Septic arthritis of the native hip by granulicatella adiacensa case report and literature review

Introduction

Septic arthritis of the native hip is a rare condition in the adult population [1] Portier E, Zeller V, Kerroumi Y, Heym B, Marmor S, Chazerain P. Arthroplasty after septic arthritis of the native hip and knee: retrospective analysis of 49 joints. J Bone Joint Infect. 2022:7(2):81-90.. Its incidence has been reported at approximately 2 to 10 per 100,000 person-years [2] Fukushima K, Uekusa Y, Koyama T, Ohashi Y, Uchiyama K, Takahira N, Takaso M. Efficacy and safety of arthroscopic treatment for native acute septic arthritis of the hip joint in adult patients. BMC Musculoskeletal Disorders 2021;22(1):318.. Granulicatella adiacens is a nutritional variant of streptococcus known to be a commensal of the oral flora [3] Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol. 2005;43(11):5721–5732.. This germ has been involved as a causative pathogen mainly in endocarditis and less frequently in infections of other systems [2], Fukushima K, Uekusa Y, Koyama T, Ohashi Y, Uchiyama K, Takahira N, Takaso M. Efficacy and safety of arthroscopic treatment for native acute septic arthritis of the hip joint in adult patients. BMC Musculoskeletal Disorders 2021;22(1):318.[3], Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol. 2005;43(11):5721–5732.[4] Quenard F, Seng P, Lagier JcH, Fenollar F, Stein A. Prosthetic joint infection caused by Granulicatella adiacens: a case series and review of literature. BMC Musculoskeletal Disorders 2017;18(1):276.. To our knowledge, there are no reports of this microorganism as a cause of septic arthritis of the native hip. Therefore, this paper aims to present a case of septic arthritis of the native hip caused by this fastidious germ.

Case

A 58-year-old woman consulted at our department with a history of high blood pressure, dyslipidemia and primary uncemented left total hip arthroplasty for osteoarthritis 9 months before, with a satisfactory result and a Harris Hip Score of 92 points. She presented walking without assistance complaining of right hip pain of 2 months duration. She referred dull pain, with an intensity of 5 on the visual analog scale and having received a steroid injection in the painful hip 6 weeks after the onset of symptoms and 15 days before consultation. Physical examination showed moderate pain during motion, with hip flexion 10 to 100°, internal rotation of 15° and external rotation of 20°. There was no fever or erythema in the area. At that time, an X-ray of both hips was performed which showed a normal right hip and left THA (Figure 1).

As a complementary method of diagnosis, we requested an MRI. The following week she returned with an MRI, using an elbow crutch on the left hand due to increased pain (Visual Analog Scale 9) and intolerance to weight bearing. The MRI showed an increase in synovial fluid in the right hip (Figure 2). With suspicion of septic arthritis, we performed an arthrocentesis in the operating room and requested a blood test with infection related makers (normal values: White Blood Cell Counts < 9000 mm3, Erythrocyte sedimentation rate < 16mm/1st hour, C-reactive Protein <0.3mg/dL). Results were compatible with infection: WBC 16500mm3, ESR:26 and CRP: 0.1mg/dL. We decided to perform an arthroscopic lavage and collection of samples for bacteriological culture.

An empirical antibiotic therapy with Vancomycin and Ceftazidime was started. After one week (day 8) of culture in enriched media, Granulicatella adiacens was recovered and, according to the antibiogram, ATB was adapted to Ceftriaxone 1g/12 hours + Gentamicin 80 mg/ 8 hours for four weeks following by 8 weeks of minocycline orally. Sensitivity to Vancomycin was also reported. As additional data, the samples from the arthroscopy were negative. In addition, given the association of this germ with bacterial endocarditis, although she was asymptomatic, an echocardiogram was performed, and endocarditis was concomitantly diagnosed. Two weeks after treatment, she started again with pain in the right hip, so xray, laboratory and hip MRI were repeated. Xray showed chondrolysis with loss of the joint space. The laboratory values were similar to those of the initial diagnosis, while MRI showed hyperintensity in the femoral head in the STIR sequence, interpreted as subchondral necrosis secondary to septic arthritis. (Figures 3-4).

We therefore decided to perform open debridement, reaming the acetabular cavity and placing an articulated custom-made spacer coated with Vancomicyn loaded cement. Two grams of Vancomycin were added to each dose of 40 grams of cement. (Figure 5).

Intraoperative, severe damage to both acetabular and femoral head cartilage was noted. The seven intraoperative samples sent to culture were negative. The patient continued the same ATB treatment, evolving favorably regarding her infectious disease.

At two months postoperatively, the patient is recovering uneventfully, ESR and CRP have returned to normal values and a reimplantation of a definitive THA is planned at the end of the antibiotic treatment. She is currently completing the second of three months of planned parenteral ATB treatment, walking without pain with the assistance of a cane.

Discussion

Granucitella species are gram-positive anaerobic cocci, which are part of the normal flora of the upper respiratory, intestinal, urogenital, and oral tract [2] Fukushima K, Uekusa Y, Koyama T, Ohashi Y, Uchiyama K, Takahira N, Takaso M. Efficacy and safety of arthroscopic treatment for native acute septic arthritis of the hip joint in adult patients. BMC Musculoskeletal Disorders 2021;22(1):318.. They are facultatively anaerobic species with slow growth in standard culture media, which can cause delays in diagnosis and, consequently, treatment [2], Fukushima K, Uekusa Y, Koyama T, Ohashi Y, Uchiyama K, Takahira N, Takaso M. Efficacy and safety of arthroscopic treatment for native acute septic arthritis of the hip joint in adult patients. BMC Musculoskeletal Disorders 2021;22(1):318.[3], Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol. 2005;43(11):5721–5732.[4], Quenard F, Seng P, Lagier JcH, Fenollar F, Stein A. Prosthetic joint infection caused by Granulicatella adiacens: a case series and review of literature. BMC Musculoskeletal Disorders 2017;18(1):276.[5] Seng P, Drancourt M, Gouriet F, La Scola B, Fournier P-E, Rolain JM, et al. Ongoing revolution in bacteriology: routine identification of bacteria by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Clin Infect Dis. 2009;49(4):543–551.. Due to their difficult growth, they often require molecular diagnostic techniques. Recently MALDI-TOF mass spectrometry was reported as a fast and accurate method of diagnosing these pathogens [5] Seng P, Drancourt M, Gouriet F, La Scola B, Fournier P-E, Rolain JM, et al. Ongoing revolution in bacteriology: routine identification of bacteria by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Clin Infect Dis. 2009;49(4):543–551.. In the case presented, given the specific requirements for developing Granulicatella adiacens, cultures were positive after one week in blood culture bottles with pyridoxine. This specific requirement was previously reported by Shailaja et al [6] Shailaja TS, Sathiavathy KA, Unni G. Infective endocarditis caused by Granulicatella adiacens. Indian Heart J 2013;65(4):447-449. .

Bone or joint infections by this germ are infrequent [1], Portier E, Zeller V, Kerroumi Y, Heym B, Marmor S, Chazerain P. Arthroplasty after septic arthritis of the native hip and knee: retrospective analysis of 49 joints. J Bone Joint Infect. 2022:7(2):81-90.[4] Quenard F, Seng P, Lagier JcH, Fenollar F, Stein A. Prosthetic joint infection caused by Granulicatella adiacens: a case series and review of literature. BMC Musculoskeletal Disorders 2017;18(1):276.. Reviewing the literature, we have found a few cases of vertebral osteomyelitis [7] Fukuda R, Oki M, Ueda A, Yanagi H, Komatsu M, Itoh M, Oka A, Nishina M, Ozawa H, Takagi A. Vertebral osteomyelitis associated with Granulicatella adiacens. Tokai J Exp Clin Med. 2010;35(4):126–129., periprosthetic hip infections [4], Quenard F, Seng P, Lagier JcH, Fenollar F, Stein A. Prosthetic joint infection caused by Granulicatella adiacens: a case series and review of literature. BMC Musculoskeletal Disorders 2017;18(1):276.[8] Badrick TC, Nusem I, Heney C, Sehu M. Granulicatella adiacens: An uncommon diagnosis of prosthetic hip joint infection. A case report with review of the literature. IDCases 2021;25:e01204., and the report of only one case affecting a native joint [9] Hepburn MJ, Fraser SL, Rennie TA, Singleton CHM, Delgado B. Septic arthritis caused by granulicatella adiacens: diagnosis by inoculation of synovial fluid into blood culture bottles. Rheumatol Int 2003;23(5):255-257.. It was reported in 2003 by Hepburn et al., who reported septic arthritis of the knee in a 68-year-old woman. These authors did not highlight any risk factors for native septic arthritis, such as rheumatoid arthritis, diabetes, immunocompromised status, drug abuse, or previous surgeries [10] Hassan AS, Rao AL, Manadan AM, Block JA. Peripheral bacterial septic arthritis: review of diagnosis and management. J Clin Rheum 2017;23(8):435-442.. In our case, septic arthritis probably originated from hematogenous dissemination from endocarditis.

Contamination following corticosteroid or hyaluronic acid injection has been reported with a risk of 1 in 1000 [10] Hassan AS, Rao AL, Manadan AM, Block JA. Peripheral bacterial septic arthritis: review of diagnosis and management. J Clin Rheum 2017;23(8):435-442. but in our case the intraarticular steroid injection had been performed 6 weeks after the onset of symptoms.

Regarding the treatment of septic arthritis, there is no clear recommendation on the duration of ATB treatment [11] Davis CM, Zamora RA. Surgical options and approach for septic arthritis of the native hip and knee joint. J Arthroplasty 2020;35(3S):S14-S18.. Although this will depend on different factors, there is some consensus regarding administering at least 2-3 weeks of IV antibiotics followed by 2 to 4 weeks orally [11], Davis CM, Zamora RA. Surgical options and approach for septic arthritis of the native hip and knee joint. J Arthroplasty 2020;35(3S):S14-S18.[12] Ross JJ. Septic arthritis of native joints. Infect Dis Clin North Am 2017;31(2):203-218.. In the case of arthritis caused by Granulicatella adiacens, given its low frequency, there is no formal recommendation yet. Although not in native joints, Quenard et al [4] Quenard F, Seng P, Lagier JcH, Fenollar F, Stein A. Prosthetic joint infection caused by Granulicatella adiacens: a case series and review of literature. BMC Musculoskeletal Disorders 2017;18(1):276.. reported 5 cases of periprosthetic infection with this germ using, in addition to surgical treatment, an ATB therapy of 180 days without reporting subsequent recurrences.

In combination with systemic ATB therapy, a recent review recommends performing serial arthrocentesis (in patients at high surgical risk), arthroscopic lavage, or open surgical debridement [11] Davis CM, Zamora RA. Surgical options and approach for septic arthritis of the native hip and knee joint. J Arthroplasty 2020;35(3S):S14-S18.. Regarding arthroscopic or open treatment, the literature has reported similar results [10], Hassan AS, Rao AL, Manadan AM, Block JA. Peripheral bacterial septic arthritis: review of diagnosis and management. J Clin Rheum 2017;23(8):435-442.[11], Davis CM, Zamora RA. Surgical options and approach for septic arthritis of the native hip and knee joint. J Arthroplasty 2020;35(3S):S14-S18.[12] Ross JJ. Septic arthritis of native joints. Infect Dis Clin North Am 2017;31(2):203-218.. Additionally, in chronic cases and with joint damage, staged treatment using AB-spacers is the best option [11], Davis CM, Zamora RA. Surgical options and approach for septic arthritis of the native hip and knee joint. J Arthroplasty 2020;35(3S):S14-S18.[13] Sharff KA, Richards EP, Townes JM. Clinical management of septic arthritis. Curr Rheumatol Rep 2013;15(6):332.. In the case presented, we decided to perform a staged treatment with a PMMA spacer with ATB after failed arthroscopic lavage. Given the sensitivity to vancomycin obtained in the antibiogram we used primary components covered with vancomycin loaded cement. A regular polished tapered stem was used on the femoral side and a polyethylene dual mobility liner on the acetabular side. The outer aspect of this liner is smooth, so it was roughened to promote cement adherence.

To our knowledge, this is the first report of septic arthritis in a native hip caused by Granulicatella adiacens as the only infecting germ. We emphasize its association with asymptomatic endocarditis and the difficulty of its isolation in standard culture media, as well as the absence of established guidelines for its therapeutic approach. We will continue with the treatment of this patient to report the final results in the future.