Abstract

A rare case of bilateral septic arthritis of knees with streptococcus G with rapid joint destruction is reported. Case description: A 57-year-old female was admitted with high grade fever 39º centigrade and a ten day history of increasing pain, redness, restriction of movements and swelling of both her knees. She had no medical co-morbidity apart from chronic oesophagitis. Emergency bilateral arthroscopic washouts were performed which yielded turbid fluid. Gram staining of the aspirate demonstrated gram positive cocci and cultures grew Streptococcus G. Recurrence of joint effusions and rise of inflammatory markers necessitated repeat of Arthroscopic washouts. She was treated initially with high dose intravenous followed by oral antibiotics for six weeks. She was discharged two weeks post surgery on oral antibiotics. Routine follow up over six months demonstrated accelerated articular destruction in the right knee. She underwent a total knee replacement 15 months post initial surgery and is currently walking normally without support. Conclusion: Articular affection with Streptococcus G is rare. Demonstration of the organism in the joint is the key to the diagnosis and successful treatment. Accelerated articular destruction is an undesirable sequlae of pyogenic articular infection.

Introduction

The annual incidence of pyogenic arthritis was estimated at 4-10/1,00,000 in two retrospective studies in the United Kingdom.¹ Despite improvements in antibiotic therapy, pyogenic arthritis remains frequently fatal in debilitated patients and commonly results in permanent functional loss.^2,3 Damage to bone and articular cartilage occurs as a result of both virulence of the organism and the defence responses mounted by the host.⁴ Staphylococcus aureus contributes over two thirds of identified organisms; a range of streptococci and gram negative bacilli are next in frequency.

Group G Streptococci (GGS) commonly cause infections in animals and are normally recovered from the vagina, oro-pharynx, skin and occasionally from the gastrointestinal tract in humans.⁵ Septic arthritis caused by streptococcus G has a prolonged course.⁶ Group G streptococcal arthritis may be associated with gastrointestinal abnormalities that allow a portal of entry for an otherwise innocuous organism, and that this represents a rare enteropathic arthropathy.⁷

We are reporting a rare case of bilateral spontaneous onset septic arthritis of knees with streptococcus G which resulted in accelerated articular breakdown.

Case Report

A non-diabetic ambulatory 57-year-old female, who had no prior remarkable illness, was admitted under the care of the physicians in our hospital with a 10 day history of pain, redness and decreased movements of both knees. She had no additional medical co-morbidity apart from chronic anemia which was secondary to chronic oesophagitis and chronic depression which was well controlled. There was no history of preceding trauma or systemic infection. She was pyrexial on admission with a temperature of 101.5° F (38.6°C). An orthopaedic consult was requested by the admitting physicians. On examination she had bilateral knee effusions with extreme restriction of knee movements, local erythema and increased local temperature. Both her knees were aspirated aseptically and the aspirate was sent for urgent bacteriological analysis. Laboratory tests demonstrated a white cell count of 13,600/cmm the erythrocyte sedimentation rate was 50 mm and the CRP was 275mg/l. Gram staining of the aspirate from both knees demonstrated gram positive cocci, there were numerous polymorphs and no crystals were detected. Plain radiographs of both her knees demonstrated early osteoarthritis bilaterally with predominant medial compartment affection (Fig 1).

She underwent emergency bilateral arthroscopic washouts and was commenced on high dose intravenous Benzyl Penicillin and Flucloxacillin. Post operatively she was transferred to the intensive therapy unit on account of profound hypotension which was attributed to septicaemia. Cultures of the knee aspirates and blood cultures grew Lancefield Group G Streptococci. Her antibiotic therapy was altered and she was commenced on high dose intravenous Ceftriaxone. Following arthroscopic washouts her inflammatory markers showed marginal improvement her white cell count decreased to 11,000/cmm and CRP was 250. Within 48 hours of surgery her general condition deteriorated and she was pyrexial with a temperature of 102°F (39°C) she had bilateral large knee effusions. Laboratory investigations revealed a white cell count of 8300/cmm, erythrocyte sedimentation rate was 130 and CRP was 115 mg/l. She underwent repeat bilateral arthroscopic washouts the aspirate obtained at the second washouts was turbid and was admixed with particulate matter. Bacteriological analysis of the aspirates.

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