive protein level of 2.51 mg/dl. Radiographs showed soft tissue edema of the left upper limb and a hypertranslucent lesion in the capitulum (Fig. 2). An MRI scan demonstrated excessive joint fluid and a high-signal intensity area in the capitulum on T2 weighted images. The boy was c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
Journal of Pediatric Orthopaedics B 2014, 23:285–287 Keywords: elbow, Pseudomonas aeruginosa, septic arthritis Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan Correspondence to Terue Hatakenaka, MD, Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan Tel: + 81 263 37 2659; fax: + 81 263 35 8844; e-mail: [email protected]
Arthrocentesis of the left elbow was performed before surgery and 20 ml of yellowish-brown pus-like liquid was extracted. During surgery, degeneration of the cartilage of the capitulum, bone defects just beneath the cartilage, and marked synovitis of the elbow joint were observed. Synovectomy was performed, and the joint was irrigated with a large quantity of salines. A Penrose drain was placed in the left elbow joint. Intravenous antibiotic therapy using cefotaxime and cefotiam was initiated after surgery. These antibiotics are known to be effective against Staphylococcus aureus and Haemophilus influenza, two pathogens that are frequently responsible for septic arthritis. Two days after surgery, a culture of the pus showed the growth of P. aeruginosa; therefore, the antibiotics were changed to ceftazidime and meropenem, which are effective against P. aeruginosa. The patient’s high fever continued, and 6 days after surgery, we changed the antibiotics again to amikacin and cefozopran. Subsequently, his inflammatory symptoms gradually resolved. Antibiotic therapy was discontinued 20 days after surgery, and the patient was discharged home. His C-reactive protein level became negative for infection 30 days after surgery. At a 5-year follow-up examination, the patient had no pain and was experiencing no difficulty in his daily life, but he has a slightly abnormal range of motion of his left elbow joint: 1401 of flexion (right side, 1451), 01 of extension (101), 801 of pronation (801), and 851 of supination (851). In addition, although he had no visible deformity of his upper extremities and a carrying angle DOI: 10.1097/BPB.0000000000000016
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
286
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
Fig. 1
Fig. 3
(a)
∗
Radiographs taken at the first examination at our upper extremity orthopedic outpatient clinic. The examiner diagnosed a supracondylar fracture on the basis of the slight irregularity of the distal posterior humerus (arrow).
(b)
Fig. 2
Radiographs taken at the most recent examination. Hypoplasia of the left capitulum (arrow), hypertrophy of the radial head (arrowhead), and early ossification of the trochlea (asterisk) are observed on the involved side (a) in comparison with the normal side (b). Radiographs taken at the follow-up examination. Soft tissue edema of the left upper limb and a hypertranslucent lesion in the capitulum are evident in the left elbow.
of the left elbow 101 (right side, 101), he exhibited gross lateral elbow instability. Radiographs showed hypoplasia of the left capitulum, hypertrophy of the radial head, and early ossification of the trochlea. The epiphyseal line of the capitulum suggested closure (Fig. 3).
Discussion Septic arthritis of the elbow is uncommon, accounts for only 2–20% of all cases of septic arthritis in children [1–5]. Therefore, the correct diagnosis is often missed and appropriate treatment may thus be delayed. In this
case, the patient was examined by a number of orthopedists and yet was initially misdiagnosed with a sprain or supracondylar fracture. Septic arthritis and osteomyelitis are interrelated. Septic arthritis may progress to osteomyelitis if treatment is delayed. Conversely, osteomyelitis of the metaphysis may progress to septic arthritis [6]. In our case, the initial radiographs revealed no remarkable abnormality of the elbow. We suspect that septic arthritis of the elbow occurred first and that the infection inside the joint may have spread into the capitulum because of the delay in appropriate treatment. However, there was no initial MRI scan to exclude the possibility that the osteomyelitis occurred first and progressed to septic arthritis. The literature [4] is not instructive, as there are no significant
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Septic arthritis of the elbow in a child Hatakenaka et al. 287
differences in parameters such as the sex, age, symptoms, or bacterial agents between patients with septic arthritis in combination with osteomyelitis and those with septic arthritis alone. Septic arthritis caused by P. aeruginosa is rare, and there has been no case in which this organism was isolated from the elbow. Pseudomonas aeruginosa is a Gram-negative aerobic bacillus that is widespread in nature, especially in moist environments. The organism rarely causes disease in a healthy host and is considered an opportunistic pathogen, causing infections in patients with physical, phagocytic, or immunologic defects of their host defense mechanisms [7]. Our patient had no history of any disorder other than iron-deficiency anemia; he is now 6 years old and has exhibited no other defects to date. Therefore, it is unclear why he was susceptible to infection with P. aeruginosa and whether his irondeficiency anemia was relevant to the infection. The other problem in this case, besides the delay in the diagnosis of the septic arthritis of the elbow, was the delay in the implementation of appropriate antibiotic therapy effective against P. aeruginosa. We are not certain whether the 2-day delay in the implementation of appropriate antibiotic therapy substantially altered the course of the disease in this particular patient. However, in general, antibiotics effective against the causative organism should be administrated as soon as possible. In the past, the first-line antibiotics of choice were first-generation or second-generation cephalosporins because S. aureus and H. influenza were the most common causative organisms. Recently, bacterial agents other than S. aureus and H. influenza have been more frequently reported, and multiple drug-resistant bacteria have been isolated in many cases. Therefore, we consider it mandatory not to delay the implementation of effective antibiotic therapy until the organism has been isolated; instead, we recommend the use of carbapenems, which have a wide spectrum, as the first-line therapy. After the organism has been isolated, the antibiotic regimen should be ‘de-escalated’ and the carbapenems replaced by more specific antibiotics.
In the majority of cases of septic arthritis of the elbow, the prognosis for recovery without major sequelae is good if drainage is performed within 12 days [8]. In our patient, the 15-day delay before drainage may have led to the osteomyelitis of the capitulum and resulted in some persistent radiographic abnormalities. Although our patient has no subjective symptoms 5 years postoperatively, he has a slightly abnormal range of motion and gross lateral instability. It will be necessary to continue to observe his progress in the future because it is possible that he will develop various functional disorders such as severe cubitus valgus and osteoarthritis of the elbow. Conclusion
Septic arthritis of the elbow caused by P. aeruginosa is uncommon in children. Children with arthralgia and/or joint swelling with fever should be carefully examined for septic arthritis. The use of carbapenems as the first-line antibiotic therapy is desirable to avoid any delay in effective treatment.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2 3 4 5 6 7
8
Paterson DC. Acute suppurative arthritis in infancy and childhood. J Bone Joint Surg Br 1970; 52:474–482. Sequeira W, Swedler WI, Skosey JL. Septic arthritis in childhood. Ann Emerg Med 1985; 14:1185–1187. Wilson NI, Di Paola M. Acute septic arthritis in infancy and childhood. 10 years’ experience. J Bone Joint Surg Br 1986; 68:584–587. Caksen H, Oztu¨rk MK, Uzu¨m K, Yu¨ksel S, Ustu¨nbas¸ HB, Per H. Septic arthritis in childhood. Pediatr Int 2000; 42:534–540. Young TP, Maas L, Thorp AW, Brown L. Etiology of septic arthritis in children: an update for the new millennium. Am J Emerg Med 2011; 29:899–902. Ogden JA, Lister G. The pathology of neonatal osteomyelitis. Pediatrics 1975; 55:474–478. Ohl CA, Pollack M. Infections due to Pseudomonas species and related organisms. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s principles of internal medicine. 15th ed. New York, USA: McGraw-Hill Companies; 2001. pp. 963–968. Kawakami H, Sekiguchi M, Fukusi S, Saitou T, Suguro T. Pyogenic arthritis of elbow joint in infancy -two cases report-. J Jpn Soc Bone Joint Infec 2006; 20:39–43.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Septic arthritis of the elbow in a child due to Pseudomonas aeruginosa: a case report Terue Hatakenaka, Kazutaka Uemura, Toshiro Itsubo, Masanori Hayashi, Shigeharu Uchiyama and Hiroyuki Kato We present a rare case of septic arthritis of the elbow in a child caused by Pseudomonas aeruginosa infection. In our patient, the 15-day delay before drainage may have led to the osteomyelitis of the capitulum and resulted in some persistent radiographic abnormalities. Although our patient has no subjective symptoms 5 years postoperatively, he has a slightly abnormal range of motion and gross lateral instability. Children with elbow pain and/or swelling with fever should be carefully examined for septic arthritis. Pseudomonas aeruginosa should always be kept in mind in such cases to avoid any delay in effective treatment. J Pediatr Orthop B
c 2014 Wolters Kluwer Health | Lippincott 23:285–287 Williams & Wilkins.
Introduction
diagnosed with septic arthritis of the left elbow and osteomyelitis and was admitted to the hospital. Emergency surgery was performed on the same day.
Septic arthritis of the elbow is relatively uncommon in children. Our report describes a case of septic arthritis of the elbow in a child caused by Pseudomonas aeruginosa infection.
Case report A 15-month-old boy complained of pain in his left elbow after falling down on it. On the following day, he was brought to an orthopedic clinic, and radiographs showed no abnormalities. Three days after the fall, he visited the pediatric department of our hospital for a periodic examination for iron-deficiency anemia and was referred to our orthopedic department for ongoing swelling and pain in his elbow. Radiographs showed no abnormalities at that time, and he was diagnosed with an elbow sprain. Five days after the first examination at our orthopedic department, he was examined in our upper extremity orthopedic outpatient clinic. On examination, he had a fever of 381C and swelling, local heat, and pain in his elbow. Radiographs showed slight irregularity of the distal posterior humerus (Fig. 1). On that basis a left supracondylar fracture was diagnosed and a posterior splint applied. Upon follow-up examination after 1 week, the patient continued to have fever and swelling, local heat, and pain in his elbow. Laboratory investigation revealed a white blood cell count of 11 100/ml and a C-reactive protein level of 2.51 mg/dl. Radiographs showed soft tissue edema of the left upper limb and a hypertranslucent lesion in the capitulum (Fig. 2). An MRI scan demonstrated excessive joint fluid and a high-signal intensity area in the capitulum on T2 weighted images. The boy was c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
Journal of Pediatric Orthopaedics B 2014, 23:285–287 Keywords: elbow, Pseudomonas aeruginosa, septic arthritis Department of Orthopedic Surgery, Shinshu University School of Medicine, Nagano, Japan Correspondence to Terue Hatakenaka, MD, Department of Orthopedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan Tel: + 81 263 37 2659; fax: + 81 263 35 8844; e-mail: [email protected]
Arthrocentesis of the left elbow was performed before surgery and 20 ml of yellowish-brown pus-like liquid was extracted. During surgery, degeneration of the cartilage of the capitulum, bone defects just beneath the cartilage, and marked synovitis of the elbow joint were observed. Synovectomy was performed, and the joint was irrigated with a large quantity of salines. A Penrose drain was placed in the left elbow joint. Intravenous antibiotic therapy using cefotaxime and cefotiam was initiated after surgery. These antibiotics are known to be effective against Staphylococcus aureus and Haemophilus influenza, two pathogens that are frequently responsible for septic arthritis. Two days after surgery, a culture of the pus showed the growth of P. aeruginosa; therefore, the antibiotics were changed to ceftazidime and meropenem, which are effective against P. aeruginosa. The patient’s high fever continued, and 6 days after surgery, we changed the antibiotics again to amikacin and cefozopran. Subsequently, his inflammatory symptoms gradually resolved. Antibiotic therapy was discontinued 20 days after surgery, and the patient was discharged home. His C-reactive protein level became negative for infection 30 days after surgery. At a 5-year follow-up examination, the patient had no pain and was experiencing no difficulty in his daily life, but he has a slightly abnormal range of motion of his left elbow joint: 1401 of flexion (right side, 1451), 01 of extension (101), 801 of pronation (801), and 851 of supination (851). In addition, although he had no visible deformity of his upper extremities and a carrying angle DOI: 10.1097/BPB.0000000000000016
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
286
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
Fig. 1
Fig. 3
(a)
∗
Radiographs taken at the first examination at our upper extremity orthopedic outpatient clinic. The examiner diagnosed a supracondylar fracture on the basis of the slight irregularity of the distal posterior humerus (arrow).
(b)
Fig. 2
Radiographs taken at the most recent examination. Hypoplasia of the left capitulum (arrow), hypertrophy of the radial head (arrowhead), and early ossification of the trochlea (asterisk) are observed on the involved side (a) in comparison with the normal side (b). Radiographs taken at the follow-up examination. Soft tissue edema of the left upper limb and a hypertranslucent lesion in the capitulum are evident in the left elbow.
of the left elbow 101 (right side, 101), he exhibited gross lateral elbow instability. Radiographs showed hypoplasia of the left capitulum, hypertrophy of the radial head, and early ossification of the trochlea. The epiphyseal line of the capitulum suggested closure (Fig. 3).
Discussion Septic arthritis of the elbow is uncommon, accounts for only 2–20% of all cases of septic arthritis in children [1–5]. Therefore, the correct diagnosis is often missed and appropriate treatment may thus be delayed. In this
case, the patient was examined by a number of orthopedists and yet was initially misdiagnosed with a sprain or supracondylar fracture. Septic arthritis and osteomyelitis are interrelated. Septic arthritis may progress to osteomyelitis if treatment is delayed. Conversely, osteomyelitis of the metaphysis may progress to septic arthritis [6]. In our case, the initial radiographs revealed no remarkable abnormality of the elbow. We suspect that septic arthritis of the elbow occurred first and that the infection inside the joint may have spread into the capitulum because of the delay in appropriate treatment. However, there was no initial MRI scan to exclude the possibility that the osteomyelitis occurred first and progressed to septic arthritis. The literature [4] is not instructive, as there are no significant
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Septic arthritis of the elbow in a child Hatakenaka et al. 287
differences in parameters such as the sex, age, symptoms, or bacterial agents between patients with septic arthritis in combination with osteomyelitis and those with septic arthritis alone. Septic arthritis caused by P. aeruginosa is rare, and there has been no case in which this organism was isolated from the elbow. Pseudomonas aeruginosa is a Gram-negative aerobic bacillus that is widespread in nature, especially in moist environments. The organism rarely causes disease in a healthy host and is considered an opportunistic pathogen, causing infections in patients with physical, phagocytic, or immunologic defects of their host defense mechanisms [7]. Our patient had no history of any disorder other than iron-deficiency anemia; he is now 6 years old and has exhibited no other defects to date. Therefore, it is unclear why he was susceptible to infection with P. aeruginosa and whether his irondeficiency anemia was relevant to the infection. The other problem in this case, besides the delay in the diagnosis of the septic arthritis of the elbow, was the delay in the implementation of appropriate antibiotic therapy effective against P. aeruginosa. We are not certain whether the 2-day delay in the implementation of appropriate antibiotic therapy substantially altered the course of the disease in this particular patient. However, in general, antibiotics effective against the causative organism should be administrated as soon as possible. In the past, the first-line antibiotics of choice were first-generation or second-generation cephalosporins because S. aureus and H. influenza were the most common causative organisms. Recently, bacterial agents other than S. aureus and H. influenza have been more frequently reported, and multiple drug-resistant bacteria have been isolated in many cases. Therefore, we consider it mandatory not to delay the implementation of effective antibiotic therapy until the organism has been isolated; instead, we recommend the use of carbapenems, which have a wide spectrum, as the first-line therapy. After the organism has been isolated, the antibiotic regimen should be ‘de-escalated’ and the carbapenems replaced by more specific antibiotics.
In the majority of cases of septic arthritis of the elbow, the prognosis for recovery without major sequelae is good if drainage is performed within 12 days [8]. In our patient, the 15-day delay before drainage may have led to the osteomyelitis of the capitulum and resulted in some persistent radiographic abnormalities. Although our patient has no subjective symptoms 5 years postoperatively, he has a slightly abnormal range of motion and gross lateral instability. It will be necessary to continue to observe his progress in the future because it is possible that he will develop various functional disorders such as severe cubitus valgus and osteoarthritis of the elbow. Conclusion
Septic arthritis of the elbow caused by P. aeruginosa is uncommon in children. Children with arthralgia and/or joint swelling with fever should be carefully examined for septic arthritis. The use of carbapenems as the first-line antibiotic therapy is desirable to avoid any delay in effective treatment.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2 3 4 5 6 7
8
Paterson DC. Acute suppurative arthritis in infancy and childhood. J Bone Joint Surg Br 1970; 52:474–482. Sequeira W, Swedler WI, Skosey JL. Septic arthritis in childhood. Ann Emerg Med 1985; 14:1185–1187. Wilson NI, Di Paola M. Acute septic arthritis in infancy and childhood. 10 years’ experience. J Bone Joint Surg Br 1986; 68:584–587. Caksen H, Oztu¨rk MK, Uzu¨m K, Yu¨ksel S, Ustu¨nbas¸ HB, Per H. Septic arthritis in childhood. Pediatr Int 2000; 42:534–540. Young TP, Maas L, Thorp AW, Brown L. Etiology of septic arthritis in children: an update for the new millennium. Am J Emerg Med 2011; 29:899–902. Ogden JA, Lister G. The pathology of neonatal osteomyelitis. Pediatrics 1975; 55:474–478. Ohl CA, Pollack M. Infections due to Pseudomonas species and related organisms. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s principles of internal medicine. 15th ed. New York, USA: McGraw-Hill Companies; 2001. pp. 963–968. Kawakami H, Sekiguchi M, Fukusi S, Saitou T, Suguro T. Pyogenic arthritis of elbow joint in infancy -two cases report-. J Jpn Soc Bone Joint Infec 2006; 20:39–43.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
