|Year : 2020 | Volume
| Issue : 3 | Page : 481-484
Streptococcus dysgalactiae septic arthritis of sternoclavicular joint with bacteraemia
Pruthu Narendra Dhekane, Ram Gopalakrishnan, V Lakshmi Sree, V Dedeepiya Devaprasad
Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
|Date of Submission||14-Jun-2020|
|Date of Decision||20-Jul-2020|
|Date of Acceptance||20-Aug-2020|
|Date of Web Publication||4-Nov-2020|
Dr. Pruthu Narendra Dhekane
Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Invasive infections due to Streptococcus dysgalactiae are uncommon in the adult population, and sternoclavicular joint septic arthritis (SCSA) is usually caused by other organisms such as Staphylococcus aureus and Pseudomonas aeruginosa. We hereby report a case of SCSA caused by this organism. The patient responded well to intravenous antibiotics and recovered fully without any surgical intervention.
Keywords: Septic arthritis, sternoclavicular joint, Streptococcus dysgalactiae
|How to cite this article:|
Dhekane PN, Gopalakrishnan R, Sree V L, Devaprasad V D. Streptococcus dysgalactiae septic arthritis of sternoclavicular joint with bacteraemia. Indian J Med Microbiol 2020;38:481-4
|How to cite this URL:|
Dhekane PN, Gopalakrishnan R, Sree V L, Devaprasad V D. Streptococcus dysgalactiae septic arthritis of sternoclavicular joint with bacteraemia. Indian J Med Microbiol [serial online] 2020 [cited 2020 Nov 24];38:481-4. Available from: https://www.ijmm.org/text.asp?2020/38/3/481/299821
| ~ Introduction|| |
Streptococcus dysgalactiae is a Gram-positive, beta-haemolytic Streptococcus and is most frequently encountered as a commensal of the alimentary tract, genital tract or, less commonly, as a part of the skin flora.
S. dysgalactiae infections in humans range from superficial skin infections and tonsillitis to severe necrotising fasciitis, septic arthritis and bacteraemia. We hereby report the first patient with septic arthritis of the sternoclavicular joint caused by this organism.
| ~ Case Report|| |
A 78-year-old female presented with complaints of the right shoulder region, sternoclavicular region pain and swelling for 4–5 days and fever for 2–3 days. She had a history of hypertension and coronary artery disease. Apart from these comorbid conditions, she did not have any other risk factors. On clinical examination, there were swelling and tenderness over the right shoulder region along the anterior aspect and over the right sternoclavicular joint (SCJ) region with some fullness in the medial right supraclavicular fossa region. Range of movements at the right shoulder joint was reduced. Other joints and systemic examination findings were unremarkable.
Laboratory workup showed total lymphocyte count – 12,100 cells/mm3 (neutrophils – 79%, lymphocytes – 15%, eosinophils – 03%) with anaemia Hb – 10.0 g/dl with raised C-reactive protein of 177 mg/L. Serum uric acid levels were normal (3.1 mg/dL). Her liver and renal function tests were within normal limits. HIV serostatus was negative.
Magnetic resonance imaging (MRI) of the right shoulder and sternoclavicular region was suggestive of oedema and inflammation of the right SCJ and infraclavicular space, with inflammation of pectoralis major and pectoralis minor, extending up to the cutaneous and subcutaneous plane in upper chest wall consistent septic arthritis of SCJ [Figure 1], [Figure 2], [Figure 3].
|Figure 1: Magnetic resonance imaging of the right shoulder and sternoclavicular region was suggestive of oedema and inflammation of the right sternoclavicular joint and infraclavicular space, with inflammation of pectoralis major and pectoralis minor, extending up to the cutaneous and subcutaneous plane in upper chest wall consistent septic arthritis of sternoclavicular joint|
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|Figure 2: Magnetic resonance imaging of the right shoulder and sternoclavicular region was suggestive of oedema and inflammation of the right sternoclavicular joint and infraclavicular space, with inflammation of pectoralis major and pectoralis minor, extending up to the cutaneous and subcutaneous plane in upper chest wall consistent septic arthritis of sternoclavicular joint|
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|Figure 3: Diffusion-weighted magnetic resonance imaging of the right sternoclavicular region was suggestive of oedema and inflammation of the right sternoclavicular joint|
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She underwent ultrasound-guided needle aspiration of the right SCJ. Gram stain of pus showed Gram-positive cocci in short chains [Figure 4] and grew colonies with beta-haemolysis on blood agar [Figure 5]. Four bottles of blood culture, 2 aerobic and 2 anaerobic, were sent. Blood cultures grew Gram-positive cocci in all aerobic and anaerobic bottles. Both the isolates from pus and blood were identified by MALDI-TOF VITEK MS (bioMerieux, Marcy l'Etoile, France) as S. dysgalactiae. Antimicrobial susceptibility was tested by disc diffusion method on 5% sheep blood agar according to the Clinical and Laboratory Standards Institute guidelines which showed sensitivity to penicillin, ceftriaxone, doxycycline and vancomycin.
She was started on intravenous (IV) teicoplanin empirically and then de-escalated to IV ceftriaxone 2 g daily. Her fever settled over the next 4–5 days, and the right shoulder joint and sternoclavicular region swelling also reduced over the next 2 weeks. She received total 6 weeks of IV antibiotics, and at follow-up after 6 and 12 weeks, the swelling had completely resolved and not recurred and she had regained almost full range of motion of the shoulder joint region.
| ~ Discussion|| |
According to Facklam, Group C Streptococcus contains five species: S. dysgalactiae Subsp. dysgalactiae, S. dysgalactiae subspecies equisimilis (SDSE), Streptococcus zooepidemicus subs. equi, Streptococcus equi Subsp. zooepidemicus and Streptococcus constellatus Subsp. Pharynges.S. dysgalactiae is currently divided into the subspecies SDSE and S. dysgalactiae subspecies dysgalactiae; the former mostly associated with human disease, and the latter almost exclusively encountered in veterinary medicine. Similar to Group A streptococci, S. dysgalactiae possesses virulence factors including M protein, streptolysin O, streptolysin S, streptokinase, hyaluronidase and C5a peptidase. It is classically considered a commensal of mucosae, and the burden of disease is under-recognised. Transmission from sites of colonisation is the main mechanism for SDSE infection. In humans, they may be isolated from healthy skin as well as the naso- and oropharynx, intestinal tract and vagina.
Predisposing factors for bacteraemia and invasive infection include skin breakdown, age over 65 years, diabetes, cardiovascular disease and malignancy or immunosuppression. There have been very few reported cases of Group C streptococcal septic arthritis in the literature. The patients have ranged in age from 11 months to 70 years, with majority being males and having an underlying rheumatological disorder. Our patient apart from being above 70 years of age and having coronary artery disease did not have any rheumatological disorder, immunosuppression or suffer from any trauma.
Septic arthritis or osteomyelitis caused by S. dysgalactiae has been reported rarely in the literature. In a prior reported case series of 10 cases, there was no predilection for any specific joint involvement and both large and small joints were involved in the upper and lower extremities equally. The infection was monoarticular in majority (70%) and polyarticular (30%) in remaining patients. Bacteraemia was documented in 50% of the patients. All of these patients were treated with penicillin. Our patient was treated with IV ceftriaxone for dosing convenience on outpatient parenteral antimicrobial therapy basis.
Sternoclavicular joint septic arthritis (SCSA) represents only 0.5%–1% of all joint infections in the general population. The most common cause is Staphylococcus aureus, followed by Pseudomonas species. SCSA usually presents with fever and pain on the neck and anterior chest, which can radiate to the shoulders. Erythema and swelling of the skin over the sternoclavicular area are common, with the route of infection being unknown in most of the cases.
The SCJ infection has been described mainly in patients with predisposing risk factors, including IV drug abuse, subclavian vein catheter placement, haemodialysis diabetes mellitus and rheumatoid arthritis. Other risk factors included alcohol abuse, corticosteroid treatment, infective endocarditis, cancer, chronic liver disease, surgery (particularly median sternotomy), trauma and radiation therapy. SCSA caused by Group C Streptococcus has not been documented so far in the literature to the best of our knowledge.
Sternoclavicular septic arthritis usually presents with fever and pain on the neck and anterior chest, which can radiate to the shoulders and erythema and swelling of the skin over the sternoclavicular area. Plain radiographs usually show no obvious septic destruction. Bodker et al. proposed that MRI should be the initial image investigation of SCSA. It can demonstrate joint subluxation, joint destruction, periarticular inflammation and SCJ abscess.
Our patient had a good resolution of pain and swelling of the shoulder region after 6 weeks of IV antibiotic therapy. There is no good-quality evidence to support the addition of rifampicin in the clinical setting, but combination therapy has been recommended for severe Group C streptococcal infection on the basis ofin vitro tolerance to penicillin and some retrospective clinical data. Although in our case we did not give any additional rifampicin as the isolate was penicillin susceptible. Medical treatment may be sufficient in some early-stage patients, and surgery is often needed. Surgical operation may involve simple incision and drainage. For a radical intervention, debridement, arthroplasty and flap reconstruction are usually necessary. Occasionally, excision of the medial end of the clavicle, first rib and manubrium is obligatory. Complete SCJ resection and pectoralis flap closure resulted in no recurrences among patients with SCJ septic arthritis, while debridement and antibiotic therapy alone were associated with recurrence in five of six patients.
We conclude that S. dysgalactiae should be added to the list of organisms causing SCSA and empiric therapies should cover for this organism as well.
I wish to express my sincere regards to Dr. Ram Gopalakrishnan, Dr. Lakshmi Sree and Dr. V Dedeepiya Devaprasad for their guidance throughout the work. They provided valuable inputs that steered this case report to successful completion.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]