We present the first reported case of prosthetic joint infection caused by
A 78-year old Chinese female was referred to the Royal National Orthopaedic Hospital (RNOH) with a 6-month history of worsening buttock pain following a fall onto her right hip. The pain was intermittent and unresponsive to analgesia or physiotherapy, and she was unable to walk 10 m without a walking aid. Eighteen months prior she underwent an uncomplicated right Corail Pinnacle total hip replacement (THR) for osteoarthritis resulting in a well-healed scar and good function.
Her past medical history included hypertension; L2/L3 and L5/S1 nerve root decompression; hysterectomy 3 months after the initial THR; and two tympanoplasties of the left ear but was otherwise healthy. She did not smoke or drink alcohol and she reported a penicillin allergy with a rash.
Examination revealed a well-healed posterolateral scar with no erythema, swelling or discharge but was otherwise unremarkable. The patient denied having fevers, shivering or acute infections since hip replacement surgery. Blood
tests showed a raised C-reactive protein (CRP) of 21 mg/L (normal range
0–5 mg/L) and erythrocyte sedimentation rate (ESR) of 50 mm/h (normal range
0–12 mm/h) and a neutrophil count of
Single-photon emission computed tomography (SPECT) showing increased signal around the right hip and signs of chronic periosteal reaction around the femur.
Fluoroscopic aspiration of the right hip yielded viscous fluid and tissue
samples that were sent for microbiological analysis.
Based on the rarity of the organism cultured and uncertainty around the
diagnosis of prosthetic joint infection (PJI), the MDT recommended repeat aspiration for synovial leukocyte counts and culture. This demonstrated a leukocyte count of 14 440 cells/cu.mm (
Subsequently the MDT recommended surgical treatment with a single-stage
revision of the hip which was performed 26 months after the index operation. Operative findings included acetabular and femoral components
that were loose and easily explanted with minimal bone loss. Five deep
intraoperative samples were sent. A definitive Corail Pinnacle revision THR
was re-implanted with vancomycin-impregnated bone graft (Osteomycin). Empiric antibiotic therapy with intravenous teicoplanin (10 mg/kg 12-hourly for three doses then 24-hourly) and two doses of amikacin (15 mg/kg once daily)
was commenced. All five samples grew
By day 11 after surgery the wound was dry, she was mobilising well, and a plain film demonstrated a well-positioned prosthesis. She was switched to an oral regimen of rifampicin 450 mg twice daily and moxifloxacin 400 mg daily and discharged on day 13.
She tolerated antimicrobial therapy well with no adverse effects and bloods, including full blood count, Urea and electrolytes and liver function tests remained normal throughout. At clinical review after 12 weeks there was complete healing of the wound with excellent function and antibiotics were stopped. Twenty-four months after surgery she continues pain-free with no concern of relapse.
Results of a PubMed search using the terms “human”, “infection”, “
Originally described and named
In contrast, it has not been isolated as part of the normal human flora. A PubMed search using “human infection”, “
The aetiology in our patient is uncertain. She had no history of acute
infection to suggest haematogenous spread. She denied consuming
unpasteurised dairy products, so digestive transmission is unlikely. In cattle summer mastitis has been associated with transmission by a biting
fly,
The indolent presentation made it difficult to establish a definite diagnosis of PJI. Variation between published PJI definitions, particularly use of joint aspirates, synovial leukocyte counts and biomarkers, made pre-operative diagnosis uncertain. Repeat aspiration was useful in our case, where we had a high index of suspicion for PJI but growth of an unusual organism in a single pre-operative sample, as further culture of the same organism met criteria for three international definitions of PJI.
No specific evidence exists to guide the optimal surgical strategy for
treatment of
There are few data to guide the choice of antimicrobial treatment of Trueperella infection. The available data from animal studies demonstrate conflicting in vitro activity against penicillin, gentamicin, and tetracyclines. The overuse of these antimicrobials in agriculture may account for this variation (Rezanejad et al., 2019; Ribeiro et al., 2015). Rifampicin and moxifloxacin were used based on susceptibility testing, high oral bioavailability, good bone penetration, and biofilm activity (Osmon et al., 2013). Following a single-stage exchange, 12-week duration of antibiotic treatment is generally recommended (Osmon et al., 2013; Parvizi et al., 2018). Local vancomycin may have contributed to the successful outcome.
In conclusion, we report the first case of PJI caused by
Consent was received from the patient prior to submission for publication.
No data sets were used in this article.
Study design planning was done by TA and SW. The study was conducted by TA and SW. TA wrote the paper. TA and SW revised the paper.
The authors declare that they have no conflict of interest.
The authors would like to acknowledge Jonathan Miles, Consultant Orthopaedic Surgeon at the Royal National Orthopaedic Hospital.
This paper was edited by Parham Sendi and reviewed by two anonymous referees.