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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusion
 ~ Acknowledgment
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 31  |  Issue : 1  |  Page : 87-89
 

Primary meningococcal arthritis of sacroiliac joint: A rare case report


1 Department of Microbiology , M. K. C. G Medical College, Brahmapur sishubhaban, Odisha, India
2 Department of Paediatrics, Sishubhaban, Berhampur, Odisha, India

Date of Submission12-Jun-2012
Date of Acceptance04-Aug-2012
Date of Web Publication15-Mar-2013

Correspondence Address:
S Sahu
Department of Microbiology , M. K. C. G Medical College, Brahmapur sishubhaban, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.108743

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 ~ Abstract 

Infection of the sacroiliac joint is a rare entity. Clinical signs and symptoms are usually nonspecific and result in delayed diagnosis. We report a rare case of primary meningococcal arthritis of right sacroiliac joint in an 11-year-old male child. Synovial fluid aspirated from the joint space showed Gram-negative diplococci which were confirmed as Neisseria meningitidis by culture and necessary biochemical tests followed by serogrouping by using polyvalent antisera. He was treated successfully with antibiotics.


Keywords: Neisseria meningitidis, primary infection, septic arthritis


How to cite this article:
Sahu S, Mohanty I, Narasimham M V, Pasupalak S, Parida B. Primary meningococcal arthritis of sacroiliac joint: A rare case report. Indian J Med Microbiol 2013;31:87-9

How to cite this URL:
Sahu S, Mohanty I, Narasimham M V, Pasupalak S, Parida B. Primary meningococcal arthritis of sacroiliac joint: A rare case report. Indian J Med Microbiol [serial online] 2013 [cited 2019 Sep 19];31:87-9. Available from: http://www.ijmm.org/text.asp?2013/31/1/87/108743



 ~ Introduction Top


Acute septic arthritis refers to pyogenic inflammation of a joint space as a result of bacterial infection. Bacteria spread to the joint most often through a haematogenous route. Direct invasion, for example, during trauma, or contiguous spread from periarticular tissue harbouring the infection is also well described. Arthritis due to meningococcal disease is not uncommon. The clinical spectrum of meningococcal infection ranges from asymptomatic carriage to fulminant sepsis like meningitis and septicaemia. [1] Meningococcal arthritis is a complication of  Neisseria More Details meningitidis infection and occurs in about 2 to 10% of cases. [2] However, primary meningococcal arthritis is a rare condition even in children. [1] Infection of the sacroiliac joint is uncommon, comprising only 1 to 2% of all cases of septic arthritis. [3] We report a very rare case of primary septic arthritis of the sacroiliac joint due to N. meningitidis without meningococcemia.


 ~ Case Report Top


An 11-year-old boy presented with acute pain of the right hip joint and buttock for 2 days. The boy had severe pain and was unable to stand or walk. There was no history of diarrhoea, vomiting, headache, chills and rigors. He did not have any seizures, altered sensorium, and any history of trauma or upper respiratory tract infection prior to this. On physical examination, he was febrile (100˚F), skin was normal without any rash or eruptions, mild pallor, pulse rate of 86/min, blood pressure 110/70 mm, oropharynx was normal, chest was clear and no organomegaly. Neurological examination did not reveal any abnormalities and meningeal signs were absent. On local examination, the right hip joint showed severe pain and tenderness with restricted movement. There was extreme pain on ambulation. The other joints were normal. The laboratory investigations revealed haemoglobin, 10.2 g/dl; total leucocyte count, 11200/μl; differential count - polymorphonuclear leukocyte (neutrophil): 72% and Lymphocyte: 28%; platelet count 2,25,000/μl; raised erythrocyte sedimentation rate - 102 mm in 1 hour and raised C-reactive protein. The renal and liver function tests were within normal limits. Other laboratory tests including blood culture, throat culture, antistreptolysin O test, rheumatoid factor and complement levels were normal. X-ray of the chest was normal. X-ray of pelvis with both hip joints showed irregularities in the right joint margin and blurring of fat planes were seen adjoining right hip joint suggestive of early stage of inflammatory process [Figure 1]. Joint fluid aspirated was slightly turbid in nature. Microscopic examination by Gram staining showed abundant polymorphonuclear leucocytes and the presence of extracellular Gram-negative diplococci [Figure 2]. The sample was inoculated on sheep blood agar, chocolate agar and MacConkey agar and incubated in 5 to 7% CO 2 at 35°C for 48 hours in a candle jar. Colonies were catalase positive and oxidase positive. Carbohydrate utilisation tests were done and the organism was identified as N. meningitidis. Serogrouping was done by using N. meningitidis antisera poly (groups A-D) (Difco) on isolated bacteria and showed positive result. The patient was diagnosed based on the above positive findings as a case of primary septic arthritis due to N. meningitidis. The organism was tested for antimicrobial susceptibility testing on Mueller-Hinton Agar with 5% sheep blood agar incubated in candle-jar at 35°C, using Kirby-Bauer disc diffusion method as per CSLI guidelines. The organism was sensitive to ceftriaxone, cefuroxime, and resistant to penicillin, ampicillin, chloramphenicol, gentamicin and ciprofloxacin. He was treated with intravenous ceftriaxone 1 g twice in a day for 14 days followed by oral cefuroxime 250 mg BD for another week. To relieve pain and spasm of muscles, the patient was given skin traction for 2 weeks. The patient responded well to the above treatment.
Figure 1: X-ray of pelvis showing early stages of infl ammation on right sacroiliac joint

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Figure 2: Gram staining of synovial fl uid showing Gram-negative diplococci

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 ~ Discussion Top


Meningococcal infections are transmitted by aerosolisation or by contact with respiratory secretions, leading to either upper respiratory infection or colonisation. The prevalence of carrier state varies from 3 to 5% in healthy children. [4] Dissemination of the microorganism through blood stream leads to meningococcal disease. Arthritis is a recognised complication of acute meningococcal sepsis with or without meningitis.

Most common cause of Bacterial arthritis is Staphylococcus aureus (44%), followed by Streptococcus pyogenes,  Escherichia More Details coli and Pseudomonas spp. [5] However, primary meningococcal arthritis without other manifestations or involvement of other organs is an uncommon phenomenon.

Meningococcal infection associated arthritis can be divided into 3 types. The most common presentation is arthritis as a complication of acute meningitis or meningococcaemia and manifests either as septic or aseptic when associated with immune complex deposition. The second presentation which is less common can be due to chronic meningococcaemia leading to migratory arthritis or arthralgias. Third type is primary meningococcal septic arthritis. This is an acute septic arthritis caused by N. meningitidis without evidence of meningitis or meningococcemia. [6] In our case, the patient presented with isolated septic arthritis of the sacroiliac joint that was not associated with any skin rash, upper respiratory tract infection or any other organ involvement.

A review of the English medical literature showed that since 1980-2002, 34 cases of primary meningococcal septic arthritis have been reported. [7] This is a rare presentation, especially in the paediatric age and few cases have been reported till now. [4] The patient, in case of septic arthritis, usually presents with fever, rigor and warm swollen painful joint. The knee is the most common joint involved. [8] But in our case, the sacroiliac joint was involved which is very rare with few reports in the literature. Direct bacterial invasion of synovium via blood-borne infection is the proposed pathogenesis of primary meningococcal arthritis. History of upper respiratory tract infection usually precedes primary meningococcal arthritis in up to 50% of cases. [9] Our case differs from the others because of absence of extra-articular disease.

Primary meningococcal arthritis is a very rare manifestation, especially in the paediatric population which may be missed. Till date, there are no reports of involvement of isolated meningococcal arthritis of sacroiliac joint in this area, to the best of my knowledge. It is important for the clinician to have knowledge about N. meningitidis as a potential pathogen in primary septic arthritis cases. Identification of N. meningitidis is necessary for appropriate and early treatment. Microscopy helps in preliminary rapid identification of organism followed by culture. Antibiotics used for the treatment of meningococcal arthritis are penicillin, ampicillin ceftriaxone, cefuroxime, ciprofloxacin, chloramphenicol and cotrimoxazole. In this case, ceftriaxone was preferred as the organism was sensitive to it and it could be given parenterally followed by cefuroxime orally. The prognosis is excellent and joint complications are rare once rapid diagnosis and treatment is given.


 ~ Conclusion Top


It is an emergency condition that needs early diagnosis and treatment as the prognosis is good in such cases. Primary meningococcal arthritis should be considered in the differential diagnosis of any acute septic arthritis. Accurate and immediate identification is required for proper treatment to avoid joint destruction.


 ~ Acknowledgment Top


Dr Premraj Satapathy MD; Radiology; for reporting X-ray findings.

 
 ~ References Top

1.Apfalter P, Horler R, Nehrer S. Neisseria meningitidis serogroup W-135 Primary monoarthritis of the hip in an immunocompetent child. Eur J Clin Microbiol Infect Dis 2000;19:475-6.  Back to cited text no. 1
    
2.Joyce M, Laing A, Mullet H, Gilmore MF, Cormican M. Isolated septic arthritis: Meningococcal infection. J R Soc Med 2003;96:237-8.  Back to cited text no. 2
[PUBMED]    
3.Attarian DE. Septic sacroiliitis: The overlooked diagnosis. J South Orthop Assoc 2001;10:57-60.  Back to cited text no. 3
[PUBMED]    
4.Efrati O, Barak A, Yahav J, Leibowitz L, Keller N, Bujanover Y. Primary Meningococcal arthritis. Isr Med Assoc J 2002;4:386-7.  Back to cited text no. 4
[PUBMED]    
5.Harwood MI, Womack J, Kapur R. Primary meningococcal arthritis. J Am Board Fam Med 2008;21:66-9.  Back to cited text no. 5
[PUBMED]    
6.Schaad UB. Arthritis in disease due to Neisseria meningitidis. Rev Infect Dis 1980:2:880-8.  Back to cited text no. 6
    
7.Giamarellos-Bourboulis EJ, Grecka P, Petrikkos GL, Toskas A, Katsilambros N. Primary meningococcal arthritis: Case report and review. Clin Exp Rheumatol 2002;20:553-4.  Back to cited text no. 7
[PUBMED]    
8.Kaandorp CJ, Dinant HJ, van de Laar MA, Moens HJ, Prins AP, Dijkmans BA. Incidence and sources of native and prosthetic joint infection: A community based prospective survey. Ann Rheum Dis 1997;56:470-5.  Back to cited text no. 8
[PUBMED]    
9.Verma N, Verma R, Sood S, Das BK, Singh P, Kumar A, et al. Primary meningococcal polyarthritis in a young man. Natl Med J India 2011;24:278-9.  Back to cited text no. 9
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]

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