KELLGREN JH, BALL J, FAIRBROTHER. RW, et al: Suppurative arthritis complicating rheumatoid arthritis. Br Med J 1: 1193, 1958. 4. RUSSELL AS, ANSELL ...
I
I
I
I
I
0
BRIEF COMMUNICATIONS
0
Infectious arthritis complicating systemic lupus erythematosus THOMAS HUNTER,* MB, BS, FRCP[C]; FRANK A. PLUMMER,t MD When a patient presents with inflammatory arthritis, especially monoarthritis, the first diagnostic consideration must be infectious arthritis. Even when a definite diagnosis of a specific chronic polyarthritis has been made the physician must continue to be on guard against complicating infectious arthritis. Infectious arthritis has been reported as a complication of gout and pseudogout' and the arthritis of sickle cell disease.2 However, rheumatoid arthritis is the most common chronic polyarthritis complicated by infectious arthritis.34 We report a case of infectious arthritis complicating systemic lupus erythematosus. Case report Symmetric inflammatory arthritis developed in a 20-year-old woman who had previously been well. The temporomandibular joint, shoulder, elbow, wrist, metacarpophalangeal and proximal interphalangeal joints. knee, ankle and metatarsophalangeal joints were involved bilaterally. The condition failed to respond to From the faculty of medicine, University of Manitoba, Winnipeg *Assistant professor of internal medicine tResident in internal medicine Reprint requests to: Dr. Thomas Hunter, University of Manitoba rheumatic disease unit, Health Sciences Centre, 800 Sherbrook St., Winnipeg, Man. R3A 1M4
salicylate therapy, and treatment with prednisone, 10 mg/d, was started when the woman was 21 vears old. She was first seen at the University of Manitoba rheumatic disease unit at age 22 years, when she was found to have nondeforming, nonerosive polyarthritis. The hemoglobin level was 11.4 g/dl, the leukocyte count 7.4 x 109/l and the erythrocyte sedimentation rate 46 mm/h (by the modified Wintrobe method). The serum creatinine level and urinalysis results were normal. The latex fixation test was negative, the fluorescent antinuclear antibody test was weakly positive and anti-deoxyribonucleic acid (DNA) antibodies were not detected. Attempts were made to reduce the dose of prednisone, but the patient was lost to follow-up. At age 25 years the woman presented with a 3-day history of a severe flare of her polyarthritis. Her temperature was 37.6°C. The only physical abnormalities were of the musculoskeletal system: active synovitis of both shoulders, elbows and wrists, of the right second and third metacarpophalangeal joints, and of the second to fourth proximal interphalangeal joints, the ankles and the metatarsophalangeal joints bilaterally. There were large tense effusions and 50 flexion deformities of both knees. The hemoglobin level was 10.5 g/dl, the leukocyte count 2.6 x
109/1 (40% mature and 6% young polymorphonuclear leukocytes, 44% lymphocytes, 9% monocytes and 1% eosinophils), the platelet count 489 x 10'/l and the erythrocyte sedimentation rate 91 mm/h (by the modified Wintrobe method). The latex fixation test was negative, the lupus erythematosus cell preparation was negative, the fluorescent antinuclear antibody test was weakly positive and the value for anti-DNA antibody binding was 57.2% (normal range 0 to 20% by the modified Farr technique). Serum complement levels were 39 mg/dl (normal range 94 to 214 mg/dl) for the third component and 6 mg/dl (normal range 20 to 50 mg/dl) for the fourth component. A VDRL test was nonreactive. The creatinine clearance, results of urinalysis and 24-hour urinary excretion of protein were normal. In synovial fluid aspirated from the left knee the leukocyte count was 13.05 x 109/l (85% polymorphonuclear leukocytes), the total protein level 5.7 g/dl and the albumin level 3.9 g/dl. Gram-staining of the synovial fluid gave negative results. Roentgenograms of the chest, hands and feet were normal. Although other clinical features of systemic lupus erythematosus were absent, on the basis of the
chronic seronegative, nonerosive polyarthritis, the hypocomplementemia and the presence of antibodies to double-stranded DNA the
CMA JOURNAL/APRIL 5, 1980/VOL. 122 791
patient was considered to have a recorded in Table I. On the basis flare of systemic lupus erythema- of the results of synovial fluid or tosus and was admitted to hospital. tissue culture the most commonly The dose of prednisone was in- involved joints were, in descending creased from 5 to 20 mg/d but order of frequency, the knee, the there was no improvement in the hip, the ankle and the elbow. Factors predisposing to infection polyarthritis. On the second hospital day the patient's temperature included intra-articular steroid therrose to 38.5°C. After 48 hours of apy in three patients, genitourinary incubation the culture of synovial infection in four patients, aseptic fluid from the left knee grew Neis- necrosis of the hip in two patients, seria gonorrhoeae. Cultures of sy- diabetes mellitus in two patients novial fluid from the right knee and and osteomyelitis in one patient, a cervical swab subsequently also who also had sickle cell trait. Details of medication were given grew N. gonorrhoeae, but cultures of blood and of rectal and throat for 21 patients, 20 of whom were receiving systemic corticosteroid swabs did not. The patient was given 12 million therapy. Three of these patients U of penicillin intravenously for 8 were also receiving azathioprine. days followed by ampicillin, 4 g/d These medications may also be conby mouth for 5 days. Within 12 sidered as factors predisposing to hours of the start of antibiotic ther- infection. Detailed case summaries were apy her temperature had returned to normal, and within 48 hours the available for 22 of the patients. effusions in the two knees had re- Prior to the onset of infectious arsolved. Within 7 days of admission thritis 12 patients had had polythe daily prednisone dose was re- arthralgia or polyarthritis, but 5 duced to 7.5 mg. The patient was patients had no prior history of discharged much improved, but was arthritis; details of the past history were unavailable for 5 patients. At subsequently lost to follow-up. the time of the infectious arthritis 12 patients were found to have Discussion monoarthritis, 1 patient had synoWe consider ourselves fortunate vitis of a hip joint and a subacroin having isolated N. gonorrhoeae mial bursa, 3 patients had arthritis from this patient's synovial fluid. involving two joints and 6 patients The pattern of her polyarthritis and had polyarthritis. The infection was the results of laboratory investiga- proven by culture to involve more tions were in keeping with a flare than one joint in five patients. of systemic lupus erythematosus. Fever was present in 15 of the 16 There was no history of genitouri- patients for whom temperatures nary symptoms and no evidence of were given. skin lesions or tenosynovitis to sugLeukocytosis was detected in 8 gest disseminated gonococcal infec- of the 15 patients for whom labotion. In retrospect the only clue to ratory data were available, and the the diagnosis was a remark made mean leukocyte count in the synoby the patient about the severity of vial fluid of 9 patients was 73.177 the recent flare: "It's never been x 109/l (range 11 to 200 x 109/l); this painful before." polymorphonuclear leukocytes preTwenty-five patients with syste- dominated. mic lupus erythematosus compliFour of the previously described cated by infectious arthritis have patients, all female, had gonococcal previously been described.6` Eight- arthritis complicating systemic lueen were female and seven were pus erythematosus."'18 The mean male. The mean age was 33.6 age was 30 years and the mean years (range 17 to 58 years). The duration of systemic lupus erythemean duration of systemic lupus matosus 9.4 years (range 1.5 to 16 erythematosus in the 21 patients in years). All four patients had a prior whom this information was avail- history of polyarthritis and three able was 6.4 years (range 1.5 to were receiving systemic cortico20 years). The organisms respon- steroid therapy. Two patients presible for the infectious arthritis are sented with symmetric polyarthritis 792 CMA JOURNAL/APRIL 5, 1980/VOL. 122
and two with monoarthritis (of the knee and the ankle). Fever was present in all four. Leukocytosis was present in two. Because of the absence of the characteristic skin manifestations, tenosynovitis and genitourinary symptoms the diagnosis was delayed in all four patients. A delay in the diagnosis of infectious arthritis complicating systemic lupus erythematosus occurred in at least six of the previously reported cases. This complication should be considered on clinical grounds when a patient with systemic lupus erythematosus presents with arthritis for the first time and when a patient with a past history of polyarthralgia or polyarthritis presents with monoarthritis or polyarthritis ot increased severity, especially if the patient is febrile or has a known focus of infection. Laboratory findings that may suggest this complication include leukocytosis or an increase in the proportion of immature polymorphonuclear leukocytes. The synovial fluid of patients with uncomplicated systemic lupus erythematosus usually shows evidence of mild inflammation, with a total leukocyte count of less than 3.0 x 109/1.23 If synovial fluid analysis is performed, the presence of more severe inflammatory changes should suggest infection. Although the frequency of infection is higher among patients with systemic lupus erythematosus than among patients with rheumatoid arthritis,24 infectious arthritis is a rare complication of sys-
arthritis. Ann Rheum Dis 31: 40, temic lupus erythematosus.18 Per1972 haps the greater degree of joint 5. MITCHELL WS, BROOKS PM, STEVENdestruction or synovitis in rheumaSON RD, et al: Septic arthritis in toid arthritis accounts for the greatpatients with rheumatoid disease: a still underdiagnosed complication. J er frequency of complicating infecRheumatol 3: 124, 1976 tious arthritis. The spectrum of bacMILLS LC, BOYLSTON BF, GREENE teria causing arthritis in patients 6. JA, et al: Septic arthritis as a comwith systemic lupus erythematosus plication of orally given steroid theralso appears to be distinctly difapy. JAMA 164: 1310, 1957 ferent from that in patients with 7. TONDREAU RL, HODES PJ, SCHMIDT ER JR: Joint infections following rheumatoid arthritis, among whom steroid therapy: roentgen manifestaStaphylococcus aureus accounts tions. Am J Roentgenol Radium for approximately 75% of comTher Nucl Med 82: 258, 1959 plicating infectious arthritis.34 This 8. GOWANS JD, GRANIERI PA: Septic arthritis: its relations to intra-articuobservation has obvious ramificalar injections of hydrocortisone acetions in the selection of antibiotic tate. N Engl J Med 261: 502, 1959 therapy before the infecting bac- 9. GUCKIAN JC, BYERS EH, PERRY JE: terium has been identified. Arizona infection of man. Report of a case and review of the literaRecently an association has been ture. Arch Intern Med 119: 170, reported between N. gonorrhoeae 1967 bacteremia and deficiencies in 10. LAMY M, AuQuIER L, FRIZAL J, et the late-acting components of al: Arthrites suppurees et septicemies staphylococciques mortelles complement (C6, C7 and C8).25 dans un cas d'arthrite rhumato7de Measurement of the serum levels et dans un cas de lupus erythemaof complement components during teux dissemine. Rev Rhum Mal remission was not possible in our Osteoartic 35: 159, 1968 patient; therefore, an associated 11. CASTELMAN B, McNEELY BU: Case records of the Massachusetts Gencomplement deficiency cannot be eral Hospital. Case 8-1968. N Engl excluded. The hypocomplementeJ Med 278: 441, 1968 mia was attributed to active sys- 12. MARTIN CM, MERRILL RH, BARRETT temic lupus erythematosus and may O JR: Arthritis due to Serratia. J Bone Joint Surg [Am] 52: 1450, have been a factor predisposing to 1970 N. gonorrhoeae bacteremia in our
patient. Unfortunately, as our case illustrates, when a patient with systemic lupus erythematosus presents with arthritis, infectious arthritis cannot be definitely excluded on clinical or laboratory grounds. A high index of suspicion on the part of the physician remains a most important factor in diagnosis. Should any doubt exist as to the nature of the synovitis, synovial fluid should be aspirated for analysis and appropriate microbiologic examination. References 1. MCCONVILLE JH, POTOTSKY RS, CALIA FM, et al: Septic and crystalline joint disease. A simultaneous occurrence. JAMA 231: 841, 1975 2. PALMER DW, ELLMAN MH: Septic arthritis and Reiter's syndrome in sickle cell disorders: case reports and implications for management. South Med J 69: 902, 1976 3. KELLGREN JH, BALL J, FAIRBROTHER RW, et al: Suppurative arthritis complicating rheumatoid arthritis. Br Med J 1: 1193, 1958 4. RUSSELL AS, ANSELL BM: Septic
13. EDELEN JS, LOCKSHIN MD, LEROY EC: Gonococcal arthritis in two pa-
tients with active lupus erythematosus. A diagnostic problem. Arthritis Rheum 14: 557, 1971 14. BERNEY S, GOLDSTEIN M, BISHKO F: Clinical and diagnostic features of tuberculous arthritis. Am J Med 53: 36, 1972 15. MORRIS JL, ZIZIC TM, STEVENS MB: Proteus polyarthritis complicating systemic lupus erythematosus. Johns Hopkins Med J 133: 262, 1973 16. GIARD DE, BAGBY GC JR, WALSH
JR: Destructive polyarthritis secondary to Mycobacterium kansasii. Arthritis Rheum 16: 665, 1973 17. KRAUSS DS, ARONSON MD, GUMP DW, et al: Hemophilus influenzae septic arthritis. A mimicker of gonococcal arthritis. Arthritis Rheum 17: 267, 1974 18. QUISMORIo FP, DUBOIS EL: Septic arthritis in systemic lupus erythematosus. J Rheumatol 2: 73, 1975 19. SMILACK JD, GOLDBERG MA: Bone and joint infection with Arizona hinshawii: a report of a case and a review of the literature. Am J Med Sci 270: 503, 1975 20. MOUGEOT-MARTIN M, KRULIK M,
GINTZBURGER 5, et al: Arthrite septique spontanee au cours du lupus erythemateux dissemine. Sem Hop Paris 52: 883, 1976
21. KAHN MF, PELTIER AP, PODRABINEK N, et al: Les infections dans le lupus erythemateux aigu dissemine. Anin Med Itnterne (Paris) 128: 31, 1977 22. HOFFMAN GS, MYERS RL, STARK FR, et al: Septic arthritis associated with Mycobacterium avium: a case report and literature review. J Rheu-
matol 5: 199, 1978 23. LABOWITZ R, SCHUMACHER HR JR: Articular manifestations of systemic lupus erythematosus. A tn Intern Med 74: 911, 1971 24. STAPLES PJ, GERDING DN, DECKER JL, et al: Incidence of infection in systemic lupus erythematosus. Arthritis Rheumn 17: 1, 1974 25. PETERSEN BH, LEE TJ, SNYDERMAN R, et al: Nisseria meningitidis and Neisseria gonorrhoeae bacteremia associated with C6, C7, or C8 deficiency. Ann Internt Med 90: 917, 1979
I BOOKS I continued from page 779 LECTURE NOTES IN MEDICAL INFORMATICS. 6. Health Care Technology Evaluation. Proceedings, Columbia, Missouri, Nov. 6-7, 1978. Edited by D.A.B. Lindberg and P.L. Reichertz. 118 pp. Illust. Springer-Verlag New York Inc., New York, 1979. $12.50, paperbound. ISBN 0-387-09561-6 MANAGING CHANGE AND COLLABORATION IN THE HEALTH SYSTEM. The Paradigm Approach. Alan Sheldon. 195 pp. Oelgeschlager, Gunn & Hain Inc., Publishers, Cambridge, Massachusetts, 1979. $20. ISBN 0-89946-003-8 MONOGRAPHS IN PAEDIATRICS. Vol. 11. Advances in Vaccination Against Virus Diseases. Edited by the Virus Department, Swiss Serum and Vaccine Institute, Bern. 74 pp. lllust. S. Karger AG, Basel, 1979. $20.50, paperbound. ISBN 3-8055-3046-3 OPERATIVE SURGERY. Fundamental International Techniques. Plastic Surgery. 3rd ed. Edited by John Watson and Robert M. McCormack. 556 pp. Illust. Butterworth (Publishers) Inc., Boston, 1979. $160. ISBN 0-407-00637-0 PAEDIATRIC EMERGENCIES. Edited by J.A. Black. 874 pp. Illust. Butterworths (Publishers) Inc., Woburn, Massachusetts, 1979. $84.95. ISBN 0-407-00131-X PLASMAPHERESIS AND THE IMMUNOBIOLOGY OF MYASTHENIA GRAVIS. Proceedings of a Symposium Sponsored by the Muscular Dystrophy Association, Children's Hospital, San Francisco, June 1978. Edited by Peter C. Dau. 371 pp. Illust. Houghton Mifflin Professional Publishers, Boston; the Macmillan Company of Canada Limited, Toronto, 1979. $54.95. ISBN 0-89289-404-0
continued on page 796
CMA JOURNAL/APRIL 5, 1980/VOL. 122 793
