Septic arthritis of the ankle due to Salmonella enteritidis: a case report.

Abstract: Salmonella septic arthritis in healthy individuals is a rare phenomenon in the United States. This case report chronicles the clinical course of a 41-year-old male farmworker who presented with a 3-week history of fever, chills, night sweats with pain, and swelling and redness of his left ankle. He had an open fracture of the ankle 2 years earlier that healed and was asymptomatic despite prior radiographic evidence of avascular necrosis of the talar dome. One month before presentation, he had an ipsilateral periungual abscess of the great toe that he opened and drained himself. Joint cultures were positive for Salmonella enteritidis that was successfully treated with a 6-week course of IV ceftriaxone.

Key Words: ankle joint, Salmonella enteritidis, septic arthritis

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Salmonella enteritidis is a motile, enteric, gram-negative bacillus that is rarely found as the primary pathologic organism of infection in the musculoskeletal system. (1) Acute arthritis caused by gram-negative bacilli can occur after instrumentation, traumatic injury to the joint, or arthrocentesis. (2) It can also be the causative agent in osteomyelitis septic arthritis (3-8) or as a postinfectious reactive arthritis. Most patients with Salmonella septic arthritis have either a predisposing disease, such as sickle cell anemia (9), (10) or systemic lupus erythematosus, (11-13) or a predisposing condition, such as a prosthetic joint (14-17) or avascular necrosis. (18) There have been only two case reports of Salmonella septic arthritis in otherwise previously healthy individuals in the United States since 1984. (3), (7) This report details a patient with septic arthritis from S. enteritidis treated within the past year in the United States.

Discussion

Salmonella consists of a large heterogeneous group of motile gram-negative bacilli that affect animals and humans. As a group, they are enteroinvasive and enteropathogenic organisms. The typical course of Salmonella enterocolitis is characterized by fever, abdominal pain, and diarrhea that persist for 3 to 5 days. Humans are infected with Salmonella almost solely by ingestion of contaminated food or drink, although under quite unusual circumstances, transmission has occurred by direct contact or inhalation. (1) Salmonella occurs naturally in many animals, and the spread is favored in the crowded conditions of a slaughterhouse. This patient indicated that he had eaten properly cooked meat on occasion from the slaughterhouse where he worked, yet he had had no gastrointestinal symptoms throughout the course of the infection. Because he worked in a swine slaughterhouse and his symptoms of fever and chills occurred after his opening of an infected toenail, transmission may have occurred through direct contact.

[FIGURE 1 OMITTED]

Although rare in an otherwise healthy patient, this organism is not uncommon in patients with a chronic disease. Patients with sickle cell anemia have an unusual predilection for these organisms in a relatively common fashion as the causative agent in osteomyelitis. (4-7), (9), (10) Also, in those patients with systemic lupus erythematosus, (11-13) this bacillus has been found as the causative agent in septic arthritis. It has also been found in patients with idiopathic vascular necrosis (18) and other diseases with a relative immunocompromised state and in those with an indwelling orthopedic prosthetic device. (14-17)

Cohen et al (19) reviewed cases of salmonella from their institution and those in the English literature treated with antibiotic therapy before 1984. From their extensive review of the extraintestinal manifestations of Salmonella infections, 44 cases of Salmonella septic arthritis were identified. Of that group, only nine had cultures where Salmonella was confirmed as a solitary organism. In these nine cases, all were monoarticular; all had elevated ESRs and approximately half had a leukocytosis. The mechanism for spread in all these cases was thought to be hematogenous from the gastrointestinal tract. All of these cases were considered to be unusually susceptible due to preexisting conditions. The patient in this case was healthy, but he had hardware secondary to an ankle fracture. Therefore, this patient would be considered at increased risk, particularly given the circumstances of his employment and the onset of the infection.

[FIGURE 2 OMITTED]

The fact that Salmonella was identified as a single organism from initial and intraoperative aspirates and that the mechanism of transmission did not appear to be from ingestion makes this a highly unusual case of Salmonella septic arthritis occurring in the United States. Fortunately, after antibiotic treatment, the patient is relatively asymptomatic and continues to work as a laborer, with only minimal discomfort.

Brevity in writing is the best insurance for its perusal.

--Rudolf Ludwig Karl Virchow

From the Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN.

Reprint requests to Russell Meldrum, MD, Department of Orthopaedic Surgery, Indiana University School of Medicine, 541 Clinical Drive, Suite 600, Indianapolis, IN 46202. Email: [e-mail]

Accepted May 1, 2003.

Copyright [C] 2004 by The Southern Medical Association 0038-4348/04/9701-0077

References

(1.) Hornick R. Nontyphoidal salmonellosis, in Hoeprich P, Jordan M (eds): Infectious Disease. Philadelphia, J.B. Lippincott, 1989, vol 1, ed 4, pp 710-716.

(2.) Parker R. Septic arthritis, in Hoeprich P, Jordan M (eds): Infectious Disease. Philadelphia, J.B. Lippincott, 1989, vol 1, ed 4, pp 1376-1382.

(3.) Birch T, Levin T, Glasser J. Salmonella osteomyelitis complicating an acute fracture in a healthy child. Clin Infect Dis 1994; 19:545-546.

(4.) Ecker M, Cramer L, Lotke P. Salmonella osteomyelitis of the tibia treated by a muscle pedicle and delayed bone grafting: A case report. Clin Orthop 1982;170:226-230.

(5.) Ishiwa N, Aoyama N, Miyazaki T, et al. A case of salmonella osteomyelitis of the rib. Nippon Kyobu Gakkai Zasshi 1994;42:101-104.

(6.) Montejo M, Aguirrebengoa K, Garcia-Alonso J, et al. Chronic osteomyelitis caused by Salmonella fyris. Clin Infect Dis 1994;19:221.

(7.) Sanchez AA, Mazurek MT, Clapper MF. Salmonella osteomyelitis presenting as fibrous dysplasia: A case report. Clin Orthop 1996;330:185-189.

(8.) Spencer J, Cattermole G, Andrade T, et al. Salmonella osteoarticular infection without predisposing factors. J R Soc Med 1999;92:363-364.

(9.) Hook EW, Campbell CG, Weens HS, et al. Salmonella osteomyelitis in patients with sickle cell anemia. N Engl J Med 1957;257:403-407.

(10.) Roberts AR, Hilburg LE. Sickle cell disease with salmonella osteomyelitis. J Pediatr 1958;52:170-175.

(11.) Picillo U, Italian G, Marcialis MR, et al. Bilateral femoral osteomyelitis with knee arthritis due to salmonella enteritidis in a patient with systemic lupus erythematosus. Clin Rheumatol 2001;20:53-56.

(12.) Lovy MR, Ryan PF, Hughes GRV. Concurrent systemic lupus erythematosus and salmonellosis. J Rheumatol 1981;8:605-612.

(13.) Shiota K, Miki F, Kanayama Y, et al. Suppurative coxitis due to Salmonella typhimurium in systemic lupus erythematosus. Ann Rheum Dis 1981;40:312-314.

(14.) Boland F, Kaushik P, Udo EE, et al. Salmonella septic arthritis complicating rheumatoid arthritis in a patient with total knee replacement. Med Princ Pract 1999;8:245-250.

(15.) Madan S, Abbas D, Jowett RL, et al. Salmonella enteritidis infection in total knee replacement. Rheumatology (Oxford) 2001;40:112-113.

(16.) Langenskiold A, Riska EB. Haematogenous salmonella infection around a metal hip endoprosthesis. Acta Orthop Scand 1967;38:220-225.

(17.) Cheng N, Mulier JC. Salmonella osteomyelitis in total hip replacement: A case report of hematogenous infection from gastrointestinal tract. Arch Orthop Trauma Surg 1982;99:281-283.

(18.) Habermann ET, Friedenthal RB. Septic arthritis associated with avascular necrosis of the femoral head. Clin Orthop 1978;134:325-331.

(19.) Cohen JI, Bartlett JA, Correy GR. Extra-intestinal manifestations of salmonella infections. Medicine 1987;66:349-388.

RELATED ARTICLE: Key Points

* Musculoskeletal Salmonella enteritidis infections are rare in individuals without known risk factors.

* Salmonella enteritidis can be spread by direct contact and without the commonly seen prodromal gastrointestinal symptoms.

* For maximal cartilage preservation, early diagnosis and appropriate surgical and antibiotic therapies are imperative in the treatment of this type of septic arthritis.

RELATED ARTICLE: Case Report

A 41-year-old white man presented to the local emergency room with the complaint of acute onset of nontraumatic left ankle pain, with swelling, redness, and warmth. At presentation, the patient was healthy, although 12 years previously he had been diagnosed with acute non-Hodgkin's lymphoma, had a complete recovery, and had been in remission for over 9 years. In addition, 10 years before presentation to the emergency room he had had a high-pressure-spray injury to the dorsum of his foot that penetrated his work boot and resulted in a third-degree burn in the first web space of the left foot. This burn was successfully treated with a 3 X 5-cm partial thickness skin graft. Also, 2 years before his presentation in the emergency room, he had sustained an open fracture of his left talar neck (Hawkins Type II) and medial malleolus when a 1,000-lb bale of hay fell onto his left ankle. This fracture was treated with emergent irrigation, debridement, and open reduction with internal fixation. Within 3 months after fixation of his ankle fracture, he returned to work without discomfort and without restrictions. He reportedly wore either high-top shoes or work boots for increased ankle stability. Six months after his injury, the patient was asymptomatic but had radiographic evidence of avascular necrosis of the talar dome that was thought to be a result of diminished blood supply to the bone due to the severity of the initial injury.

In addition to the relevant medical history, 6 months before his presentation to the emergency room with symptoms of an infection, the patient changed jobs from being an agricultural laborer to involvement with the feeding and maintenance of swine in a slaughterhouse stockyard. One month before presentation, he developed a small abscess on the tibial side of the great toe that lifted the nail from its underlying bed. He reportedly opened the abscess that was ipsilateral to the previous trauma using a pocketknife and expressed approximately 1 ml of pus. One week after opening the abscess, the patient developed fevers, chills, night sweats, and some pain over the anterolateral aspect of his left ankle. Within 3 days of the onset of these symptoms, the pain, swelling, and redness over his ankle had increased in severity, and he was admitted to the hospital for diagnosis and treatment. Preoperative radiographs of the left ankle are seen in Figure 1. An aspirate of the ankle was obtained in the emergency room, and he was started on empiric Kefzol. Blood cultures were not obtained at the time of admission. His erythrocyte sedimentation rate (ESR) at admission was 79 mm/h, his white blood cell count was 11 mg/dl, and S. enteritidis (Group D) was identified. At that time, he was taken to the operating room for hardware removal, irrigation, and debridement of the infected tissue. Each of three cultures obtained in the operating room confirmed the previously identified organism with identical sensitivities to the original aspirate.

Postoperatively, he was placed in a splint, and antibiotics were administered through a peripherally inserted central catheter into the patient's left antecubital fossa, through which he was started on a 6-week course of IV ceftriaxone. After suture removal, the patient was placed in a short-leg walking cast with weight bearing as tolerated. At 6 weeks postoperatively, the surgical wounds were healed, and the redness, warmth, and swelling were gone. However, the patient reported continued pain with walking and weight bearing. At 6 months postoperatively, his ESR was within normal limits, as was his C-reactive protein level. He reported mild ankle pain that was relieved by use of an ankle support and an occasional nonsteroidal anti-inflammatory agent. At 2-year follow-up, radiographs showed significant chondrolysis; however, the patient reported only mild to moderate ankle pain that was relieved with acetaminophen and use of his ankle brace (Fig. 2).

Russell Meldrum, MD, and Judy R. Feinberg, PHD