Isolated septic arthritis of hip joint: a rare presentation of melioidosis. A case report
Weerasinghe et al. BMC Res Notes
Isolated septic arthritis of hip joint: a rare presentation of melioidosis. A case report
N. P. Weerasinghe 0
H. M. M. Herath 1 2
T. M. U. Liyanage 1
0 Department of Microbiology, Faculty of Medicine, University of Ruhuna , P.O. Box 70, Galle , Sri Lanka
1 University Unit, Teaching Hospital , Karapitiya, Galle , Sri Lanka
2 Department of Medicine, Faculty of Medicine, University of Ruhuna , Galle , Sri Lanka
Background: Despite, Sri Lanka lies in the melioidosis endemic belt between 5°N and 10°N surrounded by countries known to have endemic melioidosis for many years, comparatively fewer cases of melioidosis infection have been reported in Sri Lanka. Melioidosis has a wide spectrum of clinical presentation, ranging from severe pneumonia to abscess formation in various organs. Isolated septic arthritis, which is a rare but well-recognized manifestation of melioidosis, could be the sole presenting problem in some patients with melioidosis. Case presentation: We report a middle aged diabetic female who has been on azathioprine for autoimmune hepatitis, presenting with pain and swelling of left hip joint. Investigations confirmed the clinical suspicion of septic arthritis, but all relevant microbiological investigations failed to isolate a causative organism. Due to the history of diabetes, possible immunosuppression with azathioprine, and failure to recognise the possible causative organism by initial investigations prompted us to investigate for melioidosis. Diagnosis of melioidosis was made by presence high titre of antibodies to melioidin antigen, and rapid response to appropriate treatment. The patient was treated with intravenous imipenem 1000 mg 6 hourly and oral cotrimoxazole (1920 mg 12 hourly) for 4 weeks followed by eradication therapy with cotrimoxazole and doxycycline. Conclusion: Given that melioidosis-induced septic arthritis share common features with septic arthritis due to other common pyogenic bacteria, differentiation of these two conditions is extremely difficult. Therefore, melioidosis needs to be considered as a possibility, when a patient with risk factors for melioidosis such as diabetes or immunosuppression presents with isolated septic arthritis. This case report has been presented to raise the awareness of an unusual presentation of melioidosis; isolated septic arthritis.
Melioidosis; Isolated septic arthritis; Immune suppression; Sri Lanka
Background
Melioidosis is a pyogenic infection with high mortality
and is caused by the facultative intracellular
gram-negative bacterium; Burkholderia pseudomallei [
1, 2
]. It is
endemic in tropical and subtropical zones of South East
Asia and Northern Australia [2]. Despite, Sri Lanka lies in
the melioidosis-endemic belt between 5°N and 10°N
surrounded by countries known to have endemic melioidosis
for many years, comparatively fewer cases of melioidosis
infection have been reported in Sri Lanka [
3
]. Commonly
identified risk factors for this infection are diabetes
mellitus, heavy alcohol use, malignancy, chronic lung,
liver and kidney disease and various other immune
suppressive conditions [
1
]. Burkholderia pseudomallei enters
the body through percutaneous inoculation or
inhalation [
1
]. The disease is known as a remarkable imitator of
other diseases such as tuberculosis, due to the wide and
variable clinical spectrum of its manifestations [
2
]. As a
result, a high index of clinical suspicion is required for
the diagnosis. Delay in the diagnosis and failure to start
appropriate and effective treatment against melioidosis,
can worsen the outcome [
4, 5
].
When compared with other bacterial infections,
melioidosis is a less common cause for isolated septic
arthritis. Even though, melioidotic bone and joint infections
are established entities, they are less commonly reported
than other manifestations of melioidosis [
6, 7
]. Knee joint
has been identified as the most commonly affected joint
in melioidosis, followed by ankle, hip and shoulder joints
[6]. Even though, melioidotic bone and joint infections
have been reported in Sri Lanka previously [
3, 8–10
],
isolated septic arthritis as the sole manifestation of
melioidosis has not been reported in Sri Lanka up to now.
Therefore, we report this unusual case of isolated septic
arthritis of left hip joint due to melioidosis in a 45-year
old female with multiple risk factors.
Case presentation
A 45-year old Sinhalese woman from Galle district in
Southern Province of Sri Lanka presented to our hospital
with a 2 week history of intermittent fever and severely
painful left hip for 3 days duration. She had a history
autoimmune hepatitis for 6 months, for which she had
been on azathioprine 50 mg daily, and poorly controlled
type 2 diabetes mellitus for 11 years.
Fever was intermittent, initially low grade and later
high grade, which abated with sweating, but not
associated with chills and rigors. She also had mild sore throat
and cough wi (...truncated)