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A 60-Year-old Man With Septic Arthritis and Hypotension After a Fall* FREE TO VIEW

Sogol Nowbar, MD; Erick Ridout, BA; Edward D. Chan, MD
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*From the Department of Internal Medicine and Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, and National Jewish Medical and Research Center, Denver, CO.

Chest. 1999;115(3):883-885. doi:10.1378/chest.115.3.883
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A 60-year-old man with alcoholic cirrhosis was admitted to the hospital with complaints of fever, chills, and a painful and swollen left elbow. The patient reported that he lost consciousness 6 days prior to admission while urinating and fell, sustaining a cut to his left elbow. He drank heavily, smoked one pack of cigarettes a day, and owned an indoor cat but denied being bitten or licked near his elbow.

Temperature, 39.1°C; BP 74/38 mm Hg; pulse, 120 beat per minute. There were peripheral stigmata of chronic liver insufficiency. The lateral surface of the left elbow was swollen and erythematous with a 2 × 2-cm area of fluctuance surrounding the laceration. There was severe limitation to movement of the elbow joint with marked pain on motion.

WBC count, 7,100/mm3; hemoglobin level, 10 g/dL; and platelet count, 68,000/mm3. Articular aspiration of left elbow: WBC count, 491,200/mm3, comprised predominantly of polymorphonuclear cells; RBC count, 150/mm3. Gram’s stain: small Gram-negative coccobacilli. Radiograph of the left elbow: healed distal left radial fracture without osteomyelitis.

He was treated with intravenously administered ceftazidime sodium, gentamicin, and cefazolin. Incision and drainage of the left elbow revealed approximately 200 mL of purulent fluid.

What is the cause of septic arthritis in this patient? What historical information about the elbow injury should be asked of the patient?

Diagnosis: Pasteurella multocida

Pasteurella multocida was isolated from both the elbow and aerobic and anaerobic blood cultures. The patient had sustained the elbow laceration on the edge of a cat litter box when he fell.

P multocida has a worldwide distribution and can be isolated from the respiratory and gastrointestinal tracts of many wild and domesticated animals. A well-recognized animal pathogen, it appears as tiny non-spore-forming, non-motile coccobacilli exhibiting bipolar staining and resembling Haemophilus species on a Gram’s stain. Carriage rates in the oral and nasal cavity of cats and dogs are estimated to be 70 to 90% and 50 to 66%, respectively. In addition, P multocida may be isolated as a commensal in the upper respiratory tracts of individuals professionally exposed to animals. Human infections most often follow direct inoculation from cat or dog bites and scratches or through contact with secretions of these animals. However, infections have been reported when no animal contact could be determined.

Superficial skin and soft tissue infections constitute the majority of P multocida infection in humans due to animal bites or scratches. They are characterized by rapid appearance of erythema, warmth, tenderness, and purulent drainage. More invasive diseases are rarer and include septic arthritis, osteomyelitis, pneumonia, meningitis, peritonitis, and bacteremia. The incidence of bacteremia in patients with localized infection is not known but is considered to occur more frequently than is commonly appreciated. Conversely, in patients with bacteremia, localized sites of P multocida infection are identified in more than 80% of the cases. Invasive forms of P multocida infections are more frequently seen in patients with impaired immune status, such as those who have chronic renal insufficiency, those who have malignancy and neoplasms, those who use corticosteroids or those who have cirrhosis; however, bacteremia may occur in previously healthy individuals. In most series of systemic infections, cirrhosis is the predominant underlying disease. The higher susceptibility to these infections in cirrhosis patients is considered due to impaired reticuloendothelial function and to portosystemic shunting.

Upper respiratory tract infections due to P multocida include sinusitis, pharyngitis, tonsillitis, epiglottitis, otitis media, and mastoiditis. In patients with underlying lung disorders, such as COPD and bronchiectasis, acute and chronic bronchitis and pneumonia may develop and are considered to occur via inhalation of droplet nuclei from an animal source. A wide spectrum of radiographic abnormalities may be seen in P multocida pneumonia, including lobar, multilobar, or patchy and diffuse distributions. Complications of pneumonia, such as lung abscess or empyema, also may develop.

Septic arthritis may be monoarticular, occurring as an extension of an overlying cellulitis, or more rarely, may be polyarticular, resulting from hematologic seeding. Various joints may be affected, including the knees, ankles, wrists, and shoulders. Interestingly, septic arthritis of the sternoclavicular joint, more commonly seen with IV drug abusers, also appears to be a predilection site in Pasteurella-associated joint infections even in non-drug abusers. Prosthetic joints and preexisting joint diseases, such as those associated with rheumatoid arthritis and osteoarthritis, also have higher susceptibility to infection by P multocida.

Successful therapy for P multocida infections requires that the organism be considered as a potential etiologic agent in the appropriate clinical setting. Penicillin is the treatment of choice for P multocida cellulitis and wound infections with a minimal inhibitory concentration of 0.1 to 0.8 μg/mL. Although infrequent, penicillin-resistant cases of P multocida occur, and therefore susceptibility testing should be performed, especially with severe infections in immunocompromised patients. Effective alternatives to penicillin include ampicillin and the third-generation cephalosporins. Although the organism is susceptible to tetracycline and chloramphenicol in vitro, the former often is considered inappropriate for life-threatening infections, and the potentially severe adverse effects of the latter are usually prohibitive in light of the availability of alternative antibiotics. The fluoroquinolones are especially promising because of their favorable in vitro susceptibility testing and their excellent penetration into soft tissues and joint spaces. Moreover, the newer fluoroquinolones may have activity against anaerobic organisms, which also frequently are present in animal bite wounds. Despite being a Gram-negative organism, aminoglycosides have variable activity against P multocida and are considered to be generally ineffective. P multocida is universally resistant to vancomycin and clindamycin. Dicloxacillin sodium and oral first-generation cephalosporins, commonly used antibiotics for soft-tissue infections in the outpatient setting, have significantly poorer activity against P multocida than penicillin. Those patients at high risk for complications (ie, those who have severe joint disease, those who have prosthetics, those who have impaired immune status) should initially receive parenteral antibiotics. For septic arthritis, repeated joint aspirations also are required. There appears to be no advantage to open or tube drainage over needle aspiration. Poor prognostic indicators include patients with underlying cirrhosis, age of 60 years or more, and hypotension.

The present patient had septic arthritis due to P multocida and developed a complication of septicemia due to underlying cirrhosis. This organism was most likely acquired by direct inoculation of the lacerated elbow with cat fecal matter. The key historical question to ask him was what object he cut his elbow on. After surgical drainage of the joint infection and identification of the organism, he was treated with IV ampicillin-sulbactam for 2 weeks, followed by an additional week of therapy with oral amoxicillin clavulanate. In retrospect, treatment with penicillin would have sufficed and been more cost-effective. Despite having poor prognostic indicators, the patient recovered completely.

1. Although P multocida soft-tissue infections are known to occur after animal bites, deep-seated infections also can develop after inhalational or inoculation exposure to animal feces.

2. Patients with impaired immune function (such as those who have cirrhosis, those who use corticosteroids, or those who have renal impairment) are at increased risk for systemic infection with P multocida. Underlying pulmonary disorders such as bronchiectasis and COPD may predispose patients to acute and chronic Pasteurella-caused pneumonia.

3. Pneumonia due to P multocida may present with a wide-spectrum of radiographic abnormalities, including lobar, multilobar, or patchy and diffuse patterns. In addition, complications, such as lung abscess or empyema, may develop.

4. The penicillin antibiotics are the most effective agents against P multocida, whereas the organism is not susceptible to aminoglycosides despite being a Gram-negative bacilli. Thus, a history of animal exposure in the immunocompromised patient should prompt the physician to suspect P multocida and to make provisions for adequate empiric antibiotic coverage.

Baker GL, Oddis CV, Medsger TA. Pasteurella multocida polyarticular septic arthritis. J Rheumatol 1987; 14:355–357

Chevalier X, Martigny J, Avouac B, et al. Report of 4 cases of Pasteurella multocida septic arthritis. J Rheumatol 1991; 18:1890–1892

Ewing R, Fainstein V, Musher DM, et al. Articular and skeletal infections caused by Pasteurella multocida. South Med J 1980; 73:1349–1352

Genne D, Siegrist HH, Monnier P, et al. Pasteurella multocida endocarditis: report of a case and review of the literature. Scand J Infect Dis 1996; 28:95–97

Klein NC, Cunha BA. Pasteurella multocida pneumonia. Sem Respir Infect 1997; 12:54–56

Koch CA, Mabee CL, Robyn JA, et al. Exposure to domestic cats: risk factor for Pasteurella multocida peritonitis in liver cirrhosis? Am J Gastroenterol 1996; 91:1447–1449

Kumar A, Kannampuzha P. Septic arthritis due to Pasteurella multocida. South Med J 1992; 85:329–330

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Ruiz-Irastorza G, Garea C, Alonso JJ, et al. Septic shock due to Pasteurella multocida subspecies multocida in a previously healthy woman. Clin Infect Dis 1995; 21:232–234

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Correspondence to: Edward D. Chan, MD, D411, Neustadt Building, National Jewish Medical and Research Center, 1400 Jackson St, Denver, CO 80206; e-mail: chane@njc.org




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