J Shoulder Elbow Surg (2015) 24, e159-e163
www.elsevier.com/locate/ymse
CASE REPORTS
Pasteurella multocida infection in a primary shoulder arthroplasty after cat scratch: case report and review of literature David Y. Ding, MDa,*, Amanda Orengo, BSb, Michael J. Alaia, MDa, Joseph D. Zuckerman, MDa a b
Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY, USA Medical College of Wisconsin, Milwaukee, WI, USA
Infected joint arthroplasty presents a significant challenge to orthopedic surgeons. Common causative organisms include Staphylococcus aureus (22%-39%), coagulase-negative staphylococci (15%-37.5%), gramnegative bacilli (4%-28.2%), streptococci (6%-11.2%), enterococci (0%-9.2%), and anaerobes (0%-6.5%).10 Occasionally, equally in immunocompromised individuals, infection can be caused by uncommon organisms. Pasteurella multocida is a rare causal organism of infected joint replacement that has only previously been reported in cases of knee and hip arthroplasties.8,12,18,19 We present an unusual case of an infected shoulder arthroplasty caused by Pasteurella multocida after a cat scratch.
Case report A 66-year-old man with common variable immunodeficiency syndrome on intravenously administered immunoglobulin and immunoglobulin M monthly injections, diabetes mellitus on an oral hypoglycemic medication, and a history of previously treated Lyme disease, presented with severe left shoulder pain secondary to advanced
This case report did not require approval by the Investigational Review Board. *Reprint requests: David Y. Ding, MD, NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 E 17th St, New York, NY 10003. E-mail address: [email protected] (D.Y. Ding).
glenohumeral arthritis (Fig. 1). Nonoperative management, including physical therapy and corticosteroid injections, was no longer effective, and shoulder arthroplasty was recommended. There was significant glenoid deficiency, and as a result, a proximal humeral replacement was performed. The glenoid was reamed to reduce the retroversion and restore concavity. His postoperative course was uneventful, with improvement of pain and progression of physical therapy, until postoperative day 26, when sudden onset of pain developed in the left shoulder during physical therapy. At that time, the patient described 2 days of low-grade fevers to 100.5 C, with some nausea and vomiting. An examination of the left shoulder showed a well-healed incision with significant subdeltoid and subacromial swelling. There was significant pain with active and passive motion. There were 2 abrasions, approximately 1 cm long, over the dorsum of his left hand that he sustained from a cat scratch. A joint aspiration of the shoulder performed in the office revealed frank purulent fluid. Cell count was 681,000 white blood cells (WBCs) with 96% neutrophils. Initial laboratory workup showed WBC count of 14,400/mL (normal, 3700-11,400/mL), C-reactive protein (CRP) of 68 mg/L (normal, 0-9 mg/L), and an erythrocyte sedimentation rate (ESR) of 67 mm/h (normal, 0-10 mm/h). As a result, the patient was immediately admitted with plans to proceed with operative irrigation and debridement. Intraoperatively, there was gross purulence with a custardlike consistency localized deep in the joint. The modular humeral head was removed, and there did not appear to be
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.03.005
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D.Y. Ding et al.
Figure 1 Preoperative (A) anteroposterior, (B) axillary, and (C) scapular-Y radiographs of the patient’s shoulder show severe degenerative changes.
Figure 2
(A) Anteroposterior and (B) axillary radiographs of the patient after irrigation and debridement with head exchange.
any purulence coming from the medullary canal. The stem was well fixed. A thorough debridement, irrigation, and head exchange was performed (Fig. 2). A drain was placed, and the wound was closed primarily. The patient was started on intravenous vancomycin and piperacillin/tazobactam while the cultures were pending. The patient did well postoperatively, with no recurrence of
fevers, decreasing drainage, and resolution of symptoms. Cultures from the aspirate and those obtained at the time of surgery grew pan-sensitive P multocida. Infectious disease was consulted, and the patient was switched to intravenous ceftriaxone (2 g daily) for 6 weeks. A repeat laboratory analysis at 6 weeks showed that inflammatory markers had returned to baseline: the WBC count was 9600/mL (normal,
P multocida infection in TSA Table I
e161
Previously published cases of Pasteurella multocida infections in joint arthroplasties
Author, date
Age (y)/sex
Animal contact
Site
Laboratory values
Antibiotic and duration
Outcome
Surgical procedure
Griffin,4 1975 Maurer,11 1975
64 F 55 F
Cat scratch Dog lick
TKR TKR
Not known Not known
Cure Cure
Not known Not known
Sugarman,20 1975
33 F
Dog lick
TKR
Not known
Ampicillin Penicillin: 2 weeks Penicillin: 60 weeks
Prosthetic removed
Arvan,1 1978
72 F
Cat bite
TKR
WBC 18,900/mL
Treatment failure; revision Cure
Spagnuolo,17 1978 Orton,14 1984
72 F
Cat bite
TKR
WBC 18,900/mL
74 F
Cat bite
TKR
WBC 8600/mL
Guion,5 1992
45 F
Dog lick
TKR
Not known
Braithwaite,2 1992
48 F
Cat bite
THR
Not known
Takwale,22 1997
57 F
Cat scratch
THR
Not known
Stiehl,18 2004
63 M
Dog and horse contact
TKR
Mehta,12 2004
84 F
Cat scratch
THR
CPR 220 mg/L ESR 121 mm/h WBC 7500/mL Borderline WBC increase
Mehta,12 2004
57 F
Cat scratch
THR
Slightly elevated WBC, ESR, CRP
Polzhofer,15 2004
73 F
Cat bite
THR
Heym,8 2006
72 F
Dog lick
TKR
CRP 194 mg/L Leukocytes 16,600/mL CRP 277 mg/L WBC 14,500/mL
Heydemann,7 2010
66 M
Cat scratch
TKR
Velez,23 2011
75 M
Cat bite
TKR
Miranda,13 2013
64 M
Cat scratch and bite
TKR
CRP 254 mg/L ESR 80 mm/h WBC 14,000/mL CRP 9.2 mg/dL
CRP 169.3 mg/L WBC 16,600/mL Neutrophils 98.3%
Penicillin: 3 weeks Penicillin: 3 weeks Penicillin and tetracycline: 12 weeks Cefotaxime: 6 weeks Penicillin and flucloxacillin: 6 weeks Penicillin: 4 weeks Ciprofloxacin: 8 weeks Piperacillin/ tazobactam ciprofloxacin Penicillin and ciprofloxacin: 1 week Ciprofloxacin: 7 weeks Penicillin: 4 weeks Ciprofloxacin: 8 weeks Clindamycin: 3 weeks
Cure Treatment failure; revision Cure Cure
Irrigation and debridement Irrigation and debridement Prosthetic revision Prosthetic revision Prosthetic revision
Cure
Prosthetic revision
Cure
Prosthetic revision
Cure
Prosthetic revision
Cure
Prosthetic revision
Cure
Irrigation and debridement
Amoxicillin and doxycycline: 8 weeks Ceftriaxone: 4 weeks
Treatment failure; revision Cure
Prosthetic revision
Ampicillin/ sulbactam: 4 weeks Amoxicillin/ clavulanate: 6 months Amoxicillin/ clavulanate and levofloxacin: 6 weeks
Cure
Irrigation and debridement
Cure
Prosthetic revision
Irrigation and debridement
(continued on next page)
e162
D.Y. Ding et al.
Table I (continued ) Author, date
Age (y)/sex
Animal contact
Site
Laboratory values
Antibiotic and duration
Outcome
Surgical procedure
Ferguson,3 2013
67 F
Dog lick
TKR
CRP 347 mg/L WBC 17.200/mL
Linezolid and ciprofloxacin: 4 weeks Ciprofloxacin: 8 weeks
Cure
Irrigation and debridement
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; F, female; M, male; THR, total hip replacement; TKR, total knee replacement; WBC, white blood cells.
3700-11,400/mL), CRP was 6 mg/L (normal, 0-9 mg/L), and ESR was 14 mm/h (normal 0-10 mm/h). The patient’s left shoulder pain improved dramatically after the surgery, and he progressed in the prescribed rehabilitation program. At 1 year after surgery, he reported mild discomfort that was much improved compared with preoperatively. Active range of motion showed forward elevation to 110 external rotation to 30 , and internal rotation to the L3 lumbar segment. Values for ESR and CRP were within normal limits.
Discussion Prosthetic joint infection occurs in approximately 1% to 2% of joint arthroplasties,16,21,24 which can be devastating to the patient functionally, emotionally, and financially.9 Our patient reported sustaining 2 cat scratches on his hand that preceded the subsequent fevers and development of shoulder pain after a period of initial improvement postoperatively. Previous reports (Table I) describe only case reports of Pasteurella as a causative organism in knee and hip replacements. To the best of our knowledge, this is the first reported P multocida infection after shoulder arthroplasty. Treatment consisted of immediate operative debridement, component exchange, and 6 weeks of intravenous antibiotics, which was successful in resolving the infection and retaining the implant. P multocida is a gram-negative coccobacillus residing in the nasopharynx of healthy cats, dogs, and other domesticated animals.3,13,23 This bacterium is subsequently transmitted to humans via a bite or scratch from the animal. The injury to human skin causes a rapid inflammatory response, enhancing the risk for hematogenous spread, which can result in the septic arthritis.7 Risk factors include rheumatoid arthritis, osteoarthritis, corticosteroid therapy, cancer, and diabetes.3,7,13 In our patient, several underlying risk factors were identified. The patient had common variable immunodeficiency, diabetes mellitus, and a history of Lyme diseasedall potentially indicating an immunocompromised state. Although P multocida is a very uncommon cause of septic arthritis, it should always be suspected, especially in
individuals with underlying risk factors in association with an animal bite or scratch. P multocida can be grown on normal media but grows better on blood or serum-containing media.6 After 24 hours of incubation at 37 C, regular smooth nontransparent grey colonies 0.5 mm to 2 mm in diameter are seen. Upon extensive review of the literature, 18 cases of Pasteurella infection have been reported in the hip and knee since 1975 (Table I),1-5,7,11,13-17,20,22,23 of which 13 involved the knee, and 5 involved the hip joint. Treatment in most cases involved a combination of surgical debridement, liner exchange, and intravenous antibiotics, with success in salvaging the prosthesis in 9 of 18 patients (50%). In the other 9 patients, a 2-stage revision was necessary to eradicate the infection. In our patient, with rapid suspicion and diagnosis, the implant was retained by use of prompt irrigation, debridement, and 6 weeks of intravenous antibiotics. Pasteurella is most sensitive to b-lactams, second-generation or third-generation cephalosporins, tetracyclines, fluoroquinolones, and oxizolidinones.7 Upon consultation with an infectious disease specialist, we chose ceftriaxone based on the culture sensitivities and its ease of dosage.
Conclusions We were able to successfully treat an acute infection of a shoulder arthroplasty caused by P multocida after a cat scratch with prompt surgical irrigation, debridement, and head exchange, combined with 6 weeks of intravenous antibiotics.
Disclaimer Joseph D. Zuckerman or members of his immediate family receive royalties and hold intellectual property rights from Exactech Inc, which produces total shoulder prostheses that might have been used in the patient in this study. The other authors, their immediate families, and any research foundations with which they are
P multocida infection in TSA affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Arvan GD, Goldberg V. A case report of total knee arthroplasty infected by Pasteurella multocida. Clin Orthop Relat Res 1978;132: 167-9. 2. Braithwaite BD, Giddins G. Pasteurella multocida infection of a total hip arthroplasty. A case report. J Arthroplasty 1992;7:309-10. 3. Ferguson KB, Bharadwaj R, MacDonald A, Syme B, Bal AM. Pasteurella multocida infected total knee arthroplasty: a case report and review of the literature. Ann R Coll Surg Engl 2014;96:e1-4. http://dx.doi.org/10.1308/003588414X13814021676710 4. Griffin AJ, Barber HM. Letter: joint infection by Pasteurella multocida. Lancet 1975;1:1347-8. 5. Guion TL, Sculco TP. Pasteurella multocida infection in total knee arthroplasty. Case report and literature review. J Arthroplasty 1992;7: 157-60. 6. Hagan WA, Bruner DW, Timoney JF. Hagan and Bruner’s microbiology and infectious diseases of domestic animals: with reference to etiology, epizootiology, pathogenesis, immunity, diagnosis, and antimicrobial susceptibility. Ithica, NY: Comstock Publishing Associates; 1988. ISBN No. 9780801418969. 7. Heydemann J, Heydemann JS, Antony S. Acute infection of a total knee arthroplasty caused by Pasteurella multocida: a case report and a comprehensive review of the literature in the last 10 years. Int J Infect Dis 2010;14(Suppl 3):e242-5. http://dx.doi.org/10.1016/j.ijid.2009.09. 007. S1201-9712(09) 00371-3. 8. Heym B, Jouve F, Lemoal M, Veil-Picard A, Lortat-Jacob A, NicolasChanoine MH. Pasteurella multocida infection of a total knee arthroplasty after a ‘‘dog lick’’. Knee Surg Sports Traumatol Arthrosc 2006;14:993-7. http://dx.doi.org/10.1007/s00167-005-0022-5 9. Kapadia BH, McElroy MJ, Issa K, Johnson AJ, Bozic KJ, Mont MA. The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center. J Arthroplasty 2014; 29:929-32. http://dx.doi.org/10.1016/j.ijid.2009.09.007. S0883-5403 (13)00698-0. 10. Lentino JR. Prosthetic joint infections: bane of orthopedists, challenge for infectious disease specialists. Clin Infect Dis 2003;36:1157-61. http://dx.doi.org/10.1086/374554
e163 11. Maurer KH, Hasselbacher P, Schumacher HR. Letter: joint infection by Pasteurella multocida. Lancet 1975;2:409. 12. Mehta H, Mackie I. Prosthetic joint infection with Pasturella multocida following cat scratch: a report of 2 cases. J Arthroplasty 2004;19:525-7. http://dx.doi.org/10.1016/j.arth.2003.11.012 13. Miranda I, Angulo M, Amaya JV. Acute total knee replacement infection after a cat bite and scratch: a clinical case and review of the literature. Rev Esp Cir Ortop Traumatol 2013;57:300-5. http://dx.doi. org/10.1016/j.recote.2013.04.008. S1888-4415(13)00068-4. 14. Orton DW, Fulcher WH. Pasteurella multocida: bilateral septic knee joint prostheses from a distant cat bite. Ann Emerg Med 1984;13: 1065-7. S0196-0644(84)80073-6. 15. Polzhofer GK, Hassenpflug J, Petersen W. Arthroscopic treatment of septic arthritis in a patient with posterior stabilized total knee arthroplasty. Arthroscopy 2004;20:311-3. http://dx.doi.org/10.1016/j. arthro.2003.11.039 16. Reina N, Delaunay C, Chiron P, Ramdane N, Hamadouche M. Infection as a cause of primary total hip arthroplasty revision and its predictive factors. Orthop Traumatol Surg Res 2013;99:555-61. http:// dx.doi.org/10.1016/j.otsr.2013.07.001. S1877-0568(13)00118-7. 17. Spagnuolo PJ. Pasteurella multocida infectious arthritis. Am J Med Sci 1978;275:359-63. 18. Stiehl JB, Sterkin LA, Brummitt CF. Acute pasteurella multocida in total knee arthroplasty. J Arthroplasty 2004;19:244-7. S0883540303 005023. 19. Subramanian B, Holloway E, Townsend R, Sutton P. Infected total knee arthroplasty due to postoperative wound contamination with Pasteurella multocida. BMJ Case Rep 2013;2013. http://dx.doi.org/10. 1136/bcr-2013-009973 20. Sugarman M, Quismorio FP, Patzakis MJ. Letter: joint infection by Pasteurella multocida. Lancet 1975;2:1267. 21. Sukeik M, Patel S, Haddad FS. Aggressive early debridement for treatment of acutely infected cemented total hip arthroplasty. Clin Orthop Relat Res 2012;470:3164-70. http://dx.doi.org/10.1007/ s11999-012-2500-7 22. Takwale VJ, Wright ED, Bates J, Edge AJ. Pasteurella multocida infection of a total hip arthroplasty following cat scratch. J Infect 1997;34:263-4. 23. Velez FA, Laboy Ortiz IE, Lopez R, Sanchez A, Colon M, Hernan Martinez J. Pasteurella multocida: a nightmare for a replaced joint and the challenge to save it. Bol Asoc Med P R 2014;106:43-5. 24. Yi PH, Cross MB, Moric M, Sporer SM, Berger RA, Della Valle CJ. The 2013 Frank Stinchfield Award: diagnosis of infection in the early postoperative period after total hip arthroplasty. Clin Orthop Relat Res 2014;472:424-9. http://dx.doi.org/10.1007/s11999-0133089-1
www.elsevier.com/locate/ymse
CASE REPORTS
Pasteurella multocida infection in a primary shoulder arthroplasty after cat scratch: case report and review of literature David Y. Ding, MDa,*, Amanda Orengo, BSb, Michael J. Alaia, MDa, Joseph D. Zuckerman, MDa a b
Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY, USA Medical College of Wisconsin, Milwaukee, WI, USA
Infected joint arthroplasty presents a significant challenge to orthopedic surgeons. Common causative organisms include Staphylococcus aureus (22%-39%), coagulase-negative staphylococci (15%-37.5%), gramnegative bacilli (4%-28.2%), streptococci (6%-11.2%), enterococci (0%-9.2%), and anaerobes (0%-6.5%).10 Occasionally, equally in immunocompromised individuals, infection can be caused by uncommon organisms. Pasteurella multocida is a rare causal organism of infected joint replacement that has only previously been reported in cases of knee and hip arthroplasties.8,12,18,19 We present an unusual case of an infected shoulder arthroplasty caused by Pasteurella multocida after a cat scratch.
Case report A 66-year-old man with common variable immunodeficiency syndrome on intravenously administered immunoglobulin and immunoglobulin M monthly injections, diabetes mellitus on an oral hypoglycemic medication, and a history of previously treated Lyme disease, presented with severe left shoulder pain secondary to advanced
This case report did not require approval by the Investigational Review Board. *Reprint requests: David Y. Ding, MD, NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 E 17th St, New York, NY 10003. E-mail address: [email protected] (D.Y. Ding).
glenohumeral arthritis (Fig. 1). Nonoperative management, including physical therapy and corticosteroid injections, was no longer effective, and shoulder arthroplasty was recommended. There was significant glenoid deficiency, and as a result, a proximal humeral replacement was performed. The glenoid was reamed to reduce the retroversion and restore concavity. His postoperative course was uneventful, with improvement of pain and progression of physical therapy, until postoperative day 26, when sudden onset of pain developed in the left shoulder during physical therapy. At that time, the patient described 2 days of low-grade fevers to 100.5 C, with some nausea and vomiting. An examination of the left shoulder showed a well-healed incision with significant subdeltoid and subacromial swelling. There was significant pain with active and passive motion. There were 2 abrasions, approximately 1 cm long, over the dorsum of his left hand that he sustained from a cat scratch. A joint aspiration of the shoulder performed in the office revealed frank purulent fluid. Cell count was 681,000 white blood cells (WBCs) with 96% neutrophils. Initial laboratory workup showed WBC count of 14,400/mL (normal, 3700-11,400/mL), C-reactive protein (CRP) of 68 mg/L (normal, 0-9 mg/L), and an erythrocyte sedimentation rate (ESR) of 67 mm/h (normal, 0-10 mm/h). As a result, the patient was immediately admitted with plans to proceed with operative irrigation and debridement. Intraoperatively, there was gross purulence with a custardlike consistency localized deep in the joint. The modular humeral head was removed, and there did not appear to be
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.03.005
e160
D.Y. Ding et al.
Figure 1 Preoperative (A) anteroposterior, (B) axillary, and (C) scapular-Y radiographs of the patient’s shoulder show severe degenerative changes.
Figure 2
(A) Anteroposterior and (B) axillary radiographs of the patient after irrigation and debridement with head exchange.
any purulence coming from the medullary canal. The stem was well fixed. A thorough debridement, irrigation, and head exchange was performed (Fig. 2). A drain was placed, and the wound was closed primarily. The patient was started on intravenous vancomycin and piperacillin/tazobactam while the cultures were pending. The patient did well postoperatively, with no recurrence of
fevers, decreasing drainage, and resolution of symptoms. Cultures from the aspirate and those obtained at the time of surgery grew pan-sensitive P multocida. Infectious disease was consulted, and the patient was switched to intravenous ceftriaxone (2 g daily) for 6 weeks. A repeat laboratory analysis at 6 weeks showed that inflammatory markers had returned to baseline: the WBC count was 9600/mL (normal,
P multocida infection in TSA Table I
e161
Previously published cases of Pasteurella multocida infections in joint arthroplasties
Author, date
Age (y)/sex
Animal contact
Site
Laboratory values
Antibiotic and duration
Outcome
Surgical procedure
Griffin,4 1975 Maurer,11 1975
64 F 55 F
Cat scratch Dog lick
TKR TKR
Not known Not known
Cure Cure
Not known Not known
Sugarman,20 1975
33 F
Dog lick
TKR
Not known
Ampicillin Penicillin: 2 weeks Penicillin: 60 weeks
Prosthetic removed
Arvan,1 1978
72 F
Cat bite
TKR
WBC 18,900/mL
Treatment failure; revision Cure
Spagnuolo,17 1978 Orton,14 1984
72 F
Cat bite
TKR
WBC 18,900/mL
74 F
Cat bite
TKR
WBC 8600/mL
Guion,5 1992
45 F
Dog lick
TKR
Not known
Braithwaite,2 1992
48 F
Cat bite
THR
Not known
Takwale,22 1997
57 F
Cat scratch
THR
Not known
Stiehl,18 2004
63 M
Dog and horse contact
TKR
Mehta,12 2004
84 F
Cat scratch
THR
CPR 220 mg/L ESR 121 mm/h WBC 7500/mL Borderline WBC increase
Mehta,12 2004
57 F
Cat scratch
THR
Slightly elevated WBC, ESR, CRP
Polzhofer,15 2004
73 F
Cat bite
THR
Heym,8 2006
72 F
Dog lick
TKR
CRP 194 mg/L Leukocytes 16,600/mL CRP 277 mg/L WBC 14,500/mL
Heydemann,7 2010
66 M
Cat scratch
TKR
Velez,23 2011
75 M
Cat bite
TKR
Miranda,13 2013
64 M
Cat scratch and bite
TKR
CRP 254 mg/L ESR 80 mm/h WBC 14,000/mL CRP 9.2 mg/dL
CRP 169.3 mg/L WBC 16,600/mL Neutrophils 98.3%
Penicillin: 3 weeks Penicillin: 3 weeks Penicillin and tetracycline: 12 weeks Cefotaxime: 6 weeks Penicillin and flucloxacillin: 6 weeks Penicillin: 4 weeks Ciprofloxacin: 8 weeks Piperacillin/ tazobactam ciprofloxacin Penicillin and ciprofloxacin: 1 week Ciprofloxacin: 7 weeks Penicillin: 4 weeks Ciprofloxacin: 8 weeks Clindamycin: 3 weeks
Cure Treatment failure; revision Cure Cure
Irrigation and debridement Irrigation and debridement Prosthetic revision Prosthetic revision Prosthetic revision
Cure
Prosthetic revision
Cure
Prosthetic revision
Cure
Prosthetic revision
Cure
Prosthetic revision
Cure
Irrigation and debridement
Amoxicillin and doxycycline: 8 weeks Ceftriaxone: 4 weeks
Treatment failure; revision Cure
Prosthetic revision
Ampicillin/ sulbactam: 4 weeks Amoxicillin/ clavulanate: 6 months Amoxicillin/ clavulanate and levofloxacin: 6 weeks
Cure
Irrigation and debridement
Cure
Prosthetic revision
Irrigation and debridement
(continued on next page)
e162
D.Y. Ding et al.
Table I (continued ) Author, date
Age (y)/sex
Animal contact
Site
Laboratory values
Antibiotic and duration
Outcome
Surgical procedure
Ferguson,3 2013
67 F
Dog lick
TKR
CRP 347 mg/L WBC 17.200/mL
Linezolid and ciprofloxacin: 4 weeks Ciprofloxacin: 8 weeks
Cure
Irrigation and debridement
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; F, female; M, male; THR, total hip replacement; TKR, total knee replacement; WBC, white blood cells.
3700-11,400/mL), CRP was 6 mg/L (normal, 0-9 mg/L), and ESR was 14 mm/h (normal 0-10 mm/h). The patient’s left shoulder pain improved dramatically after the surgery, and he progressed in the prescribed rehabilitation program. At 1 year after surgery, he reported mild discomfort that was much improved compared with preoperatively. Active range of motion showed forward elevation to 110 external rotation to 30 , and internal rotation to the L3 lumbar segment. Values for ESR and CRP were within normal limits.
Discussion Prosthetic joint infection occurs in approximately 1% to 2% of joint arthroplasties,16,21,24 which can be devastating to the patient functionally, emotionally, and financially.9 Our patient reported sustaining 2 cat scratches on his hand that preceded the subsequent fevers and development of shoulder pain after a period of initial improvement postoperatively. Previous reports (Table I) describe only case reports of Pasteurella as a causative organism in knee and hip replacements. To the best of our knowledge, this is the first reported P multocida infection after shoulder arthroplasty. Treatment consisted of immediate operative debridement, component exchange, and 6 weeks of intravenous antibiotics, which was successful in resolving the infection and retaining the implant. P multocida is a gram-negative coccobacillus residing in the nasopharynx of healthy cats, dogs, and other domesticated animals.3,13,23 This bacterium is subsequently transmitted to humans via a bite or scratch from the animal. The injury to human skin causes a rapid inflammatory response, enhancing the risk for hematogenous spread, which can result in the septic arthritis.7 Risk factors include rheumatoid arthritis, osteoarthritis, corticosteroid therapy, cancer, and diabetes.3,7,13 In our patient, several underlying risk factors were identified. The patient had common variable immunodeficiency, diabetes mellitus, and a history of Lyme diseasedall potentially indicating an immunocompromised state. Although P multocida is a very uncommon cause of septic arthritis, it should always be suspected, especially in
individuals with underlying risk factors in association with an animal bite or scratch. P multocida can be grown on normal media but grows better on blood or serum-containing media.6 After 24 hours of incubation at 37 C, regular smooth nontransparent grey colonies 0.5 mm to 2 mm in diameter are seen. Upon extensive review of the literature, 18 cases of Pasteurella infection have been reported in the hip and knee since 1975 (Table I),1-5,7,11,13-17,20,22,23 of which 13 involved the knee, and 5 involved the hip joint. Treatment in most cases involved a combination of surgical debridement, liner exchange, and intravenous antibiotics, with success in salvaging the prosthesis in 9 of 18 patients (50%). In the other 9 patients, a 2-stage revision was necessary to eradicate the infection. In our patient, with rapid suspicion and diagnosis, the implant was retained by use of prompt irrigation, debridement, and 6 weeks of intravenous antibiotics. Pasteurella is most sensitive to b-lactams, second-generation or third-generation cephalosporins, tetracyclines, fluoroquinolones, and oxizolidinones.7 Upon consultation with an infectious disease specialist, we chose ceftriaxone based on the culture sensitivities and its ease of dosage.
Conclusions We were able to successfully treat an acute infection of a shoulder arthroplasty caused by P multocida after a cat scratch with prompt surgical irrigation, debridement, and head exchange, combined with 6 weeks of intravenous antibiotics.
Disclaimer Joseph D. Zuckerman or members of his immediate family receive royalties and hold intellectual property rights from Exactech Inc, which produces total shoulder prostheses that might have been used in the patient in this study. The other authors, their immediate families, and any research foundations with which they are
P multocida infection in TSA affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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