Prosthetic joint infection by Mycobacterium tuberculosis: an unusual case report with literature review.

Abstract: Prosthetic joint infection with Mycobacterium tuberculosis usually involves the hips or knees and can result from either local reactivation, or less often from hematogenous spread. Predisposing conditions include rheumatoid arthritis, chronic steroid use and pulmonary diseases. The most common symptom at presentation is pain, and the most common physical finding is joint swelling and/or a draining sinus tract. The sedimentation rate is helpful when elevated but is nonspecific, and initial skin testing is only helpful when positive. The diagnosis depends on culture and histologic examination of tissue. Removal of the joint combined with oral antituberculous treatment is necessary when the infection is discovered greater than six weeks post joint replacement. Early diagnosis leads to decreased morbidity. Tuberculous infection of prosthetic joints is a rare disease and its diagnosis depends on a high degree of clinical suspicion.

Key Words: prosthetic, mycobacterial, infection

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Skeletal involvement occurs in approximately 1% of the population with active tuberculosis and is one of the more common extrapulmonary manifestation of the disease. (1) This article presents a case of a prosthetic knee joint infection with Mycobacterium tuberculosis and reviews the literature.

Case Report

The patient, a 75-year-old white female, developed a Baker cyst of her right lower extremity which required removal. Postoperatively, she had persistent drainage which required debridement of the wound. She was readmitted to the hospital several months later because of persistent problems with the leg wound and underwent an excision and radical debridement of the posterior knee wound with closure, arthrotomy and radical synovectomy. She was diagnosed with a septic arthritis of the right knee and possible osteomyelitis of the distal femoral condyle and proximal tibia. Her intraoperative cultures grew Staphylococcus aureus, and she was treated with a combination of IV vancomycin and oral antibiotics for a lengthy course of therapy. Postoperative aerobic and anaerobic cultures were negative and she clinically was doing well.

She was readmitted three months later for total knee replacement. Her cultures at the time of surgery showed no growth and Gram stain showed no organisms. She had vancomycin cement placed at the time of total knee arthroplasty. Three months postarthroplasty, she was noted to have fluid draining from her incision site, with a 2- to 3-mm wound and surrounding erythema. She underwent irrigation and debridement of the knee which revealed a significant amount of necrotic subcutaneous fat. Her cultures were negative, but synovial fluid demonstrated 10 to 20 white cells per low power field. She continued to have intermittent drainage from her knee and the patient was seen a month later, at which time her synovial fluid was recultured for acid-fast bacilli (AFB), fungus, and aerobic and anaerobic cultures. AFB culture subsequently grew Mycobacterium tuberculosis. A follow-up smear 3 weeks after culture was positive for AFB. The patient was treated with isoniazid, ethambutol, rifampin and pyrazinamide. Notably, tuberculin skin testing was negative and chest x-ray revealed no pulmonary disease.

The patient's course was complicated by jaundice due to rifampin and a draining sinus tract at her knee that grew Staphylococcus aureus. The patient had removal of the prosthetic knee joint and spacer placement along with vancomycin and rifampin bead placement. She completed 18 months of INH/ethambutol and a lengthy course of antistaphylococcal therapy. Her symptoms completely resolved and she had no recurrence of drainage or sinus tracts.

Discussion

Prosthetic joint infections following total hip or knee replacement occur at a rate of less than 1% for the hip (2) and between 0.5 and 2% for the knee. (3) These patients usually present with progressive pain, fever, swelling and draining sinus tracts. Plain x-rays may show lucency at the bone-cement interface, (4) cement fractures, or motion of components with stress views. Common bacterial etiologies include coagulase-negative Staphylococcus, Staphylococcus aureus, aerobic Gram negative bacilli and anaerobes. (5) Mycobacterium tuberculosis is an uncommon cause of prosthetic joint infection. (4) Prosthetic joint infection with M tuberculosis usually involves the hips or knees and can result from either local reactivation or less often from hematogenous spread. (1,6-15) In 1977, McCullough (6) reported the first case of tuberculosis as a late complication of total hip replacement. Local reactivation can occur as long as 42 years after initial infection (14) and may be related to trauma associated with surgery. (7) Reactivation at a latent tuberculous site such as the lungs, kidneys or mesenteric nodes may result in subsequent seeding of the prosthesis. (6) Of the 15 reported cases, 12 were due to reactivation (1,7,10,11,14,16) and 3 to hematogenous spread. (6,9,13,15)

Diseases that predispose prosthetic joints to tuberculous infection include rheumatoid arthritis, chronic steroid use and pulmonary disease. (16) The most common sign at presentation is pain, and the most common physical finding is joint swelling and/or a draining sinus tract. (7) The correct diagnosis of a tuberculous joint infection is more difficult in individuals undergoing arthroplasty. A documented Mycobacterium tuberculosis infection involving another system, such as prior pulmonary or urinary tract tuberculosis, should raise the clinician suspicion of tuberculous infection in a prosthetic joint. (12)

In individuals with late onset infection, the radiographic findings are of limited value because of previous surgical alteration, (16) and the findings may resemble avascular necrosis. (1) The sedimentation rate is helpful when elevated but is a nonspecific finding, especially in the postoperative period. In one study, 15 of 17 reported cases demonstrated a high ESR. (16) Wolfgang (16) found positive initial PPD skin tests in 12 of the 16 reported cases.

The diagnosis depends on culture and histologic examination of tissue. (12) Histologic preparation may reveal acid-fast organisms or simply caseating granulomas without identification of M tuberculosis bacteria, although granulomas can also represent a reaction to the prosthesis. (4) Tokumoto et al (7) noted a characteristic histopathologic appearance of granulomas in two of their three reported cases.

Acid-fast cultures are essential to confirm the diagnosis. Smears for detection of acid-fast organisms in joint fluid or sinus drainage were positive in 2 of 6 reported cases, cultures were positive in 5 of 6 synovial fluid specimens, and cultures from biopsy tissue detected tuberculous infection in 7 of 8 specimens. These data are comparable to those involving tuberculous infection in native joint arthritis, in which the incidence of positive synovial fluid cultures was approximately 79% and the incidence of positive biopsy specimens was 94%. (7) Other bacteria may be isolated from the joint and considered an etiology of infection, the most common being Staphylococcus aureus. Coinfection cannot be ruled out, but persistence of clinical infection despite eradication of organisms is an important clue to the tuberculous infection. (7)

Risk factors for prosthetic joint infection include prosthetic joint replacement as a treatment for old tuberculosis infection, a practice that has been criticized because of the danger of reactivation of quiescent infection. (17) Periprosthetic tuberculous infection may be first recognized at the time of arthroplasty with AFB culture, or with histologic evidence of mycobacterial infection. (8) These infections may also be diagnosed more than 6 weeks after initial arthroplasty and may be due to hematogenous spread or local reactivation. Trauma is well-known as a predisposing factor in skeletal tuberculosis, and injury to tissue around the prosthesis could be important in such reactivation. (8) This raises the possibility that mechanical grinding of synovial tissue may lead to a breakdown of old TB granuloma, as a potential cause of TB reactivation.

The necessity for removal of the infected prosthetic joint in addition to adjunctive antituberculous therapy remains controversial. In one study of two cases of arthroplasties infected with tuberculosis, both were managed by retention of the implant and prolonged drug therapy. In neither case did it later become necessary to remove the implant. (16) In a larger study of ten cases of M tuberculosis infection diagnosed at the time of arthroplasty or within 6 weeks of arthroplasty, all cases were treated with standard antituberculous therapy without implant removal. The majority of these cases had a favorable outcome over a follow-up period ranging from 9 months to 10 years. However, patients with tuberculous infections discovered months or years after joint arthroplasty often failed medical therapy, and surgical removal in combination with antituberculous therapy was typically necessary for cure. (8)

In patients with a history of previous tuberculosis, either cured or latent, investigators have suggested the use of prophylactic antituberculous medication. Eskola et al (17) administered antituberculous prophylaxis for 2 to 3 weeks before and 3 weeks after the operation. At an average of 6.3 years follow up, all of these patients were markedly improved. In patients in whom the prosthesis is removed and antituberculous therapy is administered, safe joint replacement appears to be a safe procedure. (3) Our patient was diagnosed one year after insertion of the arthroplasty and as in other studies, required removal of the prosthesis and antituberculous therapy for complete recovery.

Conclusion

Tuberculous infection of prosthetic joints is a rare disease and its diagnosis depends on high clinical suspicion, especially in the setting of persistent drainage with negative cultures. Because early diagnosis has been shown to decrease morbidity, AFB smears and cultures, as well as histologic materials, should be ordered routinely in those patients with signs of infection undergoing total joint replacement.

References

1. Hecht RH, Meyers MH, Thornhill-Joynes M, et al. Reactivation of tuberculous infection following total joint replacement: a case report. J Bone Joint Surg Am 1983;65:1015-1016.

2. Harris WH, Sledge CB. Total hip and total knee replacement (1), N Engl J Med 1990;323:725-731.

3. Harris WH, Sledge CB. Total hip and total knee replacement (2). N Engl J Med 1990;323:801-807.

4. Lusk RH, Wienke EC, Milligan TW, et al. Tuberculous and foreign-body granulomatous reactions involving a total knee prosthesis. Arthritis Rheum 1995;38:1325-1327.

5. Atkins BL, Athanasou N, Deeks JJ, et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty: the OSIRIS Collaborative Study Group. J Clin Microbiol 1998;36:2932-2939.

6. McCullough CJ. Tuberculosis as a late complication of total hip replacement. Acta Orthop Scand 1977;48:508-510.

7. Tokumoto JI, Follansbee SE, Jacobs RA. Prosthetic joint infection due to Mycobacterium tuberculosis: report of three cases. Clin Infect Dis 1995;21:134-136.

8. Spinner RJ, Sexton DJ, Goldner RD, et al. Periprosthetic infections due to Mycobacterium tuberculosis in patients with no prior history of tuberculosis. J Arthroplasty 1996;11:217-222.

9. Gale DW, Harding ML. Total knee arthroplasty in the presence of active tuberculosis. J Bone Joint Surg Br 1991;73:1006-1007.

10. Lin E, Oliver S, Caspi I, et al. Hip arthroplasty in quiescent mycobacterial infection of hip. Orthop Rev 1986;15:232-236.

11. Levin ML. Miliary tuberculosis masquerading as late infection in total hip replacement. Md Med J 1985;34:153-155.

12. Wolfgang GL. Tuberculosis joint infection. Clin Orthop Relat Res 1978;136:257-263.

13. Bryan WJ, Doherty JH Jr, Sculco TP. Tuberculosis in a rheumatoid patient: a case report. Clin Orthop 1982;171:206-208.

14. Johnson R, Barnes KL, Owen R. Reactivation of tuberculosis after total hip replacement. J Bone Joint Surg Br 1979;61-B:148-150.

15. Baldini N, Toni A, Greggi T, et al. Deep sepsis from Mycobacterium tuberculosis after total hip replacement: case report. Arch Orthop Trauma Surg 1988;107:186-188.

16. Wolfgang GL. Tuberculosis joint infection following total knee arthroplasty. Clin Orthop Relat Res 1985;201:162-166.

17. Eskola A, Santavirta S, Konttinen YT, et al. Arthroplasty for old tuberculosis of the knee. J Bone Joint Surg Br 1988;70:767-769.

Fares J. Khater, MD, Imran Q. Samnani, MD, Jay B. Mehta, MD, FCCP, Jonathan P. Moorman, MD, PhD, and James W. Myers, MD

From the Divisions of Infectious Diseases and Pulmonary Medicine, Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University; and Medical Service, James H. Quillen VAMC, Johnson City, TN.

Reprint requests to Jonathan Moorman, MD, PhD, Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Box 70622, Johnson City, TN 37614. Email: [e-mail]

Accepted May 11, 2006.

RELATED ARTICLE: Key Points

* Mycobacterium tuberculosis infection can occur in prosthetic joints, often in the setting of steroid use.

* A high degree of clinical suspicion is necessary to make a diagnosis of mycobacterial prosthetic joint infection.

* Aggressive diagnostic and therapeutic measures, including prosthesis removal, are needed to cure mycobacterial prosthetic joint infections.

Table. Clinical presentation, treatment and outcome of knee and hip
arthroplasties infected with Mycobacterium tuberculosis.

Case                      Joint  Age/sex  ESR     Clinical

 1 McCullough et al 1977  Hip    70 F     100     Pain, sinus discharge
 2 Johnson et al 1979     Hip    48 F     35      Pain
 3 Johnson et al 1979     Hip    51 F     12      Pain
 4 Bryan et al 1982       Knee   72 F     NA      Pain, swelling and
                                                    warmth
 5 Hecht et al 1983       Hip    27 M     Normal  Pain, swelling,
                                                    draining sinus
 6 Wolfgang et al 1985    Knee   61 M     43      Pain, swelling
 7 Levin et al 1985       Hip    75 F     55      Tenderness
 8 Lin et al 1986         Hip    70 F     NA      Pain
 9 Lin et al 1986         Hip    49 F     NA      Pain, draining sinus
10 Baldini et al 1988     Hip    61 M     NA      Sinus, fistula
11 Gale et al 1991        Knee   67 M     NA      Pain
12 Tokumoto et al 1995    Knee   70 F     97      Pain, swelling
13 Tokumoto et al 1995    Hip    72 F     93      Spontaneous drainage
14 Tokumoto et al 1995    Knee   71 F     NA      Pain, swelling
15 Spinner et al 1996     Knee   70 F     40      Fever, purulent
                                                    drainage
16 Current case           Knee   75 F     87      Purulent drainage

Case                      Pathogen  PPD       Treatment        Outcome

 1 McCullough et al 1977  TB        Not done  Anti-TB + joint  Good
                                                retained
 2 Johnson et al 1979     TB        Not done  Ant-TB + joint   Good
                                                removed
 3 Johnson et al 1979     TB        Not done  Anti-TB + joint  Good
                                                removed
 4 Bryan et al 1982       TB        Not done  Anti TB + joint  Good
                                                removed
 5 Hecht et al 1983       TB        Positive  Anti-TB + joint  Good
                                                removed
 6 Wolfgang et al 1985    TB        Not done  Anti-TB + joint  Good
                                                removed
 7 Levin et al 1985       TB        Not done  Anti TB + joint  Good
                                                removed
 8 Lin et al 1986         TB        Not done  Anti-TB + joint  Good
                                                retained
 9 Lin et al 1986         TB        Positive  Anti-TB + joint  Good
                                                retained
10 Baldini et al 1988     TB        Not done  Anti-TB + joint  Good
                                                removed
11 Gale et al 1991        TB        Not done  Anti-TB + joint  Good
                                                retained
12 Tokumoto et al 1995    TB        Not done  Anti-TB + joint  Good
                                                removed
13 Tokumoto et al 1995    TB        Not done  Anti-TB + joint  Good
                                                removed
14 Tokumoto et al 1995    TB        Not done  Anti-TB + joint  Good
                                                removed
15 Spinner et al 1996     TB        Not done  Anti-TB with     Good
                                                debridement
16 Current case           TB        Negative  Anti-TB with     Good
                                                joint removal