Letter to the Editor
Prosthesis Infection by Mycobacterium tuberculosis in a Patient With Rheumatoid Arthritis: A Case Report and Literature Review
Infección protésica por Mycobacterium tuberculosis en paciente con artritis reumatoide: reporte de un caso y revisión bibliográfica
César Egües Dubuc
, Miren Uriarte Ecenarro, Nerea Errazquin Aguirre, Joaquín Belzunegui Otano
Corresponding author
Servicio de Reumatología, Hospital Universitario Donostia, Guipúzcoa, Spain
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(B) CT: an increase in thickness can be seen in the wall of the ileum. (C) Technetium and gallium bone scan: increased uptake is seen in the right knee. (D) MRI: a posterior cystic mass is seen on the femur.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Prosthetic knee infection by <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> (MT) is rare.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Reviews in 2011 and 2013 found 7 and 15 cases of prosthetic infections due to MT, respectively.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> Since the introduction of biological treatment for rheumatoid arthritis (RA), there has been an increase in the incidence of infection by MT, mainly in patients treated with antagonists to tumor necrosis factor (anti-TNF).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> One study showed an MT infection rate of 49 per 100,000 person-years in patients with RA treated with anti-TNF versus 8.7<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> in patients with RA not treated with these agents. Here, we present a case of prosthetic infection by MT in a patient with RA treated with anti-TNF.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is a 77-year-old woman who had RA treated with methotrexate 7.5<span class="elsevierStyleHsp" style=""></span>mg/weekly and infliximab (IFX) 3<span class="elsevierStyleHsp" style=""></span>mg/kg, and a right knee prosthesis. In March 2012 she developed cough, and fever with nightly sweating lasting for 2 months; BK and sputum culture were requested, both negative. She received IFX in May and in June went to a review visit referring multiple respiratory infections during that time. In August she was assessed by Orthopedics, finding fever, pain and swelling of the right knee; discharged with a suspected prosthetic infection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). In November, she was hospitalized in Internal Medicine (IM) for partial bowel obstruction and was discharged on prednisone 15<span class="elsevierStyleHsp" style=""></span>mg/day; during admission, a computed tomography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) was performed, showing a pulmonary nodule indicative of granuloma and chest and retroperitoneal lymphadenopathy. In January 2013 she came to the Rheumatology clinic due to knee pain, and IFX was suspended; she also was assessed by IM, who recommended surgery for the persistent intestinal subocclusion. In April, she was evaluated by General Surgery and operated. Pathologic examination showed necrotizing granulomatous lymphadenitis and necrotizing granulomatous inflammation and ulceration of the mucosa in the small intestine; microbiological study was negative for <span class="elsevierStyleItalic">Mycobacterium</span>. Rifater<span class="elsevierStyleSup">®</span> was begun and QuantiFERON<span class="elsevierStyleSup">®</span> performed, which was negative. In June, she went to Rheumatology for leg edema and pain in the right knee; Doppler ultrasound was performed, showing a cystic mass of 10<span class="elsevierStyleHsp" style=""></span>cm, which was drained and analyzed; an MRI was also requested (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). The drained fluid PCR was positive for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> complex. During this period, the patient had slightly higher acute phase reactants; Orthopedics also performed a scintigraphy, suggestive of periprosthetic infection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Currently, Orthopedics dismissed surgery and the patient continues on a tuberculostatic.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Prosthetic infection MT may be a reactivation of a latent focus that reaches the joint by hematogenous or local reactivation.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> Risk factors for prosthetic infection are: RA or other immunosuppressive conditions, peri- and postoperative joint infections, non-adjacent previous infection, previous surgery on the same joint, prolonged surgery, higher body mass index, postoperative hematoma, advanced age and diabetes mellitus.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Risk factors for MT prosthetic infection are: advanced age (>70 years), past MT infection and immunosuppressive conditions<span class="elsevierStyleSup">.</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment usually is medical and surgical; it is recommended to obtain tissue samples or pre-antibiotic liquid; if the patient has a poor clinical condition, we recommend starting vancomycin and cephepime.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The surgery depends on: etiology, time of the infection presentation from the implantation of the prosthesis and comorbidities. Surgical options include prosthetic replacement (in one or two [the recommended] times), debridement and retention of the prosthesis and prosthetic resection in case a reimplantation is not contemplated.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> A study in patients with RA and prosthetic infection concluded that prosthetic replacement in 2 times has a better prognosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The choice of surgery in MT infection is controversial for the few cases reported.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> 6–9 months of treatment are recommended for osteoarticular tuberculosis (2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by 4–7 months of isoniazid and rifampicin),<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> but can vary according to the patient characteristics and outcomes between 6 and 24 months.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This patient had a prosthetic infection secondary to a tuberculosis, but we recommend, according to the literature, a combined treatment: prosthetic replacement in 2-times and 4-tuberculosis drugs for a minimum of 6 months.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no disclosures to make.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Egües Dubuc C, Uriarte Ecenarro M, Errazquin Aguirre N, Belzunegui Otano J. Infección protésica por <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> en paciente con artritis reumatoide: reporte de un caso y revisión bibliográfica. Reumatol Clin. 2014;10:347–349.</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" => 1110 "Ancho" => 1503 "Tamanyo" => 220784 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) X-ray of the right knee: increased soft tissue is observed. (B) CT: an increase in thickness can be seen in the wall of the ileum. (C) Technetium and gallium bone scan: increased uptake is seen in the right knee. (D) MRI: a posterior cystic mass is seen on the femur.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New developments in diagnosis and treatment of infection in orthopedic implants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 1 | 2 |
| 2024 October | 32 | 39 | 71 |
| 2024 September | 29 | 34 | 63 |
| 2024 August | 49 | 46 | 95 |
| 2024 July | 60 | 25 | 85 |
| 2024 June | 48 | 21 | 69 |
| 2024 May | 52 | 46 | 98 |
| 2024 April | 42 | 20 | 62 |
| 2024 March | 39 | 27 | 66 |
| 2024 February | 37 | 30 | 67 |
| 2024 January | 60 | 23 | 83 |
| 2023 December | 37 | 28 | 65 |
| 2023 November | 42 | 37 | 79 |
| 2023 October | 53 | 30 | 83 |
| 2023 September | 61 | 37 | 98 |
| 2023 August | 37 | 15 | 52 |
| 2023 July | 36 | 31 | 67 |
| 2023 June | 38 | 21 | 59 |
| 2023 May | 38 | 22 | 60 |
| 2023 April | 21 | 4 | 25 |
| 2023 March | 37 | 31 | 68 |
| 2023 February | 36 | 40 | 76 |
| 2023 January | 19 | 16 | 35 |
| 2022 December | 46 | 27 | 73 |
| 2022 November | 42 | 37 | 79 |
| 2022 October | 41 | 35 | 76 |
| 2022 September | 45 | 41 | 86 |
| 2022 August | 27 | 39 | 66 |
| 2022 July | 32 | 42 | 74 |
| 2022 June | 30 | 32 | 62 |
| 2022 May | 33 | 34 | 67 |
| 2022 April | 42 | 63 | 105 |
| 2022 March | 41 | 49 | 90 |
| 2022 February | 36 | 38 | 74 |
| 2022 January | 23 | 39 | 62 |
| 2021 December | 28 | 36 | 64 |
| 2021 November | 35 | 39 | 74 |
| 2021 October | 29 | 45 | 74 |
| 2021 September | 39 | 36 | 75 |
| 2021 August | 30 | 34 | 64 |
| 2021 July | 22 | 25 | 47 |
| 2021 June | 30 | 26 | 56 |
| 2021 May | 42 | 26 | 68 |
| 2021 April | 77 | 52 | 129 |
| 2021 March | 61 | 29 | 90 |
| 2021 February | 56 | 23 | 79 |
| 2021 January | 40 | 18 | 58 |
| 2020 December | 35 | 24 | 59 |
| 2020 November | 33 | 17 | 50 |
| 2020 October | 18 | 9 | 27 |
| 2020 September | 35 | 25 | 60 |
| 2020 August | 21 | 21 | 42 |
| 2020 July | 24 | 15 | 39 |
| 2020 June | 24 | 27 | 51 |
| 2020 May | 34 | 11 | 45 |
| 2020 April | 30 | 18 | 48 |
| 2020 March | 13 | 10 | 23 |
| 2019 May | 1 | 0 | 1 |
| 2019 January | 3 | 0 | 3 |
| 2018 May | 2 | 0 | 2 |
| 2018 April | 36 | 5 | 41 |
| 2018 March | 34 | 9 | 43 |
| 2018 February | 47 | 5 | 52 |
| 2018 January | 28 | 4 | 32 |
| 2017 December | 36 | 9 | 45 |
| 2017 November | 34 | 7 | 41 |
| 2017 October | 37 | 10 | 47 |
| 2017 September | 30 | 16 | 46 |
| 2017 August | 53 | 10 | 63 |
| 2017 July | 47 | 10 | 57 |
| 2017 June | 60 | 8 | 68 |
| 2017 May | 61 | 11 | 72 |
| 2017 April | 51 | 14 | 65 |
| 2017 March | 54 | 13 | 67 |
| 2017 February | 40 | 8 | 48 |
| 2017 January | 36 | 8 | 44 |
| 2016 December | 86 | 28 | 114 |
| 2016 November | 66 | 6 | 72 |
| 2016 October | 81 | 7 | 88 |
| 2016 September | 104 | 13 | 117 |
| 2016 August | 79 | 9 | 88 |
| 2016 July | 46 | 7 | 53 |
| 2016 April | 1 | 0 | 1 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 1 | 0 | 1 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 27 | 9 | 36 |
| 2015 June | 42 | 7 | 49 |
| 2015 May | 75 | 11 | 86 |
| 2015 April | 106 | 15 | 121 |
| 2015 March | 57 | 12 | 69 |
| 2015 February | 84 | 4 | 88 |
| 2015 January | 60 | 33 | 93 |
| 2014 December | 62 | 7 | 69 |
| 2014 November | 38 | 11 | 49 |
| 2014 October | 62 | 19 | 81 |
| 2014 September | 26 | 16 | 42 |
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