International Journal of Rheumatic Diseases 2014

CORRESPONDENCE

Meningococcal septic arthritis: an unexpected cause with public health implications Dear Editor, This case report highlights the need to consider meningococcal infection in the differential diagnosis of a patient with suspected septic arthritis. A 73-year-old previously well woman presented with an erythematous, tender and swollen right elbow and knee causing restricted mobility. This was preceded by 3 days of flu-like illness, fevers and chills. There was no history of headache or other symptoms to suggest meningism. Musculoskeletal examination revealed a patient with a swollen, tender erythematous right knee with a positive bulge sign, indicating excess synovial fluid. There was diffuse erythema and swelling around her right elbow extending into her forearm. Her right knee joint aspirate yielded 150 mL turbid synovial fluid with a markedly raised white cell count (WCC) and Gram-negative cocci on Gram stain. Laboratory investigations revealed an elevated white cell count (WCC) and C-reactive protein (CRP) level. Interestingly, her blood cultures remained negative throughout the admission (Table 1). Her right elbow problem was diagnosed as cellulitis. An ultrasound showed minimal effusion and no elbow synovitis. She was commenced on intravenous (i.v.) flucloxacillin empirically, then switched to i.v. benzylpenicillin based on the joint aspirate Gram stain results. She had a joint washout on day 2 of admission. Her right knee synovial fluid culture was later confirmed as Neisseria meningitides serotype W-135 (Table 2). We were contacted by Public Health with regards to contact tracing. Her close friend and the doctor who performed the joint aspirate were both prescribed a single dose of 500 mg ciprofloxacin as contact prophylaxis. On day 8 the patient was changed to oral ciprofloxacin; however, she had ongoing right knee pain and swelling. By day 13 her WCC and CRP started to increase (Table 1), she was recommenced on i.v. benzylpenicillin and underwent a repeat arthroscopic wash-

out that revealed a large hemarthrosis. This time the aspirate culture was negative. She was subsequently discharged on oral ciprofloxacin for 4 weeks with outpatient follow-up. Neisseria meningitidis is an uncommon causative organism in septic arthritis, particularly in the adult population. A large retrospective study of causative organisms in septic arthritis in adults in France over a 20-year period did not identify a single case of primary meningococcal septic arthritis.1 On the other hand, in a small retrospective review of children under 13 years of age with primary septic arthritis, one out of 13 cases were due to Neisseria meningitidis.2 Primary septic arthritis is an unusual presentation of meningococcal infection. Among all reported cases of meningococcal disease in Australia in 2011, in only 0.4% (1/241) of cases was the diagnosis of meningococcal disease made from synovial fluid cultures, compared to 35.3% from cerebrospinal fluid (CSF) and 58.5% from blood.3 Arthritis is associated with invasive meningococcal disease in 7.5% (39/ 522) of cases in a large hospital; however, the majority of these cases also involved skin lesions and Table 1 Summary of results Day Day 1

Day 9 Day 13

Test Right knee joint aspirate cell count Right knee joint aspirate culture Blood cultures White cell count C-reactive protein Coagulation profile White cell count C-reactive protein White cell count C-reactive protein

© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd

Result 217 080 cells/lL Neisseria meningitides serotype W-135 No growth after 5 days of incubation 22.3 9 109/L 362 mg/L Not available 12.2 9 109/L 32 mg/L 13.6 9 109/L 191 mg/L

Correspondence

Sue-Faye SIOW1, Shirley YU1 and Leslie SCHRIEBER1,2

Table 2 Neisseria meningitidis sensitivities Antibiotic

Minimum Inhibitory Concentration (mg/L)

Penicillin

0.125

Ceftriaxone Ciprofloxacin Rifampicin

≤ 0.008 ≤ 0.03 ≤ 0.25

Interpretation Moderately resistant Sensitive Sensitive Sensitive

meningitis.4 Isolated septic arthritis with positive joint fluid culture but no meningitis was only noted in 2.6% (1/39) of cases.4 It is important not to miss a diagnosis of meningococcal septic arthritis as contact prophylaxis is required. Also relevant is that the W-135 serotype is not part of the Australian National Immunization Program, unlike serotype C. In this case, the contacts and the lab personnel who handled the cultures should be offered the quadrivalent meningococcal vaccine. It has been suggested through observational studies that it is cost effective to vaccinate household contacts against the particular serotype in the primary case due to high rates of attack among household contacts.5 However, it is important to note that the incidence of disease due to the W-135 serotype is low (4.6%, 11/241) and therefore such interventions would have a limited role in disease control.3

2

1

Department of Rheumatology, Royal North Shore Hospital, University of Sydney, and 2Institute of Bone and Joint Research, University of Sydney, Sydney, NSW, Australia Correspondence: Dr Sue-Faye Siow, email: [email protected]

REFERENCES 1 Dubost JJ, Soubrier M, De Champs C, Ristori JM, Bussiere JL, Sauvezie B (2002) No changes in the distribution of organisms responsible for septic arthritis over a 20 year period. Ann Rheum Dis 61, 267–9. 2 Young TP, Maas L, Thorp AW, Brown L (2011) Etiology of septic arthritis in children: an update for the new millenium. Am J Emerg Med 29, 899–902. 3 Lahra MM, Enriquez RP (2012) Annual report of the Australian Meningococcal Surveillance Programme 2011. Commun Dis Intell Q Rep 36, 251–62. 4 Cabellos C, Nolla JM, Verdaguer R et al. (2012) Arthritis related to systemic meningococcal disease: 34 years experience. Eur J Clin Microbiol Infect Dis 31, 2661–6. 5 Hoek MR, Christensen H, Hellenbrand W, Stefanoff P, Howitz M, Stuart JM (2008) Effectiveness of vaccination household contacts in addition to chemoprophylaxis after a case of meningococcal disease: a systematic review. Epidemiol Infect 136, 1441–7.

International Journal of Rheumatic Diseases 2014

Meningococcal septic arthritis: an unexpected cause with public health implications.

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