Letter to the Editor
Septic Arthritis Associated to Gout and Pseudogout: The Importance of Arthrocenthesis
Artritis séptica asociada a gota y seudogota: la importancia de la artrocentesis
Beatriz Tejera
, Anne Riveros, Melania Martínez-Morillo, Jerónima Cañellas
Corresponding author
Servicio de Reumatología, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
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It is a medical emergency because of rapid anatomical and functional impairment. From the etiological viewpoint, Gram-positive bacteria such as <span class="elsevierStyleItalic">Staphylococcus aureus</span> (<span class="elsevierStyleItalic">S. aureus</span>), are implicated in over 50% of cases, followed by <span class="elsevierStyleItalic">Streptococcus</span> (15%–20%) and Gram-negative bacteria. In its epidemiology various risk factors such as advanced age, immunosuppression, presence of prosthetic joints, and patient comorbidities, influence the disease. Sometimes the early diagnosis of septic arthritis is difficult and this increases the risk of joint destruction.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a patient with two successive episodes of septic arthritis, caused by different microorganisms and microcrystalline arthritis associated with monosodium urate and calcium pyrophosphate deposits.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient, an 86-year-old woman, presented no allergies, no history of substance abuse and was independent for activities of daily living. She had a history of atrial fibrillation treated with warfarin and tophaceous gout. In the last month she presented an episode of septic arthritis of the right shoulder caused by <span class="elsevierStyleItalic">Escherichia coli</span> (<span class="elsevierStyleItalic">E. coli</span>), due to bacteremia secondary to a urinary tract infection. She was treated with intravenous ciprofloxacin 400<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h for 2 weeks (continued with a dose of 750<span class="elsevierStyleHsp" style=""></span>mg orally for 6 weeks) presenting improvement. Fifteen days after this episode, she presented with pain and swelling of her left knee which had lasted for a week without fever or other symptoms.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On physical examination, the patient was afebrile and stressed left knee monoarthritis with functional impotence for knee flexion. The rest of the examination found no significant alterations. Arthrocentesis was performed, yielding 4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> of liquid of inflammatory characteristics: 9650<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<span class="elsevierStyleSup">3</span> with a predominance of polymorphonuclear cells (94%) and glucose 75<span class="elsevierStyleHsp" style=""></span>mg/dl. Monosodium urate crystals were observed under polarized light microscopy. Gram stain was negative. The synovial fluid culture was isolated <span class="elsevierStyleItalic">Escherichia faecium</span> (<span class="elsevierStyleItalic">E. faecium</span>) sensitive only to vancomycin. Laboratory tests showed no leukocytosis (8600/109 leukocytes, 60% neutrophils, 20% lymphocytes) but elevated acute phase reactants (ESR: 100<span class="elsevierStyleHsp" style=""></span>mm in the first hour, C-reactive protein: 238<span class="elsevierStyleHsp" style=""></span>mg/dl). Urine sediment was normal and blood and urine cultures negative. We completed the study with a chest X-ray and echocardiography to rule out pulmonary and/or cardiac affection. A simple X-ray of the left knee showed signs of advanced degenerative joint disease with marked tibiofemoral joint space narrowing and increased soft tissue density and joint effusion. Magnetic resonance imaging showed a tophi in the patellar insertion of the quadriceps tendon that caused a major erosion in the upper pole of the patella (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Antibiotic treatment was initiated with vancomycin, 1<span class="elsevierStyleHsp" style=""></span>g every 48<span class="elsevierStyleHsp" style=""></span>h (adjusted for renal function).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Joint lavage was performed daily with saline but was unproductive. After 10 days of antibiotic treatment and the continued signs of knee arthritis, as well as the isolation of the germ in serial cultures, a surgical arthrotomy and debridement with subtotal synovectomy was performed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The breakdown of the articular surface and the large amount of tophaceous deposits were notable. Cultures after surgery were negative. The pathology of the synovial fluid showed urate and calcium pyrophosphate crystals. The patient remained hospitalized up to a month for intravenous treatment and rehabilitation, which was started early.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Enterococci are Gram-positive diplococci that are part of the normal flora of the human gastrointestinal tract and genital tract of women. They may also be isolated in soil, food, water, plants, birds, insects and other animals. The frequency of isolation of different species varies with the host. <span class="elsevierStyleItalic">E. faecalis</span> and <span class="elsevierStyleItalic">E. faecium</span> are the dominant species in the human gut, and between the 2 they make up 95% of the microorganisms in the gastrointestinal tract.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Multiple <span class="elsevierStyleItalic">Entercococcus</span> cause nosocomial infections (urinary infections, endocarditis, diverticulitis, meningitis and bacteremia) and are resistant to multiple antibiotics. The immunosuppressed population and patients with chronic diseases such as gout are more likely to have a septic arthritis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Several hypotheses have been put forward regarding the mechanism of coexistence of septic arthritis and microcrystalline deposition such as local pH reduction by the influx of neutrophils and lactic acid production that would favor the precipitation of uric acid crystals, articular cartilage destruction by lysosomal enzymes and the formation of intraarticular crystals, which would enhance the inflammatory effect of urate crystals by endotoxins and local temperature increase.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In contrast, the inflamed synovial allows easier access to circulating bacteria, allowing them to settle in the already affected joints (gout, pseudogout, osteoarthritis, prior septic arthritis).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Furthermore, in our case, previous hospitalization and previous antibiotic treatment probably acted as risk factors that favored a nosocomial infection and microorganism resistance to conventional antibiotics.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The largest series of septic arthritis and gout was described by Yu et al.,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and includes patients with both diseases seen in a period of 13 years (1987–2001). The germ that was most frequently isolated was <span class="elsevierStyleItalic">S. aureus</span>. In no case was <span class="elsevierStyleItalic">Enterococcus</span> isolated. In a literature review of PubMed ranging from 1972 to 2012 (keywords septic arthritis, gout, pseudogout) we found three cases in which the three diseases coexisted.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> The Spanish series of Minguez et al.,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> described 18 cases. In this series, all cases were septic arthritis associated with monosodium urate or pyrophosphate microcrystalline arthritis, i.e., a single crystal type. However, pyogenic arthritis due to <span class="elsevierStyleItalic">E. faecium</span> associated with the presence of monosodium urate crystals and pyrophosphate was not described. In clinical practice the role of arthrocentesis is fundamental in any arthritis as is synovial fluid culture despite the evidence of crystals: a delay in diagnosis and treatment triggers the destruction of the joint.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Tejera B, et al. Artritis séptica asociada a gota y seudogota: la importancia de la artrocentesis. Reumatol Clin. 2014;10:61–62.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 655 "Ancho" => 1000 "Tamanyo" => 69708 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hypotensive T2 tophi in the insertion of the quadriceps, causing bone erosion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Artritis séptica politópica: análisis de 19 casos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Mateo Soria" 1 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 42 | 14 | 56 |
| 2024 October | 201 | 37 | 238 |
| 2024 September | 141 | 27 | 168 |
| 2024 August | 166 | 60 | 226 |
| 2024 July | 194 | 45 | 239 |
| 2024 June | 150 | 50 | 200 |
| 2024 May | 133 | 42 | 175 |
| 2024 April | 140 | 25 | 165 |
| 2024 March | 108 | 39 | 147 |
| 2024 February | 120 | 25 | 145 |
| 2024 January | 130 | 33 | 163 |
| 2023 December | 88 | 33 | 121 |
| 2023 November | 125 | 17 | 142 |
| 2023 October | 147 | 40 | 187 |
| 2023 September | 149 | 39 | 188 |
| 2023 August | 92 | 22 | 114 |
| 2023 July | 140 | 27 | 167 |
| 2023 June | 181 | 47 | 228 |
| 2023 May | 188 | 44 | 232 |
| 2023 April | 132 | 8 | 140 |
| 2023 March | 177 | 29 | 206 |
| 2023 February | 163 | 32 | 195 |
| 2023 January | 128 | 30 | 158 |
| 2022 December | 152 | 41 | 193 |
| 2022 November | 184 | 20 | 204 |
| 2022 October | 196 | 32 | 228 |
| 2022 September | 228 | 35 | 263 |
| 2022 August | 155 | 56 | 211 |
| 2022 July | 186 | 60 | 246 |
| 2022 June | 165 | 37 | 202 |
| 2022 May | 200 | 45 | 245 |
| 2022 April | 265 | 51 | 316 |
| 2022 March | 278 | 55 | 333 |
| 2022 February | 321 | 39 | 360 |
| 2022 January | 188 | 43 | 231 |
| 2021 December | 192 | 45 | 237 |
| 2021 November | 170 | 46 | 216 |
| 2021 October | 245 | 56 | 301 |
| 2021 September | 178 | 61 | 239 |
| 2021 August | 176 | 50 | 226 |
| 2021 July | 210 | 89 | 299 |
| 2021 June | 180 | 51 | 231 |
| 2021 May | 141 | 35 | 176 |
| 2021 April | 230 | 58 | 288 |
| 2021 March | 180 | 22 | 202 |
| 2021 February | 111 | 22 | 133 |
| 2021 January | 103 | 23 | 126 |
| 2020 December | 78 | 26 | 104 |
| 2020 November | 79 | 8 | 87 |
| 2020 October | 84 | 16 | 100 |
| 2020 September | 89 | 21 | 110 |
| 2020 August | 66 | 17 | 83 |
| 2020 July | 66 | 13 | 79 |
| 2020 June | 67 | 21 | 88 |
| 2020 May | 60 | 17 | 77 |
| 2020 April | 58 | 30 | 88 |
| 2020 March | 16 | 6 | 22 |
| 2019 March | 1 | 0 | 1 |
| 2018 May | 19 | 2 | 21 |
| 2018 April | 249 | 27 | 276 |
| 2018 March | 233 | 23 | 256 |
| 2018 February | 178 | 17 | 195 |
| 2018 January | 170 | 13 | 183 |
| 2017 December | 177 | 12 | 189 |
| 2017 November | 168 | 18 | 186 |
| 2017 October | 194 | 12 | 206 |
| 2017 September | 159 | 9 | 168 |
| 2017 August | 154 | 16 | 170 |
| 2017 July | 166 | 18 | 184 |
| 2017 June | 158 | 30 | 188 |
| 2017 May | 193 | 22 | 215 |
| 2017 April | 204 | 11 | 215 |
| 2017 March | 201 | 23 | 224 |
| 2017 February | 155 | 15 | 170 |
| 2017 January | 160 | 9 | 169 |
| 2016 December | 174 | 47 | 221 |
| 2016 November | 202 | 34 | 236 |
| 2016 October | 199 | 23 | 222 |
| 2016 September | 222 | 31 | 253 |
| 2016 August | 264 | 52 | 316 |
| 2016 July | 105 | 30 | 135 |
| 2016 June | 1 | 0 | 1 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 1 | 0 | 1 |
| 2015 August | 3 | 0 | 3 |
| 2015 July | 52 | 8 | 60 |
| 2015 June | 104 | 39 | 143 |
| 2015 May | 120 | 51 | 171 |
| 2015 April | 76 | 53 | 129 |
| 2015 March | 69 | 45 | 114 |
| 2015 February | 75 | 26 | 101 |
| 2015 January | 85 | 52 | 137 |
| 2014 December | 71 | 47 | 118 |
| 2014 November | 61 | 36 | 97 |
| 2014 October | 71 | 52 | 123 |
| 2014 September | 47 | 42 | 89 |
| 2014 August | 52 | 40 | 92 |
| 2014 July | 50 | 39 | 89 |
| 2014 June | 61 | 37 | 98 |
| 2014 May | 66 | 27 | 93 |
| 2014 April | 74 | 20 | 94 |
| 2014 March | 81 | 34 | 115 |
| 2014 February | 52 | 23 | 75 |
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