7/28/2019 54354151
2/5
I. Mandac et al.: Septic Arthritis due toStreptococcus sanguis.
Coll. Antropol. 34 (2010) 2: 661-664other inflammatory arthr itis.
Other reported risk factorsare alcohol abuse, corticosteroid
treatment, cancer, trau-ma, radiatio n therapy, chronic liver
disease, surgery withmedian sternotomy. Most common noncontiguou s
foci ofinfection are pneumonia, cellulitis, endocarditis,
uro-sepsis, septic pulmonary emholi, spontaneous
bacterialperitonitis, epidural abscess, intra-abdominal
abscess,gingivitis and d isseminated tuberculosis. SCJ infection
isa potentially life-threatening condition because of tightanatomic
connection with the most imp ortant chest vas-cular str uct ures .
Very rarely SCJ infection occurs in pre-viously healthy
adults^.
In this article, we present a case of septic arthritiscaused hy
Streptococcus sanguis in a 56-years old malepatient. Fig.
2.Degenerative polymorphonuclear leukocytes insynovial fluid -
May-Grnwald-Giemsa, xlOOO.
Case reportA 56-year old male patien t was adm itted to our H
ospi-tal presented as fever of unknown origin, he lost morethan 30
kg of hody weight in less than 6 months and labo-ratory examination
showed anemia of chronic disease asparaneoplastic process. He had
long history of arterialhypertension and stroke. On physical
examination therewas swelling and pain of the right
sternoclavicular jointand precordial systolic murmur. In the
initial laboratoryevaluation, his hemoglobin concentration was
lower,there was leukocj^tosis with neutrophilic predominanceand
erythrocyte sedimentation rate was elevated. A largediagnostic
panel hasbeen made in searching for the loci
of infection. A chest X-ray was normal, echocardiogramdid not
detect anyvegetation on the cardiac valves. Ex-amination of
abdomen, CNS, bone marrow, immunologyparameters, tumor markers,
showed no abnormality.Computerized tomography (CT) of the right
sterno-clavicular joint showed widening of periar ticular soft
tis-su e and loss of clavicular corticalis. Synovial fiuid
wascollected by syringe and its analysis demon strated
mixedviscosity and yellow colour, opaque clarity and more than100
000 WBC/mml Cytologie analysis of synovial fiuidshowed more tha n
90% of polymorphonuelear leukocytes(Figure 1 and 2). There were no
crystals on microscopic
examination and Gram stain of fluid was n egative. Bloodcultures
were positive for S. sanguis and because of positive eytologie
evaluation of synovial fiuid, there was aeonsideration about
possible periodontal disease. Stomatologie exam ination verified
periapical ostitis and extraction of potential cause of infection
has been done. Therapy with henzilpenicilline was followed by the
graduaimprovement of clinical and lahoratory parameters.
Although viridans group streptococci and S. sanguiin particular
are rare causes of septic arthritis in nativjoints, they should be
considered in the differential diagnosis of periodontal disease. A
reasonable amount of aspirated synovial fiuid is the hest argument
in favour oan objective articular disorder In our case, such a
simplevaluation (difierential cell count analysis) was verhelpful
in making a diagnosis.
DiscussionStreptococcal septic arthritis accounts for 15-30%
oall nongonococcal causes of bacterial arthritis in adults'
S. viridans has a low virulence, and infection hy this
microorganism usually ap pears on previously injured focuseven
though its association with dental carries and hacterial
endocarditis has been well established. S. sangui
Fig. 1. CTscan of sternoclavicu lar joints ^lunva a needle in
the right sternoclavicular joint white taking sample of synovial
fluid
7/28/2019 54354151
3/5
I. Mandac et al.: Septic Arthritis due to Streptococcus sanguis.
Coll. Antropol. 34 (2010) 2: 661-664a m ember of the viridans group
of streptococci, is a wellknown commensal of the mouth, upper
respiratory tract,lower intestined tract, genitourinary tract and
skin ofhealthy humans'*-^. Clinical diagnosis requires a high
in-dex of suspicion since symptoms in the region of the SCJcan be
confused with va rious rheum atic disorders, osteo-arthrosis,
hyperostosis, Tietze's syndrome, ahscess, ortumor. Infection can
present with localized swelling withor without tenderness or
decreased range of motion. Aconcise diagnosis is imp ortan t since
mana gem ent differsdepending on the cause. Laboratory studies
usually arenot helpful since an elevated white hlood cell count
orsedimentation rate is nonspecific, and blood cultures
arefrequently negative. When possible, aspiration of thejoint for
Gram stain and culture and cytologie analysiscan be helpful in
confirming the diagnosis and direct an-tibiotic treatment.
Unfortunately, tbe failure rate witbtbis metbod is bigh due to
technical difficulty in aspira-tion of the small joint space.
Unusual organisms such astuberculosis or fungi in an appropriate
bost also sbouldbe considered*^*.
C3rtologic evaluations have to include both bacterialand
synovial fluid analysis and search for microcrystals.Paucicellular
(1000 or2000 cells/mm^) synovial fiuid usually shows a
predomi-nance of polymorphonuclear cells. However, high
cellu-larity may sometimes be associated with a predominanceof
other cells, i.e. lymphocytes, monocytes, eosinophils'^.There are
few reports of septic arthritis due to S. san-guis. Nietsche et al.
described a young man with poly-microbial infection of the
sternoclavicular joint due to S.sanguis and Pasteurella multocida^.
Patrick and Lewisdescribed a previously bealthy 56-years old man
with ob-vious dental carries wbo had septic arthritis of the
kneedue to S. sanguis^^\ Edson et al. reported a 66-year oldman who
developed septic arthritis of the knee due to S.sanguis after he
had been treated for severe periodontaldisease, which contributed
to hematogenous spread".Papaioann ides et il. p resented a case of
septic arthr itis ofthe right knee due to S. sanguis in a 73-year
old womanafter she had been treated for severe periodontal
di-sease''. Although viridans group streptococci in generaland S.
sanguis in particular, are rare causes of septic ar-thritis in
native joints, they should he considered in thedifferential
diagnosis of this disorder, especially in thesetting of severe
periodontal disease and dental caries.Cytologie analysis of
synovial fiuid may be a helpful diag-nostic method especially if
laboratory tests and blood cul-tures are nonspecific.
REFERENCES1. MOHYUDDIN A, Ear Nose Throat J. 82 (2003) 618. 2.
GAL-LUCCl F ESPOSITO P, CARNOVALE A, MADRID E . RUSSO R, UOMOG, Adv
Med Sei, 52 (2007) 125. 3. PETERS RH, RASKER JJ, JACOBSJW, PREVO
RL, KARTHAUS RR Clin Rheu matol, 11 (1992) 351 . 4.PAPAIOANNIDES D,
BONLATSI L, KORANTZOPOULOS R SINAPI-DIS D.GIOTIS C, Med Princ
Pract, 15 (2006) 77. 5. JOHNSON CC,TUNKEL AR, Viridans
streptococci, groups C and G streptococci. In:MANDELL, DOUGLAS AND
BENETT (Eds) Principles and Practice of
Infectious Disease (Philadelphia, 20051. 6. YASUDA T, TAMURA
K,FUJrWARA M, J, Bone Joint Surg Am. 77 (19951 136. 7. BEUTLERSM,
BAYER AS, Drug Ther Hosp Ed. 7 (1982) 101. 8. POTHUL A VMORRISON
NG, MARTINEZ A. Infect Med, 67 (1991) 16. 9. NIT-SCHE JF, VAUGHAN J
H, WILLIAMS G, CURD JG, Arth ritis R heum, 25(1982) 467. 10.
PATRICK MR, LEWIS D, Br J Rheum, 31 (1992) 569. 11. EDSON RS, OSMON
DR, BERRY DJ. Mayo Clin Proc, 77 (2002)709. 12. DOUGADOS M,
Bailieres Clin Rheum atol, 10 (1996) 519.
/. MandacMerkur University Hospital, Zajceva 19, 10000 Zagreb,
Croatiae-mail: imandac(g)yahoo.com
SEPTICKI ARTRITIS UZROKOVAN STREPTOCOCCUS SANGUISOM
SAZETAKSeptiki artritis moie nas tati nak on izravnog ulaska
razlicitih mikroorgan izama (bakterija, virusa, gljiva) u
zglobniprostor Bilo koji uzrocnik infekcije moze dovesti do
bakterijskog artritisa, ali bakterijski patogeni su najznacajniji
jerdovode do brzog unistenja zgloba. U radu prikazujemo slucaj
56-godisnjeg bolesnika sa septickim artritisom uzroko-vanog sa
Streptococcus viridansom koji pripada viridans grupi streptokok a.
Prim ljen je u bolnicu pod klinickom slikomfebriliteta ne poznate
etiologije, a u anam nezi se isticao podatak o gubitku vise od 30
kg tjelesne tezine una zad nekoliko
mjeseei i anemija kronicne bolesti ili u sklopu
paraneoplasticnog procesa. Duzi niz godina se lijecio od arterijske
biper-tenzije, a prebolio je i cerebrovaskularni inzult. U
fizikalnom statusu nadena je oteklina i bol desnog
sternoklaviku-larnog zgloba te sistolicki sum prekordijalno.
Ucinjena je opsezna dijagnosticka obrad a. Kom pjuterizirana
tomografija
