Pasteurella multocida I n f e c t i o n of a T o t a l H i p Arthroplasty A Case Report B. D. B r a i t h w a i t e ,
M B , B C h i r , a n d G. G i d d i n s , F R C S
Abstract: The authors report a case history of a diabetic woman requiring revision
hip arthroplasty of a Chamley total hip prosthesis that was infected with Pasteurella multocida. The infection of the loose prosthesis followed a cat bite to the same leg. Advice is given on the management of patients with infection following animal inoculations, and the subject of increased risk with a loose prosthesis is discussed. Key words: hip arthroplasty, revision, infection, Pasteurella.
Infection of total hip arthroplasties is the most c o m m o n cause of failure in the first th:_~eepostoperative years. M a n y of these infections ,are caused by low-grade organisms acquired at the time of operation. Subsequent infections are thought to be secondary to h e m a t o g e n o u s spread. The infecling organisms are most c o m m o n l y gram-positive cocci, but with later infections various other organisms are found, especially large bowel commensals and urinary tract organisms. 2'3 Rarer organisms m a y occur, especially in i m m u n o c o m p r o m i s e d patients. We report a case of Pasteurella multocida infection of a loose total hip arthroplasty.
August i990, w h e n her sister noticed she was limping. Her symptoms of pain and reduced mobility increased, consistent with aseptic loosening of the hip arthroplasty. In early December 1990 she accidentally trod on the family cat, w h o bit her left lower leg. The bite subsequently became inflamed and she was treated by her general practitioner with oral penicillin. The inflammation settled and the bite healed uneventfully. At the same time, her left hip became increasingly painful and she was unable to bear weight on her left leg. She was seen in clinic and her radiographs (Fig. I) showed some periosteal reaction, suggestive of a septic loosening. At the time of the o p e r a t i o n in March, pus was found around both the acetabular and femoral components, which were grossly loose. Pus and tissue were sent for culture and the pus grew P. multocida, which was sensitive to only penicillin. Enriched culture of the specimens taken from the capsule, fibrous m e m b r a n e , and f e m u r grew t w o strains of Staphylococcus epidermidis that were considered to be laboratory contaminants. This w o m a n u n d e r w e n t a revision of her total hip arthroplasty to a n o t h e r c e m e n t e d total hip arthroplasty using gentamicin-impregnated cement. She was given intravenous penicillin and flucloxacillin once the operative specimens had been taken. The antibiotics were continued intravenously for 4 weeks
Case Report A 48-year-old insulin-dependent diabetic w o m a n with D o w n syndrome presented with a history of increasing pain and inability to bear weight on her left leg. In 1976 she u n d e r w e n t a bilateral Charnley total hip arthroplasty for osteoarthritis secondary to congenital dislocation of the hips. Her joinl replacements allowed her to mobilize freely, without pain, until From the Nuffield Orthopaedic Centre, Oxford, England. Reprint requests: B. Braithwaite, MB, BChir, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX37LD, England.
309
310
The Journal of Arthroplasty Vol. 7 No. 3 September 1992
Fig. 1. Preoperative pelvic radiographs showing bilateral total hip arthroplasties and loosening of the left femoral component with additional periosteal reaction indicative of infection.
and t h e n orally for 2 weeks. Her w o u n d healed and she mobilized well. At 6 weeks follow-up she was progressing uneventfully.
Discussion P. multocida is a g r a m - n e g a t i v e bacillus that is found as an oral c o m m e n s a l in domestic animals. It can be cultured on blood or chocolate agar, but preferably with an a t m o s p h e r e containing 5% CO2. I d e n t i f i c a t i o n is assisted by API zone strips. It is k n o w n to cause local disease in h u m a n s following inoculation by a bite or scratch from a dog or cat. Pasteurella septic arthritis has rarely b e e n documented, and mainly in i m m u n o c o m p r o m i s e d individuals or t h o s e w i t h u n d e r l y i n g joint damage.~'5 There is one case of bilateral knee arthroplasties reported requiring replacement within 2 years of the patient being bitten by her cat. In this case, P. multocida was isolated from the joint. 4 This case report is the first we have found of a patient with P. multocida infection of a hip prosthesis. Moreover, this followed a specific inoculating event. The p a t i e n t ' s w e l l - c o n t r o l l e d diabetes will h a v e slightly r e d u c e d h e r p o l y m o r p h function, but she could not be considered i m m u n o c o m p r o m i s e d . In patients with infected arthroplasties with a history of an animal bite or scratch, infection from P. multocida s h o u l d be considered. The m i c r o b i o l o g y l a b o r a t o r y s h o u l d be w a r n e d to m a x i m i z e the chances of detection and therefore initiate appropriate treatment.
M a n y people with joint arthroplasties suffer animal bites and scratches, but P. multocida has only once been reported in infected arthroplasties. This case highlights the n e e d to be suspicious of arthroplasty infection w h e n there is increasing pain around a prosthetic joint following an animal bite.
Acknowledgments The authors w o u l d like to t h a n k Mr. P. McLardySmith, Consultant Orthopaedic Surgeon, for allowing his patient to be presented and the Microbiology department at the J o h n Radcliffe Hospital, Oxford, for their assistance.
References 1. Baker GL, Oddis CV, Medsger TA: Pasteurella multocida polyarticular septic arthritis. J Rheumatol 14(2): 355-7, 1987 2. Hunter G, Dandy D: The natural history of the patient with an infected total hip replacement. J Bone Joint Surg 59:293-297, 1977 3. Lidwell OM et al: Bacteria isolated from deep joint sepsis after operation for total hip or knee replacement and the sources of infection with staphylococcus aureus. J Hosp Infect 4:19-29, 1983 4. Orton DW, Fulcher WH: Pasteurella multocida: bilateral septic knee joint prostheses from a distant cat bite. Ann Emerg Med 13:1065-7, 1984 5. Tato F, Adam O, Schmid WM: Pasteurella multocida as a cause of septic arthritis in the elderly. J Rheumatol 47:425-7, 1988
M B , B C h i r , a n d G. G i d d i n s , F R C S
Abstract: The authors report a case history of a diabetic woman requiring revision
hip arthroplasty of a Chamley total hip prosthesis that was infected with Pasteurella multocida. The infection of the loose prosthesis followed a cat bite to the same leg. Advice is given on the management of patients with infection following animal inoculations, and the subject of increased risk with a loose prosthesis is discussed. Key words: hip arthroplasty, revision, infection, Pasteurella.
Infection of total hip arthroplasties is the most c o m m o n cause of failure in the first th:_~eepostoperative years. M a n y of these infections ,are caused by low-grade organisms acquired at the time of operation. Subsequent infections are thought to be secondary to h e m a t o g e n o u s spread. The infecling organisms are most c o m m o n l y gram-positive cocci, but with later infections various other organisms are found, especially large bowel commensals and urinary tract organisms. 2'3 Rarer organisms m a y occur, especially in i m m u n o c o m p r o m i s e d patients. We report a case of Pasteurella multocida infection of a loose total hip arthroplasty.
August i990, w h e n her sister noticed she was limping. Her symptoms of pain and reduced mobility increased, consistent with aseptic loosening of the hip arthroplasty. In early December 1990 she accidentally trod on the family cat, w h o bit her left lower leg. The bite subsequently became inflamed and she was treated by her general practitioner with oral penicillin. The inflammation settled and the bite healed uneventfully. At the same time, her left hip became increasingly painful and she was unable to bear weight on her left leg. She was seen in clinic and her radiographs (Fig. I) showed some periosteal reaction, suggestive of a septic loosening. At the time of the o p e r a t i o n in March, pus was found around both the acetabular and femoral components, which were grossly loose. Pus and tissue were sent for culture and the pus grew P. multocida, which was sensitive to only penicillin. Enriched culture of the specimens taken from the capsule, fibrous m e m b r a n e , and f e m u r grew t w o strains of Staphylococcus epidermidis that were considered to be laboratory contaminants. This w o m a n u n d e r w e n t a revision of her total hip arthroplasty to a n o t h e r c e m e n t e d total hip arthroplasty using gentamicin-impregnated cement. She was given intravenous penicillin and flucloxacillin once the operative specimens had been taken. The antibiotics were continued intravenously for 4 weeks
Case Report A 48-year-old insulin-dependent diabetic w o m a n with D o w n syndrome presented with a history of increasing pain and inability to bear weight on her left leg. In 1976 she u n d e r w e n t a bilateral Charnley total hip arthroplasty for osteoarthritis secondary to congenital dislocation of the hips. Her joinl replacements allowed her to mobilize freely, without pain, until From the Nuffield Orthopaedic Centre, Oxford, England. Reprint requests: B. Braithwaite, MB, BChir, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX37LD, England.
309
310
The Journal of Arthroplasty Vol. 7 No. 3 September 1992
Fig. 1. Preoperative pelvic radiographs showing bilateral total hip arthroplasties and loosening of the left femoral component with additional periosteal reaction indicative of infection.
and t h e n orally for 2 weeks. Her w o u n d healed and she mobilized well. At 6 weeks follow-up she was progressing uneventfully.
Discussion P. multocida is a g r a m - n e g a t i v e bacillus that is found as an oral c o m m e n s a l in domestic animals. It can be cultured on blood or chocolate agar, but preferably with an a t m o s p h e r e containing 5% CO2. I d e n t i f i c a t i o n is assisted by API zone strips. It is k n o w n to cause local disease in h u m a n s following inoculation by a bite or scratch from a dog or cat. Pasteurella septic arthritis has rarely b e e n documented, and mainly in i m m u n o c o m p r o m i s e d individuals or t h o s e w i t h u n d e r l y i n g joint damage.~'5 There is one case of bilateral knee arthroplasties reported requiring replacement within 2 years of the patient being bitten by her cat. In this case, P. multocida was isolated from the joint. 4 This case report is the first we have found of a patient with P. multocida infection of a hip prosthesis. Moreover, this followed a specific inoculating event. The p a t i e n t ' s w e l l - c o n t r o l l e d diabetes will h a v e slightly r e d u c e d h e r p o l y m o r p h function, but she could not be considered i m m u n o c o m p r o m i s e d . In patients with infected arthroplasties with a history of an animal bite or scratch, infection from P. multocida s h o u l d be considered. The m i c r o b i o l o g y l a b o r a t o r y s h o u l d be w a r n e d to m a x i m i z e the chances of detection and therefore initiate appropriate treatment.
M a n y people with joint arthroplasties suffer animal bites and scratches, but P. multocida has only once been reported in infected arthroplasties. This case highlights the n e e d to be suspicious of arthroplasty infection w h e n there is increasing pain around a prosthetic joint following an animal bite.
Acknowledgments The authors w o u l d like to t h a n k Mr. P. McLardySmith, Consultant Orthopaedic Surgeon, for allowing his patient to be presented and the Microbiology department at the J o h n Radcliffe Hospital, Oxford, for their assistance.
References 1. Baker GL, Oddis CV, Medsger TA: Pasteurella multocida polyarticular septic arthritis. J Rheumatol 14(2): 355-7, 1987 2. Hunter G, Dandy D: The natural history of the patient with an infected total hip replacement. J Bone Joint Surg 59:293-297, 1977 3. Lidwell OM et al: Bacteria isolated from deep joint sepsis after operation for total hip or knee replacement and the sources of infection with staphylococcus aureus. J Hosp Infect 4:19-29, 1983 4. Orton DW, Fulcher WH: Pasteurella multocida: bilateral septic knee joint prostheses from a distant cat bite. Ann Emerg Med 13:1065-7, 1984 5. Tato F, Adam O, Schmid WM: Pasteurella multocida as a cause of septic arthritis in the elderly. J Rheumatol 47:425-7, 1988
